GME Internal Review

TO BE COMPLETED BY FACULTY REVIEWER – FOR INFORMATION

ONLY

GME Internal Review

Date of Internal Review:

Program:

INTERNAL REVIEW TEAM:

Program Director: Program Affiliation:

Resident: Program Affiliation:

ACGME DATA:

Last ACGME site visit:

Cycle length:

Max # of residents:

Next Survey:

PROGRAM DIRECTOR & ADDITIONAL PERSONNEL ATTENDING THE REVIEW:

Program Director: Attending: Yes No

Associate Program Director: Attending: Yes No

Program Coordinator: Attending: Yes No

KEY FACULTY:

Attending: Yes No

DIRECTORS AT TEACHING SITES

LIST RESIDENTS ATTENDING THE INTERNAL REVIEW BY TRAINING YEAR

Were participating residents chosen by their peers? _____ Yes No

MATERIALS REVIEWED:

CITATIONS FROM LAST SITE VISIT:

OVERALL REVIEW OF THE INTERNAL REVIEW PIF:

GENERAL PROGRAM INFORMATION:

Briefly describe the program’s structure, leadership, affiliated hospitals, scope and length of training, trainee rotations by program year, and number current trainees by program year:

SPONSORING INSTITUTION/PROGRAM SUPPORT:

1. Does the sponsoring institution and participating sites demonstrate a commitment to quality patient centered care and educational scholarship sufficient to support the resident program? YES NO

2. Does the sponsoring institution support at least 50% of the salary for the Program Director? YES NO

3. How many associate program directors are there for your program? ____ N/A___

4. How many KCF are there for your program? ____

5. Does your program use simulation in the training of your residents? YES NO

6. Are service responsibilities limited to patients for whom your teaching service has diagnostic and therapeutic responsibilities? YES NO

(The teaching service is defined as those patients for whom your residents routinely provide care.)

7. Do your current, fully executed programs have letters of agreement or affiliation agreements on file for the current academic year for your participating institutions/external rotations? YES NO

a.) Does the PLA identify the faculty whom will assume both educational and supervisory responsibilities for the residents? YES NO

b.) Does the PLA specify the responsibilities for teaching supervision and formal evaluation of residents as specified? YES NO

c.) Does the PLA specify the duration and content of educational experience?

YES NO

d.) Does the PLA state the policies and procedures that will govern resident education during the assignment? YES NO

PROGRAM RESOURCES:

1. Does the program director, associate program director and key clinical faculty have current certification in their specialty by the ABMS? YES NO

2. Does the program director, associate program director and key clinical faculty have current medical licensure and appropriate medical staff appointments?

YES NO

3. Does the program director report to the DIO in the review and co-signature on all program information forms as well as any correspondence or documents submitted to the ACGME? YES NO

4, Does the program director monitor resident stress, mental or emotional conditions inhibiting performance or learning and drug or alcohol related dysfunction?

YES NO

5. Does the program director insure that clinical quality improvement programs are integrated into the residency program? YES NO

6. Does the program director have supervisory authority over all educational activities and teaching faculty in the program? YES NO

7. Does the program director insure that the residency does not place excessive reliance on residents for service as oppose to education? YES NO

8. Do members of the faculty demonstrate scholarship by one or more of the following:

____ 1. Peer reviewed funding

____ 2. Publication of original research or review articles and peer review journals, chapters or text books

____ 3. Publication or presentation of case reports or clinical series at local, regional or national professional and scientific society meetings

____ 4. Participation in national committees or educational organizations

If yes, mark an X by which scholarly activities have been demonstrated.

9. What percentage of faculty (PD, APD, KCF) have participated in scholarly activities as defined in question 8, over the past 3 years? ______%

10. Does the associate program director dedicate no less than 50% (at least 20 hours per week) of his/her efforts to the administrative and educational activities of the program? YES NO ____N/A

11. Do the key clinical faculty dedicate an average of at least 15 hours per week through out the year to residency administration/training? YES NO

12. Does the program and institution insure the availability of adequate resources for resident education? YES NO

13. Is adequate clinical teaching space available? YES NO

14. If on call facilities are utilized by residents, do they afford privacy, safety and a restful environment with secure space for belongings? YES NO ____ N/A

15. Are consultations from other clinical services are available in a timely manner in all care settings where residents work? YES NO

16. Do residents have ready access to specialty specific reference material in print or electronic format? YES NO

RESIDENT APPOINTMENT

1. Are there criteria for resident eligibility as specified in the institutional requirements for your program? YES NO

2. Have you accepted a transferring resident or transferred a resident since your last site visit. YES NO

If yes, did the program director provide/receive written or electronic verification of their previous educational experience and a summative competency- based performance evaluation. YES NO

3. Does the presence of other learners (other fellows, NP’s, PA’s, PhD, students, etc.) in the program interfere with resident education? YES NO

EDUCATIONAL PROGRAM AND CURRICULUM

1. Are overall goals and objectives given to the trainees (online and paper)?

YES NO

2. Are overall goals and objectives reviewed and updated every three years?

YES NO

3. Are overall written goals and objectives with competencies available by program year for each rotation experience? YES NO

4. Do faculty review rotational goals with the residents at the start of each rotation?

YES NO

5. Is the curriculum organized around the teaching assessment of the six ACGME core competencies? YES NO

6. Are there regularly scheduled didactic sessions? YES NO

7. Is the didactic program available for residents who are unable to attend a specific presentation, (web based pod cast etc)? YES NO

8. Is the resident’s time protected so they may attend the didactic series regardless of rotation? YES NO

9. Is resident attendance at lectures documented? YES NO

10. Is there a Journal Club? YES NO

11. Are there formal quality assurance programs or performance improvement programs the residents can attend to review cases or complications and near misses, improve processes or to examine systems issues that contribute to errors and resolve them? YES NO

If yes, please list how this is accomplished.

12. Does the program insure that over the course of resident training that each resident has increasing responsibility in patient care, leadership, teaching and administration?

YES NO

13. Does the curriculum advance the resident’s knowledge of the basic principles of research? ____YES ____NO

14. Do the residents participate in scholarly activity? YES NO

15. What percentage of residents/fellows participated in scholarly activities over the past 3 years? ______%

16. Does the program and institution allocate adequate educational resources to facilitate resident involvement in scholarly activities? YES NO

17. Are research opportunities identified in writing for the trainees? YES NO

EVALUATION

I. RESIDENT EVALUATIONS

1. Do individual faculty complete and review written evaluations on trainees at the completion of each rotation? YES NO

2. Does the program provide objective assessments of competence in the ACGME Core Competencies, as provided in the common program requirements?

YES NO

3. Do trainees have access to their individual evaluations from the faculty?

YES NO

4. Who meets with each trainee for formal feedback?

5. How often do you meet with each trainee for formal feedback?

6. Are these meetings recorded in the trainee’s files? YES NO

7. Does anyone have an exit meeting with graduating residents/fellows? ____YES _ NO

8. Does the program director complete a written summative evaluation on each graduate stating explicit language that the “trainee is competent to practice independently”? YES NO

9. Are any current trainees on probation? YES NO

If yes, has the GMEC been notified? YES NO

10. Have any trainees left without completing the program in the past three years?

YES NO

If yes, how many and why?

11. Do you have multiple evaluators of trainees such as peers, patients, nurses, etc. (3600 evaluation)? YES NO

If yes, who evaluates the trainees?

12. Do the trainees evaluate the program/institution at least annually?

YES NO

13. Have trainee’s suggestions for improvement or criticisms been sought?

YES NO

II. FACULTY/PROGRAM EVALUATION

1. Does the program evaluate faculty performance in relation to the educational program at least annually? YES NO

If yes, does the evaluation include or review the faculty member’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism and scholarly activities?

YES NO ____N/A

1.a. Does the evaluation include annual written confidential evaluations by the residents? YES NO ____N/A

2. Does the faculty have the opportunity to evaluate the program confidentially in writing at least annually? YES NO

3. Does the program have a committee (comprised at a minimum of the program director, representative faculty and at least one resident) which reviews the programs goals and objectives and there effectiveness annually?

YES NO

If yes, does the committee review and document formally each of the following areas:

A. Resident performance YES NO

B. Faculty development YES NO

C. Graduate performance including performance on the certification examination and program quality YES NO

D. If deficiencies are found, does the program prepare a written plan of action to document a plan of improvement, which has been approved by the teaching faculty and documented in the meeting minutes?

YES NO

DUTY HOURS

1. Provide a brief analysis of the programs most recent duty hours report.

2. How often do you run and analyze your programs duty hours report?

3. Are trainee duty hours no more than 80 hours per week averaged over 4 weeks?

YES NO

4. Do trainees have at least 1 day in 7 free of clinical activities averaged over 4 weeks? YES NO

5. Do trainees have at least 10 hours off between shifts and after call?

YES NO

6. Do trainees take in-house call no more than every 3rd night averaged over 4 weeks? YES NO ____N/A

7. Are trainees required to leave after 24 hours of continuous duty?

YES NO ____N/A

8. Are trainee duty hour work assignments in compliance requirements as specified by the ACGME? YES NO

AMBULATORY MEDICINE

1. Briefly describe any ambulatory experiences for the residents.

2. Have the ambulatory requirements for residents been met as specified by the ACGME rules/regulations for the program? YES NO

GENERAL REQUIREMENTS

1. Do trainees keep procedure or case logs? YES NO

2. Are the logs reviewed with the trainees? YES NO

If yes, how often?

3. Are trainees formally assigned mentors or advisors? YES NO

4. Do mentors/advisors assist trainees in developing personal programs for learning?

YES NO

5. Are trainees informed about post-graduate jobs and advanced training opportunities? YES NO

If yes, how?

6. Do you have contracts signed annually on file for each current trainee?

YES NO

7. Do you track and monitor all moonlighting activities?

YES NO ______N/A

If yes, do you have a written statement of permission to moonlight, signed by the program director in each residents file? YES NO

8.. Are there opportunities to participate in the department/institutional committees?

YES NO

If yes, please name the committees.

9. Has the program director been formally evaluated by the Chair with respect to their effectiveness? YES NO

If yes, when was the most recent evaluation? ____

10. Is there a departmental or program level orientation for new trainees?

YES NO

11. What is the rolling 3 year board certification pass rate for you residents who have graduated? %

CORE COMPETENCIES

Please review examples under each category below, and then give at least two specific examples of ways in which the program teaches and assesses core competencies. For an overview of the competencies, please read the ACGME Common Program Requirements or RRC Program Requirements.

· Professionalism:

(Examples: Seminars in medical ethics; American Medical Association virtual mentor program; self-care, Web-based learning modules on quality interactions with culturally diverse patient populations)

· Interpersonal and communication skills:

(Examples: Seminar on “How to Give A Talk”; teaching on how to interact with consultants; teaching how to give bad news)

· Practice–based learning and improvement:

(Examples: M&M conferences; training in hand-off methods; teaching the use of information technology to access online medical information; chart audits; finding scientific literature to support patient management; presentations at conferences; teaching medical students)

· Systems–based practice:

(Examples: Training on the roles of various healthcare providers; training in insurance/FTE payer systems; projects on improving systems of care; teaching sessions on how to run a lab; near miss reporting documenting a systems issue that affects patient care; trainee involvement in institutional or departmental committees; quality and safety projects)

· The remaining two competencies, medical knowledge and patient care, are more traditionally taught and assessed. For the purposes of this document, we do not need you to list examples.

GENERAL QUESTIONS FOR FACULTY REVIEWER

1. List the prior citations of the last ACGME site visit and how they have been corrected.

2. What are the ongoing efforts for program improvement?

3. What are the strengths and weaknesses of the program?

4. What are the ways in which the institution could help the program improve?

RECOMMENDATIONS

FINAL PROGRAM OVEVIEW

______Acceptable program compliance with no significant areas

______Acceptable program compliance with focused areas of concern requiring a response within 60 days on the part of the program

______Marginal program compliance requiring additional response by the program and potential for another follow-up internal review or mandatory progress report

______Unacceptable program compliance requiring further action by the GMEC

PLEASE ATTACH

1. Most recent ACGME survey.

2. Most recent ACGME letter from last site visit and any other correspondence since the site visit.

3. Procedural or case log summaries (if applicable) for the individual resident’s and program overall.