Format for Documentation of Internal Reviews of Residency Programs

FORMAT FOR DOCUMENTATION OF INTERNAL REVIEWS OF RESIDENCY PROGRAMS (The Internal Review Report)

Title: The Report of the Ad Hoc Committee for the Internal Review of the ______Residency Program.

Date of review ______

Date Report Presented to Graduate Medical Education Committee: ______

The ad hoc committee consisted of (list names with titles and departments)

The committee reviewed the following documents:

1. The program’s policies and procedures manual
2. The program’s objectives
3. The ACGME notification letters and the program’s written responses
4. The previous internal reviews and the program’s responses
5. The Institutional Requirements
6. The Program Requirements and, as appropriate the Program Requirements for the Subspecialties of ______. The committee assessed the program’s curriculum to ensure inclusion of the six general competencies.

The committee interviewed the following: (The program director must be on this list. There should be other faculty from the program and the program’s housestaff coordinator is encouraged to participate.)

The committee interviewed the following residents in the program (all levels should be represented)

The committee found the educational objectives of the program to be appropriate (or deficient, if that’s the case) and found that the program had adequate educational and financial resources that were being used optimally. The committee also found that the program was (highly, moderately, adequately, not) effective in achieving the educational goals.

ACGME Issues

The committee reviewed the citations/concerns noted in the last ACGME notification letter to the Program Director. These citations/concerns are listed below with the program’s response. (The citations and responses should be numbered)

1. ……..
2. ……..

The committee felt that the program had adequately addressed (numbers), but that (number) requires further attention.

Previous internal review issues

(This section should list areas noted in the previous review that required action for improvement and how the program has responded to the suggestions for improvement.)

Specifically state the ad hoc committee’s assessment of the program’s compliance with:

1. Program Requirements (and Subspecialty Requirements, if applicable)
2. Institutional Requirements
3. Implementation of ACGME six general competencies into the curriculum, evaluation process, the process used to link educational outcomes with program improvement.
4. Duty hour requirements and documentation of compliance.

Cite the areas of noncompliance, if any. If the program is in substantial compliance, state that fact using the phrase “substantial compliance.”

Current Internal Review Areas for Improvement

Review of program policies and interviews with residents and faculty resulted in the following recommendations for improvement: (List the issues with suggestions for improvement)

The ad hoc committee recommends that the Graduate Medical Education Committee adopt this report (if deficiencies are identified) and request a report from the program in approximately ( ___ months) that addresses the issues noted above.

Respectfully submitted,

Chair, Ad Hoc Committee for the Internal Review of the ______Residency Program

Internal Review Report Format – Revised Janaury 2006

Harbor UCLA Medical Center/Office of GME