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Policy Purpose

This policy defines the process for which the Graduate Medical Education Committee (GMEC) will demonstrate effective oversight of the Sponsoring Institution's accreditation through an Annual Institutional Review (AIR).


Each December, The Graduate Medical Education Committee will form a subcommittee consisting of the Designated Institutional Official, one program director, one GME faculty member, a peer-selected resident and GME administrative staff. The following list represents a sampling of the performance indicators to be reviewed by the subcommittee:

  • Board Pass Rate (first time takers, 5-year rolling average)
  • Resident Attrition
  • Faculty Attrition
  • Faculty Scholarly Activity
  • Resident Scholarly Activity
  • In-Training Exam Results
  • Faculty Survey
  • Resident Survey
  • Annual Program Evaluation Results
  • Residency Review Committee Citations

Additionally, AIR will include reviewing the progress on CLER report action items.

Upon analysis of the aforementioned performance indicators and CLER findings, the subcommittee will identify areas for growth and establish action plans for improvement. This action plan will be presented to the GMEC for review and approval. Once approved, this plan will be monitored by the Graduate Medical Education Office and reviewed with the Designated Institutional Official (DIO) regularly.

The DIO will submit a written annual executive summary of the AIR to the governing bodies of Mount Carmel Health System.

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