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Special Review Process

Policy Purpose

The ACGME requires that the GMEC demonstrate effective oversight of underperforming program(s) through a special Review process. This process must include a protocol that establishes criteria for identifying underperformance resulting in a report that describes quality improvement goals, corrective actions and how the GMEC will monitor outcomes. (ACGME Institutional Requirements, I.B.6)

Responsible Persons

  • GMEC/DIO

Designation

Underperformance by a program can be identified through a wide range of mechanisms. The following established key indicators are a representative but not an exhaustive list:

  • Substantive Non-compliance with ACGME program requirements
  • Program Attrition
    • Greater than 1 resident/fellow per year resident attrition (includes withdrawal, transfer or dismissal)
  • Resident Survey
    • Compliance below the national average for any aspect of duty hour rules
    • Downward trends in more than 2 categories other than duty hours
  • Board Passage Rate
    • Downward trend in board passage rate – per the respective program requirement
  • Faculty Survey
    • Downward trend in more than 2 categories

The GMEC will discuss whether a residency/fellowship program is underperforming and thereby subject to special review. If so determined, the DIO/GMEC must initiate a special review within 30 days of a program being identified as underperforming.

Special Review Committee (SRC)

The Special Review process will be conducted by the SRC which will include the DME/DIO, the Director of Medical Education Operations, the Accreditation Specialist. The committee should also include a faculty and resident member from the GMEC - though not from the subject program. Additional members may be included on the SRC as determined by the DIO/GMEC. The DIO will chair the SRC.

Preparation for the Special Review

The Chair of the SRC, in consultation with GMEC and/or other persons as appropriate, shall determine whether the nature of the circumstances require a focused or full special review. These concerns may range from those that broadly effect the entire operation of the program to single, specific areas of concern. Based on identified concerns, the program that is under review may be asked to submit documentation prior to the actual Special Review that will allow the SRC to gain understanding of the identified concerns.

The Special Review

Materials and data to be utilized in the review process must include:

  • The ACGME common, specialty, subspecialty-specific program, and Institutional Requirements in effect at the time of the review.
  • Accreditation letters of notification from the most recent ACGME reviews and progress reports sent to the respective RRC;
  • Previous Annual Program Evaluations (APE)
  • Results from ACGME faculty and resident surveys and
  • Any other materials the SRC considers necessary and appropriate

The SRC will conduct interviews with the Program Director, key faculty members, at least one peer selected resident(s) from each PGY level of training in the program, and other individuals deemed appropriate by the committee.

Special Review Report

The SRC shall submit a written report to the GMEC that includes, at a minimum, a description of the review process and the findings and recommendations of the committee. This report will include a description of quality improvement goals, any corrective actions designed to address identified concerns, and the process for GMEC monitoring of outcomes of the special review process. The DIO/GMEC may, at its discretion, choose to modify the Special Review Report before accepting a final version. The final SRC report shall be submitted to and approved by the GMEC.

Monitoring of Outcomes

The DIO, in conjunction with the GMEC, will monitor the outcome(s) of the special review process. The subject program will provide quarterly progress reports to the GMEC until the deficiency is deemed remediated by the DIO/GMEC.

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