GMEOC Internal Review

Refresher for Review Participants on Process & Roles

August 19, 2009

Goals of Revised Process

Ease burden on primary reviewer Spread workload across four roles

Ensure appropriate accountability Effectively prepare program for site visit New templates, interview scripts

Ensure effective documentation for ACGME Fewer citations

Four roles

Primary Reviewer (Program Director) Secondary Reviewer (Program Director or

Education Manager) Administrative Reviewer (GME or

Coordinator) Resident Reviewer Primary Reviewer determines how team will

communicate between team members to complete report

Process

Programs must be visited within 2 months of its mid-cycle from last date of accreditation

Dr. Getto’s office sends notification of Internal Review Visit w/2-3 optional dates selected by the Review Team to the Director whose Program is being reviewed

2-3 hour mandatory meeting is scheduled 5-6 months out and all team members notified

Program being reviewed submits to GME Office: Common & Specialty/Subspecialty PIF Other required Program Documentation Competency Chart

All reviewers receive materials 2-3 months in advance of GMEOC deadline for report

ACGME-Required Interviews

Meeting w/Director & Coordinator (90 minutes) Faculty may be included in this meeting

Meeting w/Residents (90 minutes) Number varies but must be representative of program May be led by Resident Reviewer

Meeting w/at least one Faculty is essential May be held at meeting w/Director or at a Section meeting Faculty member must be interviewed no minimum standard

All four Reviewers should be included in all meetings when possible

Meeting w/Coordinator to review documentation (90 minutes) Audit of Program Policies Review of Resident/Fellow Portfolios

Tips on Successful Process Effective communication among team members critical

to complete report Minimize confusion over who has which portion of the

Checklist Submit to Primary Reviewer for collation Cross-check of data between reviewers

Draft report and template sent by Primary Reviewer to Program Director for review Correct inaccuracies Program gives courtesy feedback only— otherwise may

experience “review creep” Final report and template sent to GME Office 2 weeks

before GMEOC meeting Won’t get on agenda if otherwise Timeliness ensures UWHC meets ACGME required timeframe

Questions?

Feel free to ask for assistance Program Documentation—Jeanne

Sarbacker 262-8399 Program Requirements or Review

Process—Anne Gravel Sullivan 262-5512