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GME Special Review Policy

DEPT: MEDICAL EDUCATION

POLICY #: 8240.20

GOAL

To ensure effective oversight of under-performing Graduate Medical Education programs by the Sponsoring Institution (Santa Barbara Cottage Hospital) via the Designated Institutional Official and the Graduate Medical Education Committee. Specifically, this policy will (1) establish criteria for identifying under-performance and (2) address the procedure to be utilized when a residency program undergoes a Special Review.

POLICY

Criteria for Identifying Under-performance

Under-performance by a program can be identified through a wide range of mechanisms. These may include, but are not limited to:

  • Deviations from expected results in standard performance indicators:
    • Program Attrition: A pattern of resident and/or faculty attrition 
    • Major Organizational Changes of the Program
    • Scholarly Activity 
    • Board Pass Rate: Below the minimum required by the supervising RRC 
    • Clinical Experience: Example – Case log data from the ACGME of recent graduates indicating that minimum requirements are not being met 
    • Resident or Faculty Survey:
      • Mean score less than three in two or more of the seven categories
      • Two responses with less than 50% compliance and significantly below national norm in any of the seven categories 
      • A pattern of significant downward trends since the last survey
      • Survey completion rate below the 70% (resident) or 60% (faculty) required by the ACGME
      • ACGME request for progress report related to concerns identified on the Resident or Faculty Survey
    • Milestones
    • Competencies
    • Failure to submit ACGME required data on or before identified deadlines
  • Communications about or complaints against a program indicating potential egregious or substantive noncompliance with the ACGME Common, specialty/subspecialty-specific Program, and/or Institutional Requirements; or noncompliance with institutional policy
  • A program’s inability to demonstrate progress in any of the following focus areas:
    • Integration of residents into institution’s Patient Safety Programs;
    • Integration of residents into institution’s Quality Improvement Programs and efforts to reduce Disparities in Health Care Delivery;
    • Establishment and implementation of Supervision policies;
    • Transitions in Care;
    • Duty hour policy and/or fatigue management and mitigation; and
    • Professionalism
  • Self-report by Program Director, Associate Program Director, Core Faculty or Department Chair

PROCEDURES

  • Designation: When a residency program is deemed to have met the established criteria for designation as an under-performing program, the DIO/Chair of the GMEC shall schedule a Special Review. Special Reviews shall occur within 60 days of a program’s designation as ‘underperforming.’
  • Special Review Panel: Each Special Review shall be conducted by a panel including at least:
    • One member of the GMEC who shall serve as Chair of the panel
    • One additional faculty member from a program other than the one being reviewed
    • One resident from a residency program other than the one being reviewed
    • A support staff person to support the process

Additional reviewers may be included on the panel as determined by the DIO/GMEC.

    • Preparation for the Special Review: The Chair of the Special Review panel, in consultation with the DIO/GMEC and/or other persons as appropriate, shall identify the specific concerns that are to be reviewed as part of the Special Review Process. Concerns may range from those that broadly encompass the entire operation of the program to single, specific areas of interest. Based on identified concerns, the program being reviewed may be asked to submit documentation prior to the actual Special Review that will help the panel gain clarity in its understanding of the identified concerns.
    • The Special Review: Materials and data to be used in the review process shall 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;
      • Reports from previous Internal Reviews of the program (if applicable); 
      • Previous Annual Program Evaluations (APE);
      • Results from internal or external resident surveys, if available; and,
      • Any other materials the Special Review panel considers necessary and appropriate. The Special Review panel will conduct interviews with the Program Director, key faculty members, at least one resident from each level of training in the program, and other individuals deemed appropriate by the committee.
    • Special Review Report: The Special Review panel shall submit a written report to the DIO and GMEC that includes, at a minimum, a description of the review process and the findings and recommendations of the panel. These shall include a description of the quality improvement goals, any corrective actions designed to address the identified concerns and the process for GMEC monitoring of outcomes. The GMEC may, at its discretion, choose to modify the Special Review Report before accepting a final version.
    • Monitoring of Outcomes: The DIO and the GMEC shall monitor outcomes of the Special Review process, including actions taken by the program and/or by the institution with special attention to areas of GMEC oversight, including:
      • The ACGME accreditation status of the Sponsoring Institution and its ACGME-accredited programs
      • The Quality of the GME learning and working environment within the Sponsoring Institution, its ACGME-accredited programs, and its participating sites;
      • The quality of educational experiences in each ACGME accredited program that lead to measurable achievement of educational outcomes as identified in the ACGME Common and specialty/subspecialty-specific Program Requirements;
      • The ACGME-accredited programs’ annual evaluation and improvement activities; and,
      • All processes related to reductions and closures of individual ACGME-accredited programs, major participating sites, and the Sponsoring Institution.

COTTAGE HEALTH SYSTEM POLICY
RECOMMENDED BY: A. Gersoff, M.D. (DIO) DATE: 11/14
ORIGINAL POLICY EFFECTIVE DATE: 4/29/14
APPROVED BY: E. Wroblewski, M.D. (VPMA) DATE: 11/14
DATE REVISED:
DATE REVIEWED:11/14