GME Annual Institutional Review Policy (AIR)

POLICY #: 8240.21


To establish a written protocol for the Annual Institutional Review in accordance with ACGME requirements.


1. The GMEC must demonstrate effective oversight of the Sponsoring Institution’s (Santa Barbara Cottage Hospital) accreditation through an Annual Institutional Review (AIR).

2. The GMEC must identify institutional performance indicators for the AIR (see below).

3. The DIO must annually submit a written executive summary of the AIR to the Governing Body. The written executive summary must include:

A) A summary of institutional performance on indicators for the AIR; and,

B) Action plans and performance monitoring procedures resulting from the AIR.

4. Annually, members of the GMEC will conduct and present the AIR. If a sub-committee of the GMEC is formed to conduct the review, that sub-committee will include at least one resident.

5. Institutional Performance Indicators

A) The AIR Report must include:

i. The most recent ACGME institutional letter of notification (when available);

ii. Results of ACGME surveys of residents/fellows and core faculty

iii. Each of its ACGME-accredited programs’ ACGME accreditation information, including accreditation statuses and citations.

B) The AIR Report may include review and discussion of:

i. GMEC responsibilities (from Institutional Requirements)

ii. Last ACGME accreditation letter

iii. CLER report (when available)

iv. Last annual report to Governing Body

v. In-house program survey results

vi. Use of data in decisions

vii. APE results and data use

viii. Clinical Experience and Education (Work Hour) compliance

ix. Policies (specifically Clinical Experience and Education (Work Hours), Supervision, Transition of Care, etc.)

x. Board passage rate data

xi. Graduate feedback (when available)

xii. Program Goals & Objectives

xiii. Resident QI and Patient Safety Projects

xiv. Selected ADS data

xv. Rotation schedule/block

xvi. Changes since last CLER or self-study visit

xvii. ACGME Citations/Responses xviii. Residency alignment with Institution mission

C) The AIR Report will include a discussion of the 6 CLER Focus Areas:

i. Patient Safety

1. When available, the AIR committee will review

a. Number of resident recorded events

b. Training sessions

c. Open/closed recorded events

d. Risk meetings

e. Residents ability to report without fear

ii. Quality Improvement; reducing disparities

1. When available, the AIR committee will review

a. Current projects: title, residents/faculty, status, outcome

b. Potential projects: ideas, who may be interested, options

c. Didactic sessions: Title, date, audience, feedback

d. Institutional health disparity goals: Results/outcomes of projects

iii. Supervision

1. When available, the AIR committee will review

a. Number of lapses

b. Procedure/protocol for reporting lapses

c. Communication channels

d. “Credentialing” database, who can do what, availability to support staff, training

iv. Transition in care

1. The AIR committee may conduct a GME Audit/Observation looking for standardized approach

v. Clinical Education and Experience

1. When available, the AIR committee will review

a. Clinical Education and Experience statistics

b. Clinical Education and Experience policies

c. Documented education, for residents/fellows and faculty, on management and mitigation

vi. Professionalism

1. When available, the AIR committee will review

a. Timeliness of assignment completion (faculty & resident evaluations, other assignments)

b. Reports of resident mistreatment

c. Other breaches of professionalism

6. The AIR committee will prepare a written plan of action to document initiatives to improve performance in one or more of the areas listed above as well as delineate how they will be measured and monitored.  The action plan will be reviewed and approved by the GMEC and documented in meeting minutes. The DIO will submit a written annual executive summary of the AIR to the Governing Body.


RECOMMENDED BY: A. Gersoff, M.D. (DIO) DATE: 4/14
APPROVED BY: E. Wroblewski, M.D. (VPMA) DATE: 1/18, 1/21