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GME Annual Institutional Review Policy (AIR)

POLICY #: 8240.21


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


  • The GMEC must demonstrate effective oversight of the Sponsoring Institution's (Santa Barbara Cottage Hospital) accreditation through an Annual Institutional Review (AIR).
  • The GMEC must identify institutional performance indicators for the AIR (see below).
  • The AIR must include monitoring procedures for action plans resulting from the review.
  • The DIO must submit a written annual executive summary of the AIR to the Governing Body.


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.

Institutional Performance Indicators

The AIR Report must include:

  • Results of the most recent institutional self-study visit (when available)
  • Results of ACGME surveys of residents/fellows and core faculty
  • Letters of Notification of ACGME-accredited programs' accreditation statuses and self-study visits.

The AIR report may include review and discussion of:

  • GMEC responsibilities (from Institutional Requirements)
  • Last ACGME accreditation letter
  • CLER report (when available)
  • Last annual report to Governing Body
  • In-house program survey results
  • Use of data in decisions
  • APR results and data use
  • Duty hour compliance
  • Policies (specifically Duty Hours, Supervision, Transfer of Care, etc)
  • Board passage rate data
  • Graduate feedback (when available)
  • Program Goals & Objectives
  • Resident QI and Patient Safety Projects
  • Selected ADS data
  • Rotation schedule/block
  • Changes since last CLER or self-study visit
  • ACGME Citations/Responses
  • Residency alignment with Institutional mission

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

  • Patient Safety
    • When available, the AIR committee will review
      • Number of resident recorded events
      • Training sessions
      • Open/Closed recorded events
      • Risk meetings
      • Residents ability to report without fear
  • Quality Improvement; reducing disparities
    • When available, the AIR committee will review
      • Current projects: title, residents/faculty, status, outcome
      • Potential projects: ideas, who may be interested, options
      • Didactic sessions: title, date, audience, feedback
      • Institutional health disparity goals: results/outcomes of projects
  • Supervision
    • When available, the AIR committee will review
      • Number of lapses
      • Procedure/protocol for reporting lapses
      • Communication channels
      • "Credentialing" database, who can do what, availability to support staff, training
  • Transition in care
    • The AIR committee may conduct a GME Audit/Observation looking for standardized approach
  • Duty Hours; fatigue management and mitigation
    • When available, the AIR committee will review
      • Duty Hours statistics
      • Duty Hours policies
      • Documented education, for residents/fellows and faculty, on management and mitigation
  • Professionalism
    • When available, the AIR committee will review
      • Timeliness of assignment completion (faculty & resident evaluations, other assignments)
      • Reports of resident mistreatment
      • Other breaches of professionalism

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: 4/14