GME Annual Institutional Review Policy (AIR)
DEPT: MEDICAL EDUCATION
POLICY #: 8240.21
GOAL
To establish a written protocol for the Annual Institutional Review in accordance with ACGME requirements.
POLICY
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.
COTTAGE HEALTH POLICY
RECOMMENDED BY: A. Gersoff, M.D. (DIO) DATE: 4/14
ORIGINAL POLICY EFFECTIVE DATE: 4/22/14
APPROVED BY: E. Wroblewski, M.D. (VPMA) DATE: 1/18
DATE REVISED: 1/18
DATE REVIEWED:
