I.B.6. The GMEC must demonstrate effective oversight of underperforming programs through a Special Review process. (Core)
I.B.6.a) The Special Review process must include a protocol that: (Core)
I.B.6.a). (1) establishes criteria for identifying underperformance; and, (Core)
I.B.6.a). (2) results in a report that describes the quality improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes. (Core)
To define underperforming ACGME-accredited residency and fellowship programs
To define the GMEC special review processes
To define methods to oversee and resolve the issues
The GMEC will establish criteria for identifying program underperformance, develop protocols to use for special reviews and provide reports that describe the quality improvement goals and corrective actions that the program will use and the process that the GMEC will use to monitor outcomes.
The GMEC will identify underperformance through the following established criteria, which may include, but are not limited to, the following:
Loss of major education necessities
Evidence of scholarly activity (excluding typical and expected departmental presentations)
Board pass rate – acceptable by ACGME specialty standards
Case logs/Clinical experience – acceptable by ACGME specialty-specific standards
Non-compliance with responsibilities
Inability to demonstrate success in the CLER focus areas
Inability to meet established ACGME common and program specific requirements
Notification from RRC requests for progress reports and site visits, unresolved citations or new citations or other actions by the ACGME resulting from annual data review or other actions
A special review will occur when:
The Program Oversight Subcommittee will schedule a Special Review within 45 days of a program’s being identified as underperforming.
The Special Review Committee will include the Chair and/or Vice Chair of the Program Oversight Committee acting as Chair of the Special Review Committee, an administrative member of the GME Committee, a staff member from the GME Office and, as determined by the DIO or designee, faculty members and residents or fellows who are not members of the program under review.
The members of the program to be interviewed should include, but are not limited to, the program director, other key faculty members and peer selected residents/fellows. The Chair of the department and other individuals as determined by the Program Oversight Committee also could be interviewed.
The Program Oversight Subcommittee will determine materials and data to be used during the Special Review.
The Program Oversight Subcommittee will conduct the special review through review of materials, data and other information provided by the program and through interviews with identified individuals.
The Program Oversight Subcommittee will prepare a written report to be presented to the GMEC for review and approval. At a minimum, the report will contain:
Monitoring of Outcomes
The GMEC will monitor outcomes of the Special Review by documenting discussions and follow up in the GMEC minutes.