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Special Review

 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)

Purpose:

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

Policy:

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.

Procedure:

The GMEC will identify underperformance through the following established criteria, which may include, but are not limited to, the following:

Program attrition

  1. Change in program director more frequently than every 2 years.
  2. Greater than 1 resident/fellow per year resident attrition (withdrawal, transfer or dismissal) over a 2 year period

Loss of major education necessities

  1. Changes in major participating sites
  2. Consistent incomplete resident complement
  3. Major program structural change

Recruitment performance

  1. Unfilled positions over three years

Evidence of scholarly activity (excluding typical and expected departmental presentations)

  1. Graduating residents – minimum of 50% scholarly activity
  2. Faculty (Core) – minimum of 80% scholarly activity

Board pass rate – acceptable by ACGME specialty standards

Case logs/Clinical experience – acceptable by ACGME specialty-specific standards

ACGME surveys

  1. Resident survey – Resident overall dissatisfaction with the program including but not limited to egregious single year issues and issues that extend over more than one year.
  2. Faculty survey –  minimum of 60% completion rate

Non-compliance with responsibilities

  1. Failure to submit milestones data to the ACGME and to the GMEC
  2. Failure to submit data to requesting organizations or GMEC (ACGME/ABMS)

Inability to demonstrate success in the CLER focus areas

  1. Patient Safety
  2. Health Care Quality
  3. Care Transitions
  4. Supervision
  5. Duty Hours, Fatigue Management and Mitigation
  6. Professionalism

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

Special Review:

A special review will occur when:

  1. A program has met three or more of the criteria established to initiate the review, (focused to full review)
  2. A severe and unusual deficiency in any one or more of the established criteria (focused to full review)
  3. There has been a significant complaint against the program,(focused to full review)
  4. The program is applying for accreditation (review of the application) and again approximately one year after the ACGME has accredited the program (full review).
  5. Transferred programs (full review)
  6. As periodically determined by the DIO

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:

  1.  A description of the quality improvement goals to address identified concerns,
  2.  A description of the corrective actions to address identified concerns and
  3. The process for the GMEC to monitor outcomes of corrective actions taken by the program.

Monitoring of Outcomes

 The GMEC will monitor outcomes of the Special Review by documenting discussions and follow up in the GMEC minutes.