Internal Review Process


As required by the Accreditation Council for Graduate Medical Education (ACGME), all graduate medical education training programs (residency and fellowship) at UTHSC-H undergo a periodic internal review as described in the ACGME "Essentials of Accredited Residency Programs." The review is conducted under the guidance of the Internal Review Coordinator. The Internal Review Executive Committee (IREC), a subcommittee of the Graduate Medical Education Committee (GMEC) prepares and presents the Internal Review Report to the GMEC. The GMEC reviews the final report of each Internal Review and makes recommendations if indicated. Internal reviews must be conducted by the mid-point between ACGME site visits.
IRC

I. Internal Review Executive Committee


The Internal Review Executive Committee includes (a) at least two faculty members from the GME Committee, who may also be Program Directors, (b) at least two residents, (c) a Medical Educator from the Office of Educational Programs, and (d) a representative from the Office of Graduate Medical Education.

The IREC includes (a) at least two faculty members from the GME Committee, who may also be Program Directors, (b) at least two residents, (c) a Medical Educator from the Office of Educational Programs, and (d) a representative from the Office of Graduate Medical Education.

The IREC prepares Internal Review Reports of all Residency and Fellowship Programs at the midpoint between RRC Site Visits in accordance with the ACGME Institutional Requirements.

For each Internal Review, the IREC appoints:
  • faculty members outside of the committee and the program being reviewed to interview the Program Director and a representative number of faculty from the program,
  • residents to interview a representative number of residents from each PGY level in the program being reviewed.

  • The Interviewers are provided with an Interview Guide to follow for the interview, as well as a list of areas to explore more closely.
    The Internal Review Documents will be available to the IREC and the Interviewers.

II. Internal Review Questionnaire

The IREC uses the ACGME Program Information Form (PIF) as the Internal Review Questionnaire. The Internal Review Notice is sent to the Program Director at least six months prior to the scheduled midpoint. The Program Director is asked to provide a list of all faculty members and residents from each level of training. The IREC will choose the faculty to be interviewed. The Program Director should submit the completed PIF and supporting documents in electronic format to the Internal Review Coordinator no later than the deadline date listed in the Internal Review Notice. Download the IRQ.

III. Internal Review Documents

The Internal Review Documents will be available for all members of the Internal Review Executive Committee and the Interviewers. A document checklist can be downloaded here. The documents include the following:

1. Internal Review ProtocalDownload
2. Copy of ACGME Institutional Requirements, Common Program Requirements and specialty and subspecialty Program Requirements
3. Questionaires: Faculty, Resident & Coordinator
4. Accreditation Letters of notification from previous ACGME reviews and progress reports sent to the respective RRC.
5. Last Internal Review Report
6. Completed PIF (completed by Program Director) with the following attachments.

The Internal Review Executive Committee reviews the IR Documents and assigns interviews with the Program Director, key faculty, residents,and coordinator to discuss the Program. Other individuals deemed appropriate by the Committee may also be interviewed. Discussions may include program innovations, changes that have been made based on the latest ACGME Residency Review Committee (RRC) recommendations, perceived problems related to the Program, and plans for corrections.

At the IREC meeting, the committee reviews and discusses all information pertinent to the Program including the Internal Review Resident Questionnaire and the IR Document List. The IREC assesses the following:
  • compliance with ACGME Program and Institutional Requirements;
  • the effectiveness of the Program in addressing previous ACGME citations or concerns, and/or previous GMEC concerns;
  • the effectiveness of the Program in meeting its program goals and objectives;
  • the adequacy of available educational and financial resources to support the Program;
  • The effectiveness of the program in defining the specific knowledge, skills and attitudes required, and in providing educational experiences for the residents to demonstrate competency in the following areas: patient care skills, medical knowledge, interpersonal and communications skills, professionalism, practice-based learning, and systems-based practice;
  • the program's use of evaluation tools to ensure that the residents demonstrate competence in each of the six areas;
  • the development and use of dependable outcome measures by the program for each of the general competencies; and
  • the effectiveness of the Program in implementing a process that links educational outcomes with program improvement.
The IREC also addresses the following topics assessed during the interview/survey process:
  • the administration of the program;
  • the quality of the educational program;
  • resident performance
  • faculty development activities
  • resident participation in QA activity;
  • supervision and duty hours;
  • conferences and scholarly activity;
  • resident, faculty and program evaluation;
  • the adequacy of support services/facilities at affiliated hospitals;
  • institutional support for the program;
  • the quality of residents in the program; and
  • strengths and weakness of the program.

IV. Internal Review Report


Based on the Interviewers' reports, a designee of the IREC prepares a draft of the Internal Review Report (IRR). It is approved by the IREC and is sent to the Program Director, DIO and the Senior Associate Dean for Educational Programs for review. A designee of the IREC will present the IRR to the GMEC. The Program Director is invited to respond to the report and to attend the GMEC meeting when the report is formally presented and discussed. The Department Chair is also invited to the GMEC meeting. A copy of the final report is sent to the Program Director, the Department Chair, and to the Dean of the Medical School. A follow up written report may be requested by the GMEC to assure the program's progress in complying with the IREC's recommendations.
Jacqueline Brooks
is the Internal Review Coordinator and will be happy to answer any questions related to the Internal Review Process.