Department of Medical Education
GE 20

Procedure

1. The Department of Medical Education will conduct Internal Reviews of all the Residency Programs. The Internal Reviews will take place at approximately the midpoint of their accreditation cycle.
2. The review will assess the educational quality of the program being reviewed, and will follow the attached protocol approved by the Education and Research Committee/GMEC.
3. The review will also focus on whether the program complies with institutional policies and procedures as well as with the requirements of the relevant accrediting agencies. The review will include meetings with the Program Directors, faculty and residents.
4. The review will also evaluate the resources available to the program.
5. The Internal Reviews will be presented and discussed at the Education and Research Committee/GMEC.
6. The programs will report back, between three (3) and nine (9) months after the Internal Review is adopted by the Education and Research Committee, with details on the implementation of the recommendations, if appropriate and as requested by the Committee.

Internal Review Protocol

It is the policy of the Department of Medical Education at Illinois Masonic Medical Center, in accordance with the Institutional Requirements of the Accreditation Council for Graduate Medical Education (ACGME), to conduct Internal Reviews of all the Residency Programs.

The protocol used to conduct such reviews is described in this document.

Internal Review Committee

An Internal Review Committee (IRC) is appointed by the Director of Medical Education in accordance with ACGME requirements and with the concurrence of the Education and Research Committee/GMEC. It is the task of the IRC to:

• review the background information provided to it
• interview the program director, faculty, and residents in the program and individuals outside the program as deemed appropriate
• prepare and present a review of their findings for review by the Education and Research Committee/GMEC.

Background Materials

The IRC receives and reviews the following background material:

• The Department of Medical Education Internal Review Policy and Protocol
• The ACGME Institutional Requirements and Common Program Requirements (if appropriate)
• The ACGME, ADA, AOA or CPME Program Requirements
• The Graduate Medical and Dental Education Policies and Procedures
• The reports from the two previous Internal Reviews
• The reports from the annual Exit Interviews since the last Internal Review
• The last program accreditation letter.
• The last institutional accreditation letter.

Topics to be addressed

The IRC, through the interviews and review of appropriate documentation, obtains the information necessary for the Education and Research Committee/GMEC to assess:

• The compliance of the residency program with each of the Institutional Requirements and Program Requirements
• The educational objectives of the program
• The effectiveness of the program in meeting its educational objectives
• The adequacy of available educational and financial resources to meet the educational objectives of the program
• The effectiveness of the program in addressing citations from previous letters of accreditation and previous internal reviews
• the effectiveness of the program in defining, in accordance with Program and Institutional Requirements, the specific knowledge, skills, attitudes, and educational experiences required for the resident to achieve competence in the following: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice;
• the effectiveness of the program in using evaluation tools developed to assess a resident's level of competence in each of the six general areas listed above;
• the effectiveness of the program in using dependable outcome measures developed for each of the six general competencies listed above; and,
• the effectiveness of the program in implementing a process that links educational outcomes with program improvement.

Final Report

The IRC prepares a written report using the attached form addressing all the items listed in the previous section. It should include sufficient documentation or discussion of the specialty's or the subspecialty's Program Requirement and the Institutional Requirements to demonstrate that a comprehensive review was conducted and was based on internal review protocol. The report is presented to the Education and Research Committee/GMEC. The Education and Research Committee/GMEC accepts or amends the report. If the report identifies major deficiencies, the Education and Research Committee/GMEC may requests a follow up report(s) from the Program Director in a three to nine month period.

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