<< Return to Residency Policies and Procedures



GMEC Internal Review Policy


POLICY #: 8240-18


To establish procedures for the GMEC to oversee the internal review process in compliance with ACGME requirements.


The ACGME requires that all institutions which sponsor ACGME accredited GME programs have an organized process of internal review for all its programs.  This process is an important contributor to accomplishing GMEC's oversight responsibility for the residency program(s).  In addition, the Internal Review Committee assists the residency director(s) in preparing for the RRC site survey, by assessing the program's compliance with the ACGME Institutional, Common, and specialty-specific Program Requirements.

It is the Graduate Medical Education Committee's responsibility to designate an Internal Review Committee, whose structure and function shall be in accordance with ACGME standards.  The GMEC identifies the need and schedules the internal review process as stipulated in those standards.  The GMEC receives a written report of the findings, and establishes the actions to be taken to follow-up on the results. 



1.  Timing
The internal review of the residency program must be in process and documented in the GMEC minutes by approximately the midpoint of the accreditation cycle.  The accreditation cycle is calculated from the date of the meeting at which the final accreditation action was taken to the time of the next site visit.  (See ACGME Policies and Procedures, II.B.4)

In the event that the ACGME schedules a survey earlier than originally anticipated (thereby changing the midpoint between surveys), the Designated Institutional Official (DIO) confers with the assigned IRC chair and the residency Program Director to reschedule the commencement of the internal review to the new midpoint.


2.   Committee
The GMEC will appoint an Internal Review Committee (IRC), which will include at minimum:

  • A member of the GME Committee to chair the IRC
  • A faculty member from a program other than the one being reviewed.
  • A resident from a residency program other than the one being reviewed
  • A support staff person to support the process
In addition, the GMEC will have the option to appoint an administrator and/or additional faculty members from outside the program being reviewed.  Under no circumstances may a member of the program undergoing review serve as a member of the Internal Review Committee.  

The Program Director, faculty, and residents from the program being reviewed will be interviewed and provide information to the Internal Review Committee. 


3.   Programs Without Residents
When a program has no residents enrolled at the mid-point of the review cycle, the following circumstances apply:

  • The GMEC must demonstrate continued oversight of those programs through a modified internal review that ensures the program has maintained adequate faculty and staff resources, clinical volume and other necessary curricular elements required to be in substantial compliance with the Institutional, Common and specialty-specific Program Requirements prior to the program enrolling a resident.
  • After enrolling a resident, an internal review must be completed within the second six-month period of the resident?s first year in the program.

4.   Internal Review Content
The Internal Review Committee will review current and historic program documents, and interview program faculty and residents, to assess each program's:

  • Compliance with ACGME Institutional, Common and specialty/subspecialty-specific Program Requirements; including:
    • Professionalism, Personal Responsibility, and Patient Safety
    • Transitions of Care
    • Alertness Management/Fatigue Mitigation
    • Supervision of Residents
    • Clinical Responsibilities
    • Teamwork
    • Resident Duty Hours
  • Educational objectives, and effectiveness in meeting those objectives;
  • Adequacy of educational and financial resources;
  • Effectiveness of the program in addressing areas of noncompliance and/or concern in previous ACGME accreditation letters of notification and previous internal reviews;
  • Effectiveness of educational outcomes in the ACGME general competencies;
  • Effectiveness of the program in using appropriate evaluation tools and outcome measures to assess a resident's level of competence in each of the ACGME general competencies; and,
  • Annual program improvement efforts in:
    • Resident performance using aggregated resident data;
    • Faculty development;
    • Graduate performance including performance of program graduates on the certification examination; and,
    • Program quality. 
      • Residents and faculty must have the opportunity to evaluation the program confidentially and in writing at least annually AND
      • The program must use the results of residents? assessments of the program together with other program evaluation results to improve the program
      • If deficiencies are found, the program should prepare a written plan of action to document initiatives to improve performance in those areas.
      • The action plan should be reviewed and APPROVED BY the teaching faculty and documented in the meeting minutes.
      • The program must document formal systematic evaluation of the curriculum at least annually.
  • Verification of compliance with resident duty hour requirements, and of the program's use of an ongoing and effective monitoring system;
  • Any other issues or concerns which may properly come before the Internal Review Committee

5.    Data Sources
As soon as the membership of the Internal Review Committee is designated, an appointed support staff person begins assembling the materials and data to be used by the committee in their deliberations.  Copies of all data are made available to all committee members no later than two weeks prior to the scheduled Internal Review date.

Materials and data to be used in the review process must include:

  • The ACGME Common, specialty/subspecialty-specific Program, and Institutional Requirements in effect at the time of the review;
  • Accreditation letters of notification from previous ACGME reviews and progress reports sent the respective RRC;
  • Reports from previous internal reviews by the GMEC, along with recommendations and follow-up.
  • Reports from all annual program evaluations, and resultant action plans, conducted since the last ACGME program survey.
  • Results from internal or external resident surveys, if any.
  • Documentation from the Program Director:
    • A copy of the Program Director Information Form to assist the GMEC IRC in asking appropriate questions of the program director, faculty and residents.
    • A written curriculum that incorporates the teaching of the general competencies as specified in the specialty's program requirements.
    • Samples of all evaluation tools used by the program.
    • Evidence that the program has developed and used dependable outcome measures to assess resident performance in the general competencies.
    • Evidence that the program is effective in linking educational outcomes with program improvement. (may be part of AEER)
    • Program Letters of Agreement
    • Sample of materials supplied to the applicants (those invited for an interview) of the program informing them in writing of the terms and conditions of employment and benefits.
    • Conference schedule with documentation of resident and faculty attendance.
    • Written program policies/resident manual.
    • Sample of duty hour monitoring process, and most recent duty hour summaries.

6.    Interviews

The Internal Review Committee conducts interviews with the Program Director, key program faculty members, at least one peer-selected resident from each level of training in the program, and other individuals as deemed appropriate by the Committee. (See "Faculty Interview Guide", and "Resident Interview Guide", attached)


Two weeks prior to the scheduled internal review date, the Internal Review Committee Chair, with the assistance of the assigned support staff person, initiates the process established by the program for resident selection of residents from each post-graduate level of training to represent the resident body in the internal review process.  Similarly, the process to identify and select faculty representatives is initiated.  All those to be interviewed are notified of the intended schedule.


The Program Director, and the Program Coordinator/Administrator meet with the Internal Review Committee separately from faculty and residents.  Faculty and residents may be interviewed by the committee individually or as a group, but resident interviews will be conducted without the presence of the Program Director, Coordinator/ Administrator, and/or program faculty.  The appropriate Interview Guide is completed on each interview.


The interview phase may be conducted as part of, or immediately prior to, the Internal Review Committee meeting.


7.   Internal Review Committee Meeting

The GMEC Internal Review Committee, after review of previously distributed materials and other factual program data, convene to discuss the findings of that review and the information gained during the interviews.  The Committee renders an opinion on:

  • assessment of the Program's progress in successfully resolving issues identified in previous ACGME accreditation surveys, and/or previously conducted Internal Reviews;
  • assessment of the Program's current compliance with ACGME Common and Institutional Requirements and the RRC's Special Program Requirements
  • identification of actions required by the institution and/or the program to achieve accreditation compliance and to achieve established educational objectives
  • identification of actions recommended to the institution and/or the program to enhance or strengthen the quality of the program


8.   Internal Review Report

The Chair of the Internal Review Committee, with the assistance of the support person assigned to the Committee, will produce a written report of the internal review within two weeks of the date the meeting was held.  The format for the report, highlighting the minimum requirements of what must be included, is attached.


The report is reviewed with the Program Director prior to presentation to the GMEC, but no changes to the findings of the Internal Review Committee are made.


The report is reviewed by the GMEC at its next regularly scheduled meeting.  The attendance of the Program Director (or an appropriate designee) is expected.  The Program Director may address any perceived errors of fact in the report at that time.


Any areas of noncompliance are identified, and appropriate action is recommended.  The DIO will work with the Program Director to develop a plan of action.  A six-month progress report is required of the program, indicating how the program is addressing each of the actions recommended by the GMEC.  That progress report is reviewed at the next regularly scheduled GMEC meeting.  If the report is not accepted by the GMEC as evidence of adequate progress in the identified actions, the GMEC will request an additional progress report (at a time interval identified by the GMEC), or may recommend further intervention to assure program compliance.


The DIO and GMEC will continue to monitor the response by the program to actions recommended by the GMEC until all concerns have been resolved.


NOTE: The Sponsoring Institution must submit the most recent internal review report for each training program as a part of the Institutional Review Document (IRD). If the institutional site visitor simultaneously conducts individual program reviews at the same time as the institutional review, the internal review reports for those programs must not be shared with the site visito






APPROVED BY: E. Wroblewski, MD DATE: 2/05

DATE REVISED: 2/08, 8/11, 3/12 DATE REVIEWED: 2/08, 8/11