GMEOC Internal Review

1. GMEOC Internal Review Refresher for Review Participants on Process & Roles August 19, 2009

2. Goals of Revised Process • Ease burden on primary reviewer • Spread workload across four roles • Ensure appropriate accountability • Effectively prepare program for site visit • New templates, interview scripts • Ensure effective documentation for ACGME • Fewer citations

3. Four roles • Primary Reviewer (Program Director) • Secondary Reviewer (Program Director or Education Manager) • Administrative Reviewer (GME or Coordinator) • Resident Reviewer Primary Reviewer determines how team will communicate between team members to complete report

4. Process • Programs must be visited within 2 months of its mid-cycle from last date of accreditation • Dr. Getto’s office sends notification of Internal Review Visit w/2-3 optional dates selected by the Review Team to the Director whose Program is being reviewed • 2-3 hour mandatory meeting is scheduled 5-6 months out and all team members notified • Program being reviewed submits to GME Office: • Common & Specialty/Subspecialty PIF • Other required Program Documentation • Competency Chart • All reviewers receive materials 2-3 months in advance of GMEOC deadline for report

5. ACGME-Required Interviews • Meeting w/Director & Coordinator (90 minutes) • Faculty may be included in this meeting • Meeting w/Residents (90 minutes) • Number varies but must be representative of program • May be led by Resident Reviewer • Meeting w/at least one Faculty is essential • May be held at meeting w/Director or at a Section meeting • Faculty member must be interviewed no minimum standard • All four Reviewers should be included in all meetings when possible • Meeting w/Coordinator to review documentation (90 minutes) • Audit of Program Policies • Review of Resident/Fellow Portfolios

6. Tips on Successful Process • Effective communication among team members critical to complete report • Minimize confusion over who has which portion of the Checklist • Submit to Primary Reviewer for collation • Cross-check of data between reviewers • Draft report and template sent by Primary Reviewer to Program Director for review • Correct inaccuracies • Program gives courtesy feedback only— otherwise may experience “review creep” • Final report and template sent to GME Office 2 weeks before GMEOC meeting • Won’t get on agenda if otherwise • Timeliness ensures UWHC meets ACGME required timeframe

7. Questions? • Feel free to ask for assistance • Program Documentation—Jeanne Sarbacker 262-8399 • Program Requirements or Review Process—Anne Gravel Sullivan 262-5512