College of MedicineGraduate Medical EducationPoliciesGME Special Review Policy and Protocol

GME Special Review Policy and Protocol

Applies to: WSU Elson S. Floyd College of Medicine Graduate Medical Education (GME) Trainees at all accredited and non-accredited graduate medical education training programs (i.e. residency or fellowship) sponsored by the college of medicine

Date: July 19, 2022

1.0 Policy Statement

It is the WSU College of Medicine GME policy to maintain oversight and continually evaluate all sponsored programs by conducting a Special Review of underperforming GME programs.

2.0 Definitions

Accreditation Council for Graduate Medical Education (ACGME)

The ACGME is responsible for the accreditation of post-MD medical training programs within the United States.

Annual Program Evaluation (APE)

Written documentation of a formal, systematic evaluation of the curriculum and overall residency/fellowship program submitted, through the program via the Program Evaluation Committee (PEC), to the GMEC annually.

Designated Institutional Official (DIO)

The individual in a sponsoring institution who has the authority and responsibility for all of that institution’s ACGME-accredited programs.

Program Director

The individual designated with authority and accountability for the operation of a residency/fellowship program.

Sponsoring Institution

The organization (or entity) that assumes the ultimate financial and academic responsibility for a program of GME. The sponsoring institution has the primary purpose of providing educational programs and/or health care services (e.g., a university, a medical school, a hospital, a school of public health, a health department, a public health agency, an organized health care delivery system, a medical examiner’s office, a consortium, an educational foundation).

Trainee

A physician in training at an ACGME accredited graduate medical education program, the term includes Interns, Residents, and Fellows or other trainee enrolled in an educational program whose education falls under the purview of the College of Medicine Office of Graduate Medical Education.

3.0 Responsibilities

GMEC and DIO

4.0 Procedures

The College of Medicine Graduate Medical Education Committee (GMEC) provides effective oversight of underperforming programs through a Special Review process. The Special Review process includes a protocol that establishes criteria for identifying underperformance and results in a report that describes the quality improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes. As required by the Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements, the GMEC has the responsibility for the Special Review of all training programs that are determined to be underperforming. The ultimate goal of the Special Review process is to improve the quality of College of Medicine GME training programs.

If underperformance is found, A Special Review is initiated regarding the program’s educational infrastructure and/or general program operations. This policy will outline a protocol to:

  • Establish criteria for identifying underperformance.
  • Address the procedure to be utilized when a program undergoes a Special Review
  • Develop a report that describes the quality improvement goals, corrective actions, and process(es) whereby the GMEC and/or designated sub-committee will monitor outcomes.

A Special Review is performed to evaluate an underperforming clinical training program conducted by the Sponsoring Institution via the designated institutional official (DIO) and the GMEC as per the ACGME Institutional Requirements (I.B.6.). This process is designed to oversee and critically assess the quality of educational and clinical training experience provided to the Trainee, to oversee their compliance with ACGME Institutional, Common, and Program-specific Requirements, and to guide programs in making corrective actions as necessary.

Each Special Review will assess one or more of the following:

  • Compliance with the Common, specialty/subspecialty-specific Program, and Institutional requirements;
  • Educational objectives and effectiveness in meeting those objectives;
  • Effectiveness of program in helping trainees reach Milestone goals;
  • Effectiveness in addressing areas of non-compliance and concerns in previous ACGME accreditation letters of notification
  • Effectiveness of educational outcomes in the ACGME general competencies;
  • Faculty engagement and commitment to education
  • Trainee self-assessment
  • Effectiveness in using evaluation tools and outcome measures to assess a trainee’s level of competence in each of the ACGME general competencies;
  • Annual Program Evaluation; and,
  • Trainee performance relative to the milestones.

Criteria used to identify an underperforming program, requiring initiation of a Special Review

Internal Criteria

  • Concerns identified and communicated to the GME Office by Trainees or faculty
  • Concerns identified that include the department chair or program director
  • Concerns identified on internal program surveys
  • Program-specific issues identified by the GMEC or its subcommittees
  • At the request of hospital, department, or program administration
  • Failure to submit GMEC required data on or before identified deadlines

External Criteria

  • Program accreditation status of Initial Accreditation with Warning
  • Program accreditation status of Continued Accreditation with Warning
  • Adverse accreditation status as described by ACGME policy
  • Concerns identified related to the annual ADS update information submitted by programs:
    • Board pass rate below the minimum required by the supervising RRC
    • A pattern of trainee attrition
    • A pattern of faculty attrition
    • Case log data from the ACGME of recent graduates indicating that minimum requirements are not being met
  • Concerns identified on the annual College of Medicine GME and/or ACGME resident/fellow surveys
  • Concerns identified on the annual College of Medicine GME and/or ACGME faculty surveys
  • ACGME request for progress report related to concerns identified on the Resident/Fellow or Faculty Survey
  • Failure to submit ACGME required data on or before identified deadlines

Process for Review

All training programs sponsored by College of Medicine can be subject to a Special Review if GMEC determines that a review is warranted. A special review can be requested by the DIO, COM Dean, Chair of the GMEC outside of the established criteria. A special review will occur when:

  • A program has met three or more of the criteria established to initiate the review, (focused to full review)
  • A severe and unusual deficiency in any one or more of the established criteria (focused to full review)
  • Receipt of a significant complaint against the program, (focused to full review)
  • As periodically determined by the DIO

Notification of the Special Review will be sent to the program director approximately 6-8 weeks in advance when possible.

Special Review Committee (SRC) Membership

The SRC is a sub-committee of GMEC. For each Special Review, the DIO will appoint a Special Review Committee (SRC). The SRC will consist of at a minimum 4 members to include:

  • At least two faculty members from the GMEC, not from the program being reviewed (one of whom will be designated as the Chair of the SRC),
  • The Institutional GME Coordinator
  • Other faculty members or administrators, as recommended by the GMEC Chair, Vice-chair, or DIO.
  • The DIO, and/or Associate DIO.
  • At least one trainee, not within the program being reviewed. (optional)

Review Committee Responsibilities

Specific duties for the SRC members include:

  • Participation in initial orientation meeting regarding the SRC
  • Review all materials pertinent to the review, prior to the review process
  • Participate in interviews with pertinent individuals, including:
    • The program director and associate program director(s) as applicable;
    • An appropriate representation of core clinical faculty up to 10 individuals involved in the program’s education and all applicable non-physician faculty;
    • Program’s Trainees, if less than 8 total, all should be interviewed; 8 or more, at least 50% of the Trainees distributed across each level of training in the program;
    • Other individuals deemed appropriate by the committee.
  • Draft a report, including a written summary of the interviews
  • Review final draft of the report
  • Participate in the presentation of the final report to GMEC

Special Review Materials

Materials and data to be used in the Special Review process may include the following, and will be determined by the Chair of the SRC:

  • 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, self-studies, and progress reports sent to the respective RRC;
  • Reports from previous special reviews of the program as applicable;
  • Trainee’s files (including past graduates for the most recent two years);
  • Goals and objectives for each level of training and for each major rotation, which include the ACGME core competencies;
  • Evaluations for Trainees, faculty, and program;
  • A copy of the most recent Annual Program Evaluation (APE);
  • Policy on selection and advancement of Trainees;
  • Summative letter or form for each trainee, stating that he/she is competent to practice independently;
  • Policy on moonlighting and Moonlighting Activity Forms approved by the program director;
  • Self-evaluation of Trainees using specialty specific Milestones
  • Employee/Faculty survey from the Program’s Department
  • Written description of supervisory lines of responsibility for the care of patients;
  • Policy on Clinical and Educational Work Hours (formerly Duty Hours), method of monitoring these hours, and on-call schedules;
  • Policy concerning the effect of leaves of absence on satisfying the criteria for completion of the residency program;
  • Policy on patient hand-offs;
  • Rotation schedules;
  • Conference schedules. Match results and Board scores; and,
  • Results from internal or external Trainee surveys.

Special Review Report

The SRC will prepare a report of its findings. This report must clearly state which program was reviewed and the date and location of the review. It must also identify each member of the view committee, and each Trainee and Faculty member interviewed.

The following assessments may be made as part of the report:

  • Assessment of the training program’s compliance with the institutional requirements;
  • Assessment of the training program’s compliance with each of the program requirements;
  • Assessment of the educational objectives of the program;
  • Assessment of the adequacy of available educational and financial resources to meet these objectives;
  • Assessment of the effectiveness of the program in meeting its objectives;
  • Assessment of the effectiveness of the program in addressing citations from previous ACGME letters of accreditation and/or previous special reviews;
  • Assessment of the effectiveness of the program in defining the specific knowledge, skills, and attitudes required and in providing the educational experience for the Trainees to successfully complete the Milestones;
  • Assessment of the effectiveness of the program in using evaluation tools developed to assess a Trainee’s level of competence in program Milestones;
  • Assessment of the program in using dependable outcome measures developed for each of the program Milestones;
  • Assessment of the program in implementing a process that links educational outcomes with program improvement;
  • A list of the areas of noncompliance or any concerns or comments from the Special Review Committee and a list of recommendations which must be addressed by the program director.

The report must identify any areas of non-compliance, provide recommendations for improvement, and provide a proposed timeline for remediation.

GMEC Review and Follow-up

After the SRC has approved the report, it is sent to the Chair of the GMEC for presentation at the following GMEC meeting. A representative on the SRC will make a brief presentation to GMEC emphasizing the program’s compliance with the ACGME Institutional and Program Requirements, as well as recommendations for improvement if applicable.

The GMEC may request that the program director attend the GMEC meeting and participate in the discussion regarding the special review. The GMEC will discuss and review the report and the program director’s response. The GMEC may request additional information or follow-up action from the program director.

The Chair of the GMEC will draft a letter (signed by the DIO and the Chair) that will communicate the GMEC’s decisions to the program director. The program will be instructed to provide an action plan within 4 weeks of receiving the report. An updated response and progress report must be presented to the GMEC six months after the date of the special review. This due date may be moved up if the program is found to be in substantial non-compliance of institution and/or ACGME standards. This communication will include a requirement that all deficiencies identified by the special review report be rectified by the date specified in the letter. Once received, the updated response will be presented to the GMEC for final approval.

The DIO and GMEC will monitor the response by the program to actions recommended by the SRC in this report including appropriate updates on the corrective action plan. Areas of concern and citations will remain on the GMEC agenda until fully resolved.

5.0 Related Policies

  • GME Grievance and Due Process
  • GME Evaluation and Promotion

6.0 Revision History

GMEC Approval: April 25, 2018
Revision/Review Date(s): June 15, 2021, July 19, 2022

Responsible Office: WSU College of Medicine Sponsoring Institution
Policy Contact: Designated Institutional Official
Supersedes: N/A