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

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

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

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

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

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

Questions? Feel free to ask for assistance  Program Documentation—Jeanne Sarbacker  Program Requirements or Review Process—Anne Gravel Sullivan