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Special Program Review Policy and Protocol

I. Purpose of Policy

The Dartmouth-Hitchcock (D-H) Graduate Medical Education Committee (GMEC) is responsible for the development, implementation, and oversight of a quality improvement process in the form of a Special Program Review (SPR) for ACGME-accredited graduate medical education training programs. The purpose of the SPR is to support program quality improvement efforts in areas judged noncompliant with Accreditation Council for Graduate Medical Education (ACGME) regulations. SPRs are coordinated by the GMEC Quality and Accreditation Subcommittee (QAS) in collaboration with the D-H Graduate Medical Education (GME) Office.

II. Policy Scope

This policy applies to all D-H ACGME-approved residency and fellowship programs.

III. Definitions

Resident: Any physician in an accredited graduate medical education program, including interns, residents, and fellows.

Special Program Review (SPR): Mechanism for GMEC oversight of under-performing ACGME accredited graduate medical education training programs.

Team SPR: Special Program Review comprised of a team that includes faculty and resident from outside the section where the program under review resides.

GME office SPR: Special Program Review done by GME office staff only.

IV. Policy Statement

  • Initiating a Special Program Review
    • The following criteria are used by the QAS to trigger an SPR:
      • Internal Criteria:
        • At the request of hospital, department, or program administration
        • Problems identified from internal surveys
        • Concerns communicated to the GME office or QAS by residents or faculty
        • Issues identified by the GMEC or its subcommittees
        • Routine review of newly accredited program within first 12 months of starting with first class of residents
        • Review of programs with no residents for 24 months

      • External Criteria:
        • Annual Accreditation Data System (ADS) information submitted by programs:
          • Pattern of resident or faculty attrition
          • ACGME Case Log reports indicating minimum requirements not met by recent graduates

        • Annual ACGME Resident Survey
          • Two or more categories with less than or equal to 50% compliance on any category question
          • A pattern of significant downward category trends since the last survey
          • A rating of less than 4.0 in the category “Overall Evaluation”
          • Survey completion rate below the 70%

        • Annual ACGME Faculty Survey
          • Two or more categories with less than or equal to 50% compliance on any category question
          • Pattern of significant downward category trends since the last survey
          • Survey completion rate below the 60%

        • Residency Review Committee (RRC) request for progress report

        • Concerns about board pass rates

  • Special Program Review Types
    • QAS assessment of identified issues determines if an SPR takes the form of either:
      • Team SPR
      • GME office SPR

  • Team SPR
    • Team SPRs are charged by the QAS and conducted under supervision of the Designated Institutional Official (DIO). Teams are led by a program director or faculty member from outside the section where the program under review resides. The team includes at least one resident from outside the section. GME office staff supports each review team.

    • The GME office prepares a set of materials to document elements of the training program under review. Materials are electronically archived by the GME office and made available to team members. Documentation includes:
      • ACGME ADS summary
      • ACGME Graduate Resident Case Log – Minimums Report (if available)
      • Annual Program Evaluation reports for the past two academic years
      • Previous SPR Reports and Work Plans
      • ACGME Resident Survey results for past two academic years
      • ACGME Faculty Survey results for past two academic years
      • RRC Accreditation Requirements
      • Relevant RRC correspondence
      • Relevant program policies
      • Most recent board pass rate report for graduates
      • Other materials as necessary

  • GME Office SPR
    • The DIO or delegate notifies the program director identifying specific areas of concern. The program director is responsible for reviewing the issue(s) and outlining a work plan with corrective action. The DIO or delegate meets with the program director to review the report. After confirmed by the DIO or delegate, the written report is reviewed by the QAS. Upon review the QAS determines if a satisfactory plan is in place to resolve the trigger issue(s) or if a Team SPR is required.

  • SPR Report
    • For all SPRs there must be a written report that contains the following:
      • Name of the program reviewed
      • Program leadership roster
      • Review Team roster (Team SPR only)
      • Last RRC site visit date
      • Current accreditation status
      • Start and end dates of the SPR
      • Quality improvement action items
      • Work plan to address action items

  • GMEC Monitoring of Outcomes
    • A work plan addressing corrective measures must be completed by the Program Director and submitted to the GME office within 30 days of SPR closure. The proposed work plan is reviewed and approved by the QAS with feedback.

    • The report and all work plan actions are reflected in the minutes of the QAS. Actions recorded in the QAS minutes are reported to the GMEC for approval. Reports to the GMEC are made as required, but at least quarterly.

    • A progress report of the approved SPR work plan is attached to the Annual Program Evaluation (APE).

  • Sharing SPR Findings with Faculty and Residents
    • In order to complete the review process, the program director shares the results of the review with residents and faculty in the program. Discussion of any SPR action items should take place by the Program Education Committee (PEC) as part of the Annual Program Evaluation (APE) process, with an SPR progress report submitted as an attachment to the APE report.

  • Confidentiality
    • The SPR process is a quality assurance evaluation that is protected pursuant to NH RSA 151 13a and RSA 329:29a. A confidential cover page must accompany reports and work plans, indicating NH RSA 151 13a and RSA 329:29a quality assurance protection. SPR reports and work plans are confidential and are not shared with RRC site visitors. To confirm compliance with this policy document and ACGME institutional requirements, SPR reports are included in the Institutional Review Questionnaire (IRQ) and examined by the ACGME Institutional Review Committee at the time of periodic institutional accreditation evaluation to verify that we are following approved SPR policy, protocol, and procedure.

D-H Policy ID: 11318