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Special Program Review Policy and Protocol

I. Purpose of Policy

This policy defines the way in which the Quality & Accreditation Subcommittee (QAS) of the Graduate Education Medical Committee (GMEC) supports program quality improvement efforts for Accreditation Council for Graduate Medical Education (ACGME)-accredited graduate medical education programs at Dartmouth-Hitchcock (D-H).


II. Policy Scope

This policy applies to the Program Directors of ACGME-accredited training programs and to the QAS, GMEC, Designated Institutional Official and Graduate Medical Education (GME) Office staff at D-H.


III. Definitions

Designated Institutional Official (DIO): The individual in a sponsoring institution who has the authority and responsibility for all of the ACGME-accredited GME programs.


GME Office SPR: Special Program Review completed by GME office staff only.


Graduate Medical Education Committee (GMEC): The designated institutional oversight body for all ACGME-accredited residency and fellowship training programs at D-H.


Quality & Accreditation Subcommittee (QAS): The subcommittee of the Graduate Medical Education Committee which is responsible for the development, implementation, and oversight of a quality improvement processes for ACGME-accredited graduate medical education training program at D-H.


Resident: Any physician in an ACMGE-accredited graduate medical education program including 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 representation from outside the section where the program under review resides.



IV. Policy Statement

Initiating a Special Program Review
The following criteria are used by the QAS to trigger an SPR:

Internal Criteria  External Criteria 
At the request of hospital, department, section, director, or program administration   Annual submission of Accreditation Data System (ADS) information:
- Pattern of Resident or faculty attrition
- ACGME Case Log reports indicating minimum  requirements not met by recent graduates
Concerns identified from internal surveys  Annual ACGME Resident Survey
- Two or more categories with less than or equal to 50% compliance on any 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 70%
Concerns communicated to the GME office or QAS by Residents or faculty   Annual ACGME Faculty Survey
- Two or more categories with less than or equal to 50% compliance on any question
- Pattern of significant downward category trends since the last survey
- Survey completion rate below 60%
Concerns identified by the GMEC or its subcommittees Review Committee (RC) request for progress report 
Newly accredited program within first 12 months of starting with first class of Residents  Concern about board pass rates
Programs with no Residents for 24 months

Special Program Review Types
QAS assessment of identified concern determines if an SPR takes the form of either a Team SPR or GME office SPR.

  • Team SPR
    • Team SPRs are charged by the QAS and conducted under supervision of the Designated Institutional Official (DIO) of designee. Teams are composed of:
      • A Program Director or faculty member from outside the section where the program under review resides.
      • One or more Residents from outside the section where the program under review resides.
      • GME office staff including the DIO or the Director of Operations.

    • 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 may include but is not limited to:
      • ACGME Accreditation Data Systems (ADS) summary
      • ACGME Graduate Resident Case Log – Minimums Report (if applicable)
      • Annual Program Evaluation (APE) 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
      • RC Accreditation Requirements
      • Relevant RC 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 concerns and completing a work plan with corrective action. Upon review of the work plan the QAS determines if a satisfactory plan is in place to resolve the trigger concerns 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 RC 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, as necessary.

  • 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 must share the results of the review with Residents and faculty in the program. Discussion of any SPR action items will take place by the Program Education Committee (PEC) as part of the 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 RC 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.

V. References

ACGME Institutional Requirements. (2015). Retrieved from ACGME.org: www.acgme.org/Designated-Institutional-Officials/Institutional-Review-Committee/Institutional-Application-and-Requirements

ACGME Institutional Requirements. (2015). Retrieved from ACGME.org:
www.acgme.org/Designated-Institutional-Officials/Institutional-Review-Committee/Institutional-Application-and-Requirements


D-H Policy ID: 11318

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