Special Program Review Policy and Protocol

I. Purpose of policy

This policy defines the way in which the Quality and 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 and 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, 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 70%

Concerns identified by the GMEC or its subcommittees

Review Committee (RC) request for progress report

Programs with no Residents for 24 months

Board pass rate below RC minimum requirement

 

Program with adverse accreditation status, including:

  • Initial Accreditation with Warning
  • Continued Accreditation with Warning
  • Probationary Accreditation

**For a question with widespread low compliance (below 80%) across programs, the issue will be deferred to the GME Scorecard and addressed at a broader level, and therefore will not be considered in the SPR criteria.

Special Program Review Types
The QAS assesses which type of SPR is required to address the identified concern(s), based on criteria met:

  • GME Office SPR; or
  • Team SPR

The initiation of each SPR type is addressed in the table below, however the QAS has discretion on which SPR type to initiate based on specific criteria and/or level of concern.

 

GME Office SPR

Team SPR

Initiation

Program meets single indicator from internal criteria, or external criteria 1-5

  • Program meets multiple indicators from internal criteria, and/or external criteria 1-5 and/or
  • Program meets indicator from external criteria 6

Supervision

DIO or designee

DIO or designee

Reviewers

DIO or designee

Panel, which should consist of:

  • Program director or associate program director*
  • Resident*
  • Program coordinator*
  • GME Office staff member(s)

*from outside the section where the program under review resides

Documents

  • SPR Work Plan
  • Final Report
  • Pre-SPR Work Plan
  • SPR recommendations report
  • Post-SPR Work Plan
  • Final Report

Review Process

  • The DIO, or delegate, notifies the Program Director identifying the specific area(s) of concern.
  • The Program Director reviews the concern(s) and completes a Work Plan with corrective action, with submission to the QAS within 4 weeks of initial notification.
  • The QAS reviews the work plan and determines if a satisfactory plan is in place to resolve the trigger concern, or if additional follow-up or a Team SPR is required.
  • The QAS completes a final report within two weeks of submission of the post-SPR work plan. The final report will outline quality improvement goals, corrective actions, and the process for monitoring of outcomes.
  • The program provides the QAS with a follow-up progress update 90-days after submission of the post-SPR work plan, and in the next Annual Program Evaluation.
  • The DIO, or delegate, notifies the Program Director identifying the specific area(s) of concern.
  • The Program Director reviews the concern(s) and complete a pre-SPR Work Plan with corrective action, with submission to the QAS within 4 weeks of initial notification.
  • The assigned panel reviews the pre-SPR work plan and materials which document elements of the training program under review. (See documentation list below)
  • The panel meets with program leadership, which should include: Department Chair/Section Chief, Program Director, Assoc. Program Director (if applicable), and Program Coordinator.
  • The Resident member of the panel, DIO (or designee), and GME Office accreditation specialist (or accreditation coordinator) meet with program Residents.
  • The accreditation specialist, with feedback from the assigned panel, creates and SPR recommendations report within 2 weeks of final meetings.
  • The QAS reviews the SPR recommendations report, which is then reviewed by the Program Director.
  • The Program Director completes a post-SPR work plan, updating the original pre-SPR work plan and providing additional information as requested, within 4 weeks of receipt of the SPR recommendations report.
  • The QAS completes a final report within two weeks of submission of the post-SPR work plan. The final report will outline quality improvement goals, corrective actions and the process for monitoring of outcomes.
  • The program provides the QAS with a follow-up progress update 90-days after submission of the post-SPR work plan, and in the next Annual Program Evaluation.

GMEC Oversight

  • The QAS assigns, reviews, provides feedback on, and approves all work plans and reports generated by the SPR process.
  • The QAS reports to the GMEC as required and at least quarterly.

Sharing Findings

The Program Director must share the results of the review with Residents and faculty in the program.

  • Discussion of SPR action items at the Program Education Committee (PEC) must be documented as part of the Annual Program Evaluation (APE) process.
  • Action item progress and outcomes will be tracked by the GME Office and QAS in the APE action items spreadsheet.

Team SPR documentation may include:

  • 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 (if applicable)
  • 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

SPR recommendations report must include

  • Name of the program reviewed
  • Program leadership roster
  • Panel members
  • Last RC site visit date
  • Current accreditation status
  • Start and end dates of the SPR
  • Quality improvement goals

Final report must include

  • Pre-SPR work plan (Team SPR only)
  • SPR recommendations report (Team SPR only)
  • Program defined corrective actions from SPR work plan (GME Office SPR) or post-SPR work plan (Team SPR)
  • Process for GMEC monitoring of outcomes, including timelines

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. (2021). Retrieved from ACGME.org.

D-H Policy ID: 11318