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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, 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
The QAS assesses which type of SPR is required to address the identified concerns: GME Office SPR Team SPR.

  GME Office SPR Team SPR
Supervision DIO or designee DIO or designee
Reviewers DIO or designee
  • Program Director or faculty member
  • One or more Residents
  • GME Office staff including DIO or Associate DIO
Documents SPR Work Plan
  • Pre-SPR Work Plan
  • SPR Report
  • SPR Work Plan
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.
  • The QAS reviews the work plan and determines if a satisfactory plan is in place to resolve the trigger concern(s) or if additional follow-up or a Team SPR is required.
  • The DOI, 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.
  • The SPR Team reviews the Pre-SPR Work Plan and materials which document elements of the training program under review. (See below)
  • The SPR Team members meet with program leadership and Residents.
  • The SPR Team creates an SPR Report which must be reviewed by the Program Director.
  • The Program Director completes a Work Plan, updating the original Pre-SPR Work Plan and adding additional information as requested within 30 days of receipt of the SPR Report.
  • The QAS reviews the Work Plan and determines if a satisfactory plan is in place to resolve the concerns or if additional follow-up is required.
GMEC Oversight
  • The QAS assigns, reviews, provides feedback on, and approves all work plans and reports generated by the SPR.
  • 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 must take place at the Program Education Committee (PEC) as part of the Annual Program Evaluation (APE) process.
  • Action item progress and outcomes will be tracked 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
  • 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 Report

  • 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

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. (2018). 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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