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.
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:
|Concerns identified from internal surveys|| Annual ACGME Resident Survey
|Concerns communicated to the GME office or QAS by Residents or faculty||Annual ACGME Faculty Survey
|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||
|Documents||SPR Work Plan||
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
- 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
- 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.
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
- Table of Contents
- ACGME Competencies
- Eligibility & Selection
- Agreement of Appointment
- Confidential Reporting
- GME Policies
- Academic Improvement Policy
- Affiliation Agreement & Program Letters of Agreement Policy
- Appeal of Disciplinary Action Policy
- Disaster Procedure
- Disciplinary Action Policy
- Domestic and International Off-Site Rotation Policy
- Eligibility & Selection Policies
- Evaluation Policy
- Extreme Emergent Situation Policy
- General Grievances Policy
- Governance of Shared Resources Policy
- Inbound Resident Rotators Policy
- Leave of Absence Policy
- Medical Licensing Policy (USMLE) (COMLEX)
- Moonlighting Policy
- Permanent Complement Increase Request
- Program Closure and Reduction Policy
- Resident Agreement of Appointment Policy
- Resident Learning Environment Policy
- Resident Promotion Policy
- Resident Responsibilities Policy
- Resident Stipend Policy
- Resident Supervision Policy
- Resident Transfer Policy
- Restrictive Covenant Policy
- Review, Approval and Signature Policy
- Special Program Review Policy and Protocol
- Time Lost from Residency
- Transitions of Care Policy
- Well-Being Policy
- Work Hour Policy
- Institutional Policies