Special Reviews

Scope

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Policy Statement

The GMEC must demonstrate effective oversight of underperforming programs through a Special Review process. The special review process must include a protocol that establishes criteria for identifying underperformance and results in a timely report that describes the quality improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes.  Any program with a “warning” or other adverse accreditation status must undergo a special review.

As required by the ACGME Institutional Requirements, the Graduate Medical Education Committee (GMEC) has the responsibility for the special review of all residencies that are determined to be underperforming.  As prescribed by the ACGME guidelines, this special review will assess each program’s: 

1. Compliance with the Common, specialty/subspecialty-specific Program, and Institutional Requirements;  
2. Educational objectives and effectiveness in meeting those objectives;
3. Educational and financial resources;
4. Effectiveness in addressing areas of non-compliance and concerns in previous ACGME accreditation letters of notification and previous special reviews; 
5. Effectiveness of educational outcomes in the ACMGE general competencies;
6. Effectiveness of program in helping trainees reach Milestone goals;
7. Effectiveness in using evaluation tools and outcome measures to assess a trainee’s level of competence in each of the ACGME general competencies; and, 
8. Most recent Annual Program Evaluation.

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Reason for Policy

The purpose of this policy is to comply with the Accreditation Council for Graduate Medical Education (ACGME) requirement that the Graduate Medical Education Committee (GMEC) must develop, implement and oversee a process for a Special Review Committee (SRC) for accredited residency and fellowship programs at the Indiana University School of Medicine.

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Procedures

1. Criteria for Initiating a Special Review 
   1. Internal Criteria 
      1. At the request of hospital, department, or program administration; 
      2. Concerns identified and communicated to the GME Office by trainees or faculty in a particular program;  
      3. Failure to submit GMEC required data on or before identified deadlines (example-the Annual Program Evaluation Summary); 
      4.   Program-specific issues identified by the GMEC, GMEC subcommittees, or Annual Program Evaluation review; 
      5.   Concerns regarding trainee or faculty attrition;
      6. Board pass rates;
      7. Recruitment data (if available) and/or Match results.
   2. External Criteria 
      1. Concerns related to the annual WebADS information submitted by programs; 
      2.   Concerns related to the annual ACGME Resident/Fellow Survey; 
      3.   Concerns related to the annual ACGME Faculty Survey; 
      4. Concerns related to citations and areas for improvement on the current ACGME accreditation letter;
      5. ACGME request for progress report related to concerns identified on the Resident/Fellow Survey; 
      6. Accreditation status of “with Warning” or “Probation;"
      7.   Failure to submit ACGME required data on or before identified deadlines.
2. Review Process 

   All residency and fellowship programs sponsored by IU School of Medicine can be subject to a special review by GMEC if the subcommittee determines that a review is warranted.  Notification of the special review will be sent to the program director in advance. 

3. Conduct of Special Review 

   The review will be conducted by a subcommittee appointed by the GMEC.  

4. Review Committee Membership 
   Special review committee members must be drawn from outside the department for the entirety of the review process. Minimum committee membership is three individuals, including the committee chair, at least one program director (or associate program director) and one trainee/. The committee may include non-physician administrators as deemed appropriate. An appropriate balance of faculty, trainees, and any administrators must be maintained. External reviewers may also be included on the review committee as determined by the DIO.  
    
5. Review Committee Responsibilities 
   Committee members are expected to review all provided materials and data in advance of the review.  Interviews with the program director, faculty, and peer-selected trainees from each level of training and individuals outside the program deemed appropriate by the committee will be a component of the special review process.   
    
   

   After the special review takes place, the committee is charged with drafting a report of the review, including a written summary of the interviews.  Special care will be taken to ensure that comments are not attributable to any one participant.

   Additional responsibilities for review committee chairs include providing committee leadership, reviewing the final draft of the review report, and/or participating in the presentation of the review report to the GMEC.

6. Special Review Materials 
   Materials and data used in the review process may include the following, and will be determined by the chair of the special review subcommittee: 
   1. ACGME Institutional Requirements, ACGME Common Program Requirements, and RRC Program Requirements;
   2. Letters of accreditation from previous ACGME reviews and (if applicable) progress reports to the respective RRC;
   3. Reports from previous special reviews of the program and the program director’s response including corrective actions;
   4. List of current house staff and their medical school of graduation with expected graduation or promotion date;
   5. The latest ACGME Resident/Fellow and Faculty Surveys;  
   6. A copy of the most recent Annual Program Evaluation.
7. Document Review 
   The special review committee will conduct an audit of program files which may include the following:
   • Program letters of agreement;
   • Trainee files from each level of training (including past graduates for the most recent two years);
   • A sample of Goals and objectives from one rotation for each level of training, which include the ACGME core competencies;
   • Evaluations of trainees, faculty, and program;
   • A copy of the most recent Annual Program Evaluation (APE);
   • Policy on selection and advancement of trainees;
   • Sample of a summative letter or form stating that he/she is competent to practice independently;
   • Policy on moonlighting and Moonlighting Activity Forms approved by the program director;
   • Supervision Policy;
   • Policy on work hours, method of monitoring work hours, rotation schedules, and on-call schedules;
   • Time Off Work and Leave of Absence policy;
   • Policy on transition of care;
   • Rotation schedules;
   • Conference schedules.
   • Other materials as requested by the review committee.
8. Report 

   The Special Review Subcommittee will prepare a draft report of its findings.  This report must clearly state which program was reviewed and the date and location of the review.  It must also identify each member of the view committee, and each resident/fellow and faculty member interviewed.   
   The following assessments may be made as part of the report: 

   1. Assessment of the residency program’s compliance with the institutional requirements;
   2. Assessment of the residency program’s compliance with each of the program requirements;
   3. Assessment of the educational objectives of the program;
   4. Assessment of the adequacy of available educational and financial resources to meet these objectives;
   5. Assessment of the effectiveness of the program in meeting its objectives;
   6. Assessment of the effectiveness of the program in addressing citations from previous ACGME letters of accreditation and previous special reviews;
   7. Assessment of the effectiveness of the program in defining the specific knowledge, skills, and attitudes required and in providing the educational experience for the trainees to successfully complete the Milestones;
   8. Assessment of the effectiveness of the program in using evaluation tools developed to assess a trainee's level of competence in program Milestones;
   9. Assessment of the program in using dependable outcome measures developed for each of the program Milestones;
   10. Assessment of the program in implementing a process that links educational outcomes with program improvement;
   11. A report that describes the quality improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes.

   The report must identify any areas of non-compliance, and provide a proposed timeline for remediation. 

9. GMEC Review and Follow-up 

   After the special review subcommittee has approved the draft report, the special review report is sent to the program director.  The program director will be invited to a future GMEC meeting to discuss the findings of the report.   

   At the time of the GMEC meeting, a representative serving on the special review committee will make a brief presentation to GMEC emphasizing the program’s compliance with the ACGME Institutional and Program Requirements, as well as recommendations for improvement of the program if applicable.  The program director will then be asked to share his comments and provide any updates made on the recommendations in the report. 

   The GMEC will discuss and review the report, and then vote on whether or not to approve.  The GMEC may request additional information or follow-up action from the program director.  Once approved, the GMEC chair will inform the program director of the committee’s decision. 
    
   A follow-up review of the program will be determined and communicated to the program director.  The Special Review subcommittee will continue to follow-up on the program until no further review or intervention is necessary.   

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Definitions

ACGME is the Accreditation Council for Graduate Medical Education. 

A trainee is an IUSM resident or fellow.

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Implementation

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Oversight

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History

1. Policy  gme-adm-0037 approved by GMEC and published on 23 July 2014. 
2. Policy reviewed, updated, and approved by GMEC on 27 November 2017. 
3. Policy updated for formatting 05 March 2018. 
4. Policy updated for formatting 27 June 2018.
5. Reviewed and Updated 10 April 2023.
6. Policy approved by GMEC 19 April 2023.
7. Policy updated 6 April 2026.

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