Special Review & the Special Review Committee (SRC)

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For Participating Residents/Fellow

Participating resident/fellow representatives receive a $200 participation bonus per review.

Special Review

Contacts

GME Program Manager

Please click here to find out your program's GME Program Manager.

Last Revised 07/19/2018

ACGME Requirement

ACGME Institutional Requirements:

Requirement I.B.6 – Special Review process that:

I.B.6.a).(1) establishes criteria for identifying underperformance; and,
I.B.6.a).(2) results in a report that describes the quality improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes.

The Big Picture

The Special Review occurs when a program is underperforming or when GME conducts periodical reviews of a program.

During the Special Review, the Special Review Committee (SRC) interviews the following:

program trainees
program faculty
program director
department chair/division chef

to generate a report for the Graduate Medical Education Committee (GMEC).

The GMEC review and approve the SRC recommendations for the program so that the program addresses the GMEC and SRC’s concerns.

Special Review Committee (SRC)

The Special Review Committee (SRC) is comprised of:

1 Faculty Chair
1 Resident Representative
Designated Institutional Officer (DIO)
GME Program Manager

Process

The GME Accreditation Team notifies the program of the upcoming Special Review.
Program schedules the Special Review with all its interviewees and notifies the accreditation team.
The GME Accreditation Team searches for Special Review Committee (SRC) members for the review.
Program gathers documents on the Special Review Checklist before the deadline, and notifies the accreditation team.
Program schedules the Special Review with all its interviewees and notifies the accreditation team.
The GME Accreditation Team searches for SRC members for the review.
SRC reviews the program's documents.
Special Review is conducted.
SRC drafts a report to submit to GMEC for review.
Program follows up with action items from the report.
The GME Accreditation Team monitors the program's progress until the program improves program quality.

Document Checklist

Download the Checklist

Step 1 Schedule Special Review Committee (SRC)

Step 1A

Reserve a conference room within SHC for 1.5 to 2.5 hours

Step 1B

Schedule interviews in the following order:

For programs with 5 or more trainees:

30 minutes for Resident/Fellows (all or peer selected, at least 1 from each PGY level)
30 minutes for Faculty (about 5; at least 1 from each major affiliate site)
15 min for Program Director
15 minutes for Department Chair
10 min for Committee Wrap-Up

For programs with 5 or less trainees:

15 minutes for Resident/Fellows (all or peer selected, at least 1 from each PGY level)
15 minutes for Faculty
15 min for Program Director
15 minutes for Department Chair
10 min for Committee Wrap-Up

Step 1C

Email agenda with date/location/names of interviewees to Trey Huynh-Ngo in the GME office

Step 2 Ensure the following documents are up-to-date and available in MedHub at least 3 weeks prior to SRC Site Visit

Applies to non-ACGME programs only

Competency-based overall and rotation-specific goals and objectives by PGY year not if already in MedHub
Program curriculum including didactic schedules, instructional methods, outcome measures, and assessment strategies
Copies of all evaluation instruments that are NOT already in MedHub (Please do not submit completed evaluations! Submit only blank forms)
Aggregated performance data (in-service exams, board pass rates, National Match results, and attrition rates)
Policies on supervision, duty hours, and recruitment

Applies to ACGME programs only

Most current completed Program WebADS update
Current RRC citations from your last ACGME letter
Program-specific policies and procedures concerning duty hours, moonlighting, supervision, recruitment, handovers, and leave of absence if NOT already in MedHub (they should be!)
Current Program Letters of Agreement (PLAs)
Aggregated program evaluation data if NOT already in MedHub
Minutes and action plan from most recent program evaluation meeting if NOT already in MedHub
Case/Procedure logs if applicable and NOT already in MedHub
Sample documents offering evidence of resident participation in QI and Safety Projects
Competency-based overall and rotation-specific goals and objectives by PGY year if not already in MedHub
Program curriculum including didactic schedules, instructional methods, outcome measures, and assessment strategies
Copies of all evaluation instruments that are NOT already in MedHub (Please do not submit completed evaluations! Submit only blank forms)
Aggregated performance data (in-service exams, board pass rates, National Match results, and attrition rates)

Step 3 Notify GME contact that documents are available

Tips for Pre-, During, and Post-Review

Before the review:

Notify the GME Accreditation Team when your program has scheduled the review
Consult with GME Accreditation Team if you have any questions or concerns

During the review:

Provide breakfast/lunch for review participants

After the review:

If GME reaches out to the Program, the Program Director attends the GMEC Meeting to answer questions the committee has on the review.
Program addresses the SRC recommendations.

Glossary

Special Review (SR)
Special Review Committee (SRC)