Policy Statement
Annually, the Program Evaluation Subcommittee (PES) will identify programs for special review. The review will be administered by the PES through a special review team. In addition, any interested parties are free to request a special review of their program, even if the program has not been identified by the PES as needing review. The special review process will result in a report describing the program’s quality improvement goals, corrective actions, and plan for future monitoring of outcomes by the Graduate Medical Education Committee (GMEC).
Reason for Policy
The ACGME requires that the Graduate Medical Education Committee (GMEC) demonstrate effective oversight of underperforming programs through a special review process. The purpose of the special review process is to assist programs to improve in targeted areas which are meaningful to program quality and predictive of important outcomes. The review is not punitive; rather, it is intended to aid in program quality improvement.
Forms/Instructions
The PES and GME Administration Office will provide programs and special review teams with detailed instructions about how to carry out the review. The Special Review Process Map provides an overview of the review steps and timeline.
Responsibilities
Program Evaluation Subcommittee (PES): This subcommittee of the Graduate Medical Education Committee (GMEC) is responsible for establishing relevant metrics to determine which programs will undergo a special review, and for establishing and overseeing the execution of the special review process.
Programs: Programs that are selected for special review will complete a self-study and engage with their special review team to identify quality improvement goals and generate an action plan. Programs will implement the plan, and report on their progress to their special review team and the GMEC.
Special Review Team: Members of the special review team will engage with the program to understand areas of underperformance, then assist with setting quality improvement goals and generating an action plan to report to the GMEC. The team will share best practices, and the team’s chair will attend follow-up progress meetings with the program. See also Special Review Team Roles.