Medical College of Wisconsin Affiliated Hospitals, Inc.
Midway between the RRC/ACGME reviews, each program shall undergo an internal review. The Executive Director maintains a chart with the dates of the last accreditation and the next anticipated review and will initiate the review process. The internal review will be conducted as follows:
· The Executive Director sends the Self-Review Form to the Program Director, which requests evidence that his/her program addresses the ACGME requirements and any citations mentioned in the previous review.
· The Executive Director appoints an Internal Review Team (IRT) of four, comprised of a Program Director, a member of the faculty, a resident, and an administrative representative, all coming from outside the program being reviewed.
· The Executive Director sends the IRT the self review, ACGME requirements (both the common and program-specific requirements), the previous RRC reviews, the last internal review, the Internal Review Protocol, and the Internal Report Format, along with a cover letter that explains the review process. The team is expected to read all the documents, meet and visit with the Program Director, Department Chair, faculty members, the program coordinator, and housestaff of the program to conduct a thorough review of the program to ascertain the extent to which the program meets all the ACGME requirements and if not, to recommend concrete steps for rectifying problems.
· The IRT Leader will submit a report, using the Internal Review Report Format templates, to the Executive Director addressing the strengths, weaknesses and recommendations for the program.
· The Executive Director studies the report and presents it to the Internal Reviews Committee (IRC) of the Graduate Medical Education Council (GMEC) for discussion.
· The Chair of the IRC will present a summary of the report to the GMEC for information and discussion. The Program Director of the reviewed program will be asked to comment on the review.
· A copy of the review and the recommendations of the IRC and GMEC will be forwarded to the Program Director and the Chairman of the residency’s Department by the Executive Director. The internal review is also sent to the Dean of the Medical College of Wisconsin, Senior Associate Dean for Clinical Affairs and the appropriate hospital administrator(s) if their assistance is needed in addressing the recommendations of the review report.
· The Executive Director will continue to monitor the program to ascertain that all the weaknesses are addressed and the recommendations of the internal review followed.
This revised policy was approved by the MCWAH Graduate Medical Education Council on July 18, 2005.