Graduate Medical Education

Periodic Program Reviews (PPR)

The revised ACGME Institutional Requirements (effective July 1, 2014) section 1.B.4. a) (GMEC Responsibilities) includes but is not limited to: oversight of the institution and ACGME-accredited programs (1.B.4. a (1)), the quality of the working environment (1.B.4.a (2)), the quality of the educational experiences (1.B.4.a (3)), and the ACGME-accredited programs’ annual evaluation and improvement activities (1.B.4.a (4)). Missing are requirements for an internal review at the mid-point of a program's accreditation cycle.  But, according to the ACGME, the GMEC must implement a process for continuous improvement for all ACGME-accredited programs.  The Periodic Program Review (PPR) is this process.

 

The PPR Process

Programs will be assigned a date by which the program component APE process must be complete.  This specific assigned date will recur yearly to facilitate long-term planning.  The multi-step process is outlined below:

 

  1. The program will receive a reminder notification 120 days in advance from the GME Office of the due date for completion of the program component of the APE process.  The program will be contacted by the GME Office to schedule their PPR for that month.*
  2. The program must update ADS.
  3. The program completes the APE form in New Innovations.
  4. The PEC conducts the APE.
  5. The program submits the Annual Program Evaluation Minutes and Action Plan (through New Innovations) to the GMEC Compliance and Accreditation Subcommittee by the assigned date. The program must use the Annual Program Evaluation Minutes and Action Plan template available on the GME website.
  6. The PPR will be conducted and a Periodic Program Review Report and Action Plan will be generated.
  7. The GMEC Compliance & Accreditation Subcommittee will review the Periodic Program Review Report and Action Plan and either:

    a. Accepts as written

    b.  Asks for clarification/additional documentation

    c.  Determines the need for a Special Program Review (SPR)

  8. Both the Periodic Program Review Report and Action Plan be sent to the PD after the GME Executive Committee meeting at which it was reviewed.  Progress on action plans will accessed at the time of the next APE.
  9. The Periodic Program Review Report and Action Plan created by the GMEC Compliance & Accreditation Subcommittee are presented to the GMEC.

PPR Materials

In addition to the materials required for the APE, the following will be required for the PPR:

  • Sample competency-based goals and objectives for one assignment and for each educational level of training
  • Evaluation templates (not completed evaluations):
    • Resident/fellow at the completion of each assignment
    • Evaluations demonstrating the use of multiple evaluators (e.g., faculty, peer, self)
    • Semiannual evaluation
    • Final (summative) evaluation
    • Confidential evaluations of faculty by the resident/fellow
    • Confidential evaluation of the program by faculty
    • Confidential evaluation of the program by resident/fellow
  • Policies/protocols:
    • Moonlighting
    • Definition of common patient care circumstances when the supervising faculty member must be involved
    • Documentation for episodes when resident/fellows remain on duty beyond scheduled hours
  • Evidence of resident/fellow participation in Quality Improvement projects
  • Evidence of resident/fellow participation in Patient Safety projects

These materials must be uploaded into NI no later than 10 business days prior to the scheduled PPR.

 

The PPR Participants and Meeting

The PPR will be chaired and co-chaired by two Associate and/or Assistant Deans of GME who also serve on the GMEC Compliance and Accreditation Subcommittee.  Panel members from other programs will include at least two additional faculty members, at least two residents, at least one program coordinator and others as deemed necessary by the panel chair. Interviewees will include the Departmental Chair, Program Director, Program Coordinator, Departmental Administrator, Quality Champion, Faculty Development Leader, Core Program Director or designee (if applicable), at least four representative core faculty, and two peer-selected residents from each level of training.  If the program being reviewed is a dependent subspecialty, the Program Director for the respective core program will be interviewed with the program leadership.

Reviews will be scheduled for 8:00-noon:

 

8:00-9:15am

Meeting with Chair or delegate, Program Director, Program Coordinator, Departmental Administrator, Quality Champion, Faculty Development Leader and Core Program Director or designee (if applicable)

9:15-9:30am

Break

9:30-10:30am

Meeting with Residents/Fellows

10:30-11:15am

Meeting with Representative Core Faculty

If residents/fellows rotate at the VA, the site director(s) for the VA must be present.

 

11:15-noon

If necessary, meeting with Program Director and Program Coordinator

 

 

 

PPR Report and Action Plan

The co-chairs of the panel will compose a written report and action plan detailing the findings of the panel.  The report will be submitted to the GMEC Compliance and Accreditation Subcommittee.  The GMEC Compliance and Accreditation Subcommittee will review the Periodic Program Review Report and Action Plan.  The Periodic Program Review Report and Action Plan will be submitted to the GME Executive Committee and to the GMEC.

Progress on action plans will accessed at the time of the next APE, or sooner if determined by the GMEC Compliance and Accreditation Subcommittee.

 

GMEC Monitoring of Outcomes

The GMEC Compliance and Accreditation Subcommittee will review the Periodic Program Review Report and Action Plan at its monthly meeting as designated by the GME Program Oversight Calendar and either:

 

    a.  Accepts as submitted

    b.  Asks for clarification/additional documentation

    c.  Determines the need for a Special Program Review (SPR)

 

The report is presented to the GME Executive Committee and to the GMEC.

 

*The month that completed Annual Program Evaluation Minutes and Action Plan must be submitted to the GME Office is predetermined and illustrated in the GMEC Oversight Calendar.