Graduate Medical Education

Pre Self-Study Reviews (PSSR)

 

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 Pre Self-Study Review (PSSR) is part of this process.

 

The PSSR Process (See sample timeline)

 

Programs will be assigned a date by which the program self-study materials must be complete.  This specific date will be assigned by the GME Office, according to the GME Program Oversight Calendar.  The multi-step process is outlined below:

 

  1. The program will receive a reminder notification one year in advance from the GME Office of the due date for completion of the program self-study.  The program will be contacted by the GME Office to schedule their PSSR for that month.
  2. Program assembles the self-study group
  3. The self-study group engages program leadership, faculty, trainees and staff in a discussion of program aims
  4. The self-study group reviews the SWOTs and Action Plans to determine ongoing threats and opportunities
  5. The self-study group aggregates and analyzes data to generate a longitudinal assessment of the program’s improvement
  6. The self-study group obtains stakeholder input
  7. The self-study group interprets the data and aggregates the self-study findings
  8. The self-study group discusses the findings with stakeholders
  9. The self-study group completes the Self-Study Document for use in further program improvement and as documentation for the program’s PSSR and 10-year site visit.
  10. The PSSR will be conducted and a Pre Self-Study Review Report will be generated.
  11. The GMEC Compliance & Accreditation Subcommittee will review the Pre Self-Study Review Report and either:

    a.  Accept as submitted

    b.  Ask for clarification/additional documentation and create an action plan

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

  12. The Pre Self-Study Review Report will be presented to the GME Executive Committee and to the GMEC.

PSSR Materials

 

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

  • All APE Minutes and Action Plans since the time of their last Site Visit.
  • The Self-Study Document

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

 

The PSSR Participants and Meeting

 

The PSSR will be conducted by the chair (Associate Dean for GME) and co-chair (Assistant Dean for GME) of the GMEC Compliance and Accreditation Subcommittee.  Interviewees will include members of the Self-Study group and the Program Leadership.

Reviews will be scheduled for 8:30-11:00am:

 

 

 

8:30-9:45 am                 Meeting with Self-Study group

9:45-10:00 am                 Break

10:00-11:00 am             Meeting with Program Leadership

 

PSSR Report

 

Report:  The co-chairs will compose a written report.  The report will be submitted to the GMEC Compliance and Accreditation Subcommittee.  The GMEC Compliance and Accreditation Subcommittee will develop a Pre Self-Study Program Review Report and Action Plan.  The Pre Self-Study Review Report and Action Plan will be submitted to the GME Executive Committee and to the GMEC.

 

GMEC Monitoring of Outcomes

 

The GMEC Compliance and Accreditation Subcommittee will review the Pre Self-Study Review Report at its monthly meeting as designated by the GME Program Oversight Calendar and either:

 

    • Accept as submitted
    • Ask for clarification/additional documentation
    • Determine the need for a Special Program Review (SPR)

 

A templated summary report will be created and presented by the GMEC Compliance and Accreditation Subcommittee 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 on the GME Oversight Calendar.