Graduate Medical Education

Special Program Reviews (SPR)

 

According to the ACGME Institutional, section I.B.6., the GMEC must demonstrate effective oversight of underperforming programs through a Special Review process. The Special Review process must include a protocol that establishes criteria for identifying underperformance and results in a report that describes the quality improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes. This protocol outlines the process for the Special Program Review (SPR).

 

The SPR Process ( See sample timeline)

  1. The GMEC Compliance and Accreditation Subcommittee will review the Annual Program Evaluation Minutes and Action Plan and either:

    a.  Accept

    b.  Ask for clarification/additional documentation

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

  2. If the need for an SPR is identified, a proposal for an SPR will be presented to the GMEC Executive Committee.  The committee will either:

    a.  Accept the proposal

    b.  Modify the proposal

    c.  Reject the proposal

  3. If the SPR proposal is modified or accepted, the SPR will be scheduled. If the SPR proposal is rejected, oversight of the program reverts to the standard APE process.
  4. The SPR will be scheduled within 45 days of the GMEC Executive Committee’s approval.
  5. The SPR will be conducted and a Special Program Review Report and Action Plan generated.
  6. The GMEC Compliance & Accreditation Subcommittee will review the Special Program Review Report and Action Plan and either:

    a.  Accept the report

    b.  Ask for clarification/additional documentation

    c.  Recommend Internal Probation

  7. The Special Program Review Report and Action Plan reviewed by the GMEC Compliance & Accreditation Subcommittee is presented to the GME Executive Committee and to the GMEC.
  8. Progress on action plans will accessed at the time of the next APE unless the program is placed on Internal Probation.

 

Criteria for Identifying Underperformance

In addition to the process outlined above, other potential triggers for an SPR include but are not limited to:

 

  • Negative communication from the ACGME
  • Resident complaint to ACGME
  • Duty hours non-compliance
  • Negative ACGME Faculty Survey trends
  • Negative ACGME Resident Survey trends
  • Significant concerns from APE
  • Match issues
  • Resident attrition
  • Scholarly activity deficiencies (either resident or faculty)
  • Negative Milestones trends
  • Failure to adequately address action plan items from a previous SPR
  • Other at the discretion of DIO

 

SPR Materials

 

Materials requested for the SPR will be determined by the GMEC Compliance and Accreditation Subcommittee and referenced in the proposal to the GMEC Executive Committee.  The materials will be selected based on the deficits identified.

 

SPR Program Patricipants

 

Program representatives to be interviewed during the SPR will be determined based on the deficits identified.

 

The SPR Meeting

 

The SPR will be co-chaired by the chair and co-chair of the GMEC Compliance and Accreditation Subcommittee.  Panel members from other programs will include at least one additional faculty, at least two residents, at least one program coordinator and others as deemed necessary by the panel co-chairs.  In general the panel will be composed of individuals from departments different from the department of the program under review. On occasion, inclusion of a specific member of the department might be considered to add value to the proceedings – this will be approached on a case by case basis, in consultation with the DIO.

 

SPR Report and Action Plan

 

Report:  The co-chairs of the panel will compose a Special Program Review Report and Action Plan detailing the findings of the panel.  The Special Program Review Report and Action Plan will be submitted to the GME Executive Committee and to the GMEC.

 

Action Plan:  The Special Program Review Report and Action Plan will be sent to the PD.  Progress on action plans will accessed at the time of the next APE.

 

GMEC Monitoring of Outcomes

 

GMEC monitoring of outcomes is operationalized in the GMEC Compliance and Accreditation Subcommittee with reports to the GMEC.