Transcript Internal Review - University of Wisconsin Hospital and Clinics

GMEOC Internal Review
Refresher for Review Participants
on Process & Roles
August 19, 2009
Goals of Revised Process
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Ease burden on primary reviewer
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Ensure appropriate accountability
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Spread workload across four roles
Effectively prepare program for site visit
New templates, interview scripts
Ensure effective documentation for
ACGME
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Fewer citations
Four roles
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Primary Reviewer (Program Director)
Secondary Reviewer (Program Director or
Education Manager)
Administrative Reviewer (GME or
Coordinator)
Resident Reviewer
Primary Reviewer determines how team will
communicate between team members to
complete report
Process
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Programs must be visited within 2 months of its mid-cycle from
last date of accreditation
Dr. Getto’s office sends notification of Internal Review Visit
w/2-3 optional dates selected by the Review Team to the
Director whose Program is being reviewed
2-3 hour mandatory meeting is scheduled 5-6 months out and
all team members notified
Program being reviewed submits to GME Office:
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Common & Specialty/Subspecialty PIF
Other required Program Documentation
Competency Chart
All reviewers receive materials 2-3 months in advance of
GMEOC deadline for report
ACGME-Required Interviews
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Meeting w/Director & Coordinator (90 minutes)
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Meeting w/Residents (90 minutes)
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Number varies but must be representative of program
May be led by Resident Reviewer
Meeting w/at least one Faculty is essential
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Faculty may be included in this meeting
May be held at meeting w/Director or at a Section meeting
Faculty member must be interviewed no minimum standard
All four Reviewers should be included in all meetings
when possible
Meeting w/Coordinator to review documentation (90
minutes)
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Audit of Program Policies
Review of Resident/Fellow Portfolios
Tips on Successful Process
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Effective communication among team members
critical to complete report
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Draft report and template sent by Primary Reviewer
to Program Director for review
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Minimize confusion over who has which portion of the
Checklist
Submit to Primary Reviewer for collation
Cross-check of data between reviewers
Correct inaccuracies
Program gives courtesy feedback only— otherwise may
experience “review creep”
Final report and template sent to GME Office 2
weeks before GMEOC meeting
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Won’t get on agenda if otherwise
Timeliness ensures UWHC meets ACGME required
timeframe
Questions?
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Feel free to ask for assistance
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Program Documentation—Jeanne
Sarbacker 262-8399
Program Requirements or Review
Process—Anne Gravel Sullivan 262-5512