UCLA GMEC Program Review (Special Review) Policy

UCLA GMEC PROGRAM REVIEW POLICY

PURPOSE

The ACGME’s Institutional Requirements charge the GMEC with demonstrating effective oversight of programs to ensure compliance with ACGME and UCLA GME requirements. This 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.

SCOPE

This policy applies to all UCLA-sponsored ACGME-accredited residency and fellowship programs at risk for underperformance, violation of ACGME requirements and other special circumstances.

POLICY

Special Review

Criteria for automatically initiating a special review includes one or more of the following:

  • ACGME Letter of Notification of Accreditation indicating:

    1. Initial Accreditation with Warning
    2. Continued Accreditation with Warning
    3. Adverse Accreditation Status

Special Review may also be triggered by one or more of the following:

  • Inquiry from ACGME Office of Resident Affairs
  • Annual ACGME Resident Survey identifying program compliance of less than 80% in the clinical work hours domain.
  • Annual ACGME Residents and/or Faculty Survey program means equal or below 70% in domains excluding those domains in which the majority of the programs have equal to or less than 70%.
  • Trending data from Annual ACGME or GME Resident or Faculty Surveys indicating concerns in the learning environment
  • Annual Program Evaluation and Improvement Plans that fail to satisfactorily address required elements, such as current citations, areas for improvement, and/or issues raised from prior Special Reviews.
  • Two or more changes in Program Directors during the length of the training program.
  • Request from the Designated Institutional Official, including review based on concerns raised by Residents or Faculty.
  • Request from the Program Director.
  • As per majority vote of the GMEC for all other circumstances.

Special Review may be deferred at the recommendation of the DIO with approval by the GMEC.

PROCEDURE

Special Reviews include the following components:

  • Analysis of the following documents:

    1. Documentation supporting program underperformance
    2. Most recent Letter of Notification
    3. Most recent ACGME Resident and Faculty Survey
    4. Most recent GME Resident and Faculty Survey
    5. Most recent Annual Program Evaluation and Improvement Plan
    6. Program Requirements in effect at the time of underperformance
    7. Additional documents appropriate to the criteria for underperformance as determined by the Special Review Committee
  • Interviews with those involved and/or potentially affected including Residents, Core Faculty, and other key individuals as identified.
  • Review and discussion by the Special Review Committee resulting in recommendations and remediation action plans.
    • Action Plans will be developed by the program under review and will include recommendations to the Special Review Committee
    • Action Plans must contain reporting structure, monitoring procedures, and implementation timelines.
    • Actions Plans must include a description of the improvement goals, corrective actions, and the process for GMEC monitoring of outcomes.
  • The Special Review Committee reports to the GMEC for approval of the proposed Action Plan, and for ongoing monitoring by the GMEC to ensure Action Plan completion and effectiveness.
  • The Special Review Committee shall consist of a GMEC faculty representative, GMEC resident representative, and GME staff representative.

FORMS

SPECIAL REVIEW REPORT TEMPLATE

  1. Program Identification

    • Program:
    • Accreditation Status:
    • Next Self-study date:
    • Resident complement:
    • Date of Special Review Interviews:
    • Date Special Review Report Approved by GMEC:
  2. Membership of Special Review Committee by name and position including year of training for any Resident/Fellow members:
  3. Copy of signed confidentiality agreement by all Special Review Committee members.
  4. Names of individuals interviewed by name and position including year of training for peer-selected Residents/Fellows:
  5. Materials Reviewed
    REQUIRED
    Documentation supporting program underperformance
    Letter of Notification
    ACGME Resident and Faculty Survey
    GMEC Resident and Faculty Survey
    Annual Program Evaluation and Improvement Plan
    ACGME Program Requirements

    OPTIONAL (Check all applicable for this review)
    Board Passing Rates
    Block Diagrams
    Case Logs
    Conference Schedule
    Evaluation Tools
    GMEC Minutes
    Goals and Objectives
    Milestone Data
    QI/PS projects and outcomes
    Program Policies
    Resident/Faculty Call Schedules
    Resident Files
    Other
  6. Format of Interviews
  7. Circumstance(s) requiring Special Review
  8. Status of corrective action(s) to Letter of Notification
  9. Status of corrective action(s) to ACGME and/or GME Resident/Faculty Surveys
  10. Annual Program Evaluation and Improvement Plan
  11. Concerns identified by the Special Program Review Committee from materials reviewed and interviews that must be addressed to the GMEC in a written corrective action plan
  12. Summary Statement
  13. Recommendation for submission and GMEC monitoring of Program Director’s corrective action plan to concerns identified in Section X of this report

CONFIDENTIALITY OF SPECIAL REVIEW DOCUMENTS

The Special Review is a peer-review activity conducted by the GMEC functioning as a Subcommittee of the Attending Staff Association and its Executive Committee. Each Special Program Review Committee member will be required to sign a statement of confidentiality.

Confidentiality of Special Review Documents Agreement

REFERENCES

ACGME REQUIREMENTS (Institutional Requirements (I.B.6.)

I.B.6. The GMEC must demonstrate effective oversight of underperforming program(s) through a Special Review process. (Core)

I.B.6.a) The Special Review process must include a protocol that: (Core)

I.B.6.a).(1) establishes criteria for identifying underperformance; and, (Core)

I.B.6.a).(2) results in a report that describes the improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes. (Core)

 

 

REVISION HISTORY

Effective Date: 06/25/2018

Revised: 3/27/2023