Internal Review Process

Introduction: As the Sponsoring Institution  we are required to perform Internal Reviews (IR) on all of our ACGME accredited programs midpoint between the Effective Date on their last RC letter and the next scheduled visit.  The timeframe for the IR is now noted on the RC letter.  To ensure that neither the Institution or the program receives a citation, GME Administration schedules the IR within the required timeframe and sends out notification to all participants well in advance to clear their schedules.  This method was approved by the Graduate Medical Education Committee (GMEC). 

The IR consists of a three-part process:
1) A two hour comprehensive review of the program with the program director, department/division chair and key faculty.  The IR Committee reviews program requirements, past citations, curriculum, goals and objectives, evaluation methods, duty hours, etc.  The program director is then excused and the IR Committee meets with peer-selected trainees from the program. GME prepares an IR Executive Summary which is sent to the program director to provide a preliminary response. 
2) The program director then meets 1:1 with the Program Review Committee (PRC) which is a subcommittee of the GMEC.  The PRC is comprised of faculty from the University of Minnesota as well as our major participating institutions, a hospital representative, a resident representative, the DIO, the GME Director of Education and GME administrative staff.  The PRC meets with the program director to review their preliminary response to the concerns raised at the IR.  The PRC will offer suggestions for improvement and has the authority to recommend a mentoring committee if deemed necessary.  The PRC will also determine whether follow-up is needed. 
3) The complete IR Executive Summary including the response is then presented to the full GMEC.

Our goal for this comprehensive review process is to help ensure that your program receives a positive outcome at your next accreditation site visit!

GME Contact: Lori Payne via email or at 612-626-3479.
If you are new to the IR process, please feel free to contact me to arrange a 1:1 training session or a meeting to go through any questions you may have as you are completing your Self Study Form.  You are also welcome to call or e-mail me anytime with questions. 

IR Documents (please click on link below)

Internal Review Schedule for 2008-2009 (all reviews take place from 2-4 PM in B645 unless otherwise noted)