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Internal Reviews


Internal Review Protocol (IV.A.1.b) (Parentheses refer to Institutional Requirements, IV. Internal Review)

A. Internal reviews must be in process and documented in the GMEC minutes by approximately the midpoint of the accreditation cycle (calculated from the date of the meeting when final accreditation action and generally noted on RRC report). (IV.A.2)
Follow-up mini-reviews will be conducted as necessary pending outcome. In addition, an informal Internal Review may be requested by a Program Director as a l “consultation” at any time in the accreditation cycle.

B. Internal Review Committee (IV.A.1.a.)

  1. Chair of Internal Review Committee, Claire Brett, M.D. and /or Chair, GMEC, Robert Baron, M.D. (DIO, Associate Dean for GME)
  2. Faculty member within the Sponsoring Institution but not from the GME program under review (IV.A.1.a.)
  3. Trainee representative within the Sponsoring Institution but not from the GME program under review (IV.A.1.a.)
  4. Director, GME, Amy Day
  5. Accreditation Manager, GME, Heather Nichols

C. Program internal review panel composition (IV.A.6)

  1. Department Chair (optional)
  2. Program Director
  3. Key faculty members
  4. At least one peer-selected resident/clinical fellow from each level of training
  5. Other program representatives deemed appropriate

D. GMEC internal review panel assesses the following (IV.A.4.a-g):

  1. Compliance with the Institutional, Common, and specialty/subspecialty-specific Program Requirements
  2. Educational objectives and effectiveness in meeting those objectives
  3. Educational and financial resources
  4. Effectiveness in addressing areas of non-compliance and concerns in previous ACGME accreditation letters of notification and previous internal reviews.
  5. Effectiveness of educational outcomes in ACGME general competencies
  6. Effectiveness in using evaluation tools and outcome measures to assess a resident’s level of competence in each of the ACGME general competencies
  7. Annual program improvement efforts in:
    a. resident performance using aggregated resident data
    b. faculty development
    c. graduate performance, including performance of program graduates on the certification examination
    d. program quality

E. Materials and data used in the Internal Review (IV.A.5.a-e)

  1. Program Director’s Self Study
  2. ACGME Institutional, Common, and specialty/subspecialty-specific Program Requirements in effect at the time of the review (V.A.5.a)
  3. Accreditation letters of notification from previous ACGME reviews and progress reports sent to the respective RRC (V.A.5.b)
  4. Reports from previous internal reviews of the program (V.A.5.c)
  5. Previous annual program evaluations (VA.5.d)
  6. Results from available internal or external resident surveys (VA.5.e)

F. GMEC members of the panel meet with the trainees without the faculty from the training program. The following are examples of topics pursued with the trainees.

  1. Systems available for confidential discussion of concerns
  2. Duty hours feedback
  3. Feedback about work environment
  4. Feedback about evaluation processes
  5. Feedback about education and research opportunities
  6. Feedback about career development/mentoring

G. The Internal Review Committee summarizes the process, findings, and recommendations of the meeting in a written report that is reviewed and revised by the Program Director before its presentation to the GMEC. The Internal Review Report must include (IV.B.1.a-f):

  1. Name of the program reviewed
  2. Date of the assigned midpoint and the status of the GMEC’s oversight of the internal review at that midpoint
  3. Names and titles of the internal review committee members
  4. Description of the internal review process, including the list of the groups/individuals interviewed and the documents reviewed
  5. List of citations and areas of non-compliance or any concerns or comments from the previous ACGME accreditation letter of notification with a summary of how the program and/or institution subsequently addressed each.

H. Report submitted to, reviewed and revised by GMEC

I. Final report includes a plan (including a timeline) for monitoring the response by the program to actions recommended by the GMEC (IV.B.2)

J. The Sponsoring Institution will include the most recent internal review report for each training program in the Institutional Review Document. Internal review reports are not shared with the site visitor during an RRC review of a training program.

Approved by GMEC on November 19, 2007. Revised: June 2007.


Internal Review Committee

Robert B. Baron, MD - Associate Dean & Chair, GMEC
Clair Brett, MD - Vice Chair, GMEC
Heather A. Nichols - Accreditation Manager, GME
Amy Day - Director, GME

The Internal Committee must also include at least one Faculty Member and at least one Resident from within the sponsoring institution but not from within the GME Program being reviewed.

Program Links

Graduate Medical Education
500 Parnassus Avenue, MU 250 East
San Francisco, CA 94143-0474
Telephone: (415) 476-4562
Fax: (415) 502-4166