GME Policy on Special Reviews

I. PURPOSE

The Accreditation Council for Graduate Medical Education (ACGME) requires that every Sponsoring Institution (SI) demonstrates oversight of underperforming programs through a Special Review Process.  The purpose of this policy is to establish a structured process for conducting special reviews to ensure continuous quality improvement in addition to compliance with accreditation requirements in programs sponsored by New York Medical College (NYMC).

II. POLICY

It is the policy of NYMC to perform a Special Review (as defined below) for any  program meeting any of the following criteria: (1) Accreditation with Warning; (2) Probationary Accreditation or other adverse accreditation status; (3) Multiple, extended, or serious citations (as determined by the DIO); (4) ACGME Resident/Fellow or Faculty Survey with greater than or equal to 8 items of less than 80% adherence; (5) ACGME Resident/Fellow Survey with multiple survey items under Clinical Experience and Education (work hours adherence) (as determined by the DIO); (6) Change in primary clinical site; (7) Significant non-compliance with meeting deadlines for requested information either from NYMC or from external accrediting or regulatory agencies (as determined by the DIO); (8) Complaint filed with and accepted by the ACGME Office of Resident Services or another accrediting or regulatory body; (9) Multiple or serious concerns reported to the NYMC GME Office by residents/fellow, program faculty, staff, or other individuals knowledgeable of the program (as determined by the DIO); (10) Request by a Program Director; (11) Request by a CEO or CMO of the primary clinical site; or (12) Other evidence of underperformance or accreditation vulnerability which the DIO or NYMC GMEC, through majority vote, determines to merit a Special Review

III. SCOPE

This policy applies to all ACGME- or CODA-accredited or recognized programs sponsored by NYMC.  

IV. DEFINITIONS

Special Review refers to a formal, in-depth evaluation of a GME program separate from the annual program evaluation (APE) process.
Resident refers to any person enrolled in a residency program accredited or recognized by the ACGME or CODA and sponsored by NYMC.
Fellow refers to any person enrolled in a fellowship program accredited or recognized by the ACGME and sponsored by NYMC.
ACGME is the Accreditation Council for Graduate Medical Education.
CODA is the Commission on Dental Accreditation.
DIO is the Designated Institutional Official.
GMEC is the New York Medical College Graduate Medical Education Committee.
Sponsoring Institution is New York Medical College.
Hospital refers to the hospital or other clinical site employing Residents or Fellows.

V. PROCEDURES

A. NYMC GMEC Special Review Subcommittee Membership

1.  Annually, a Special Review Subcommittee of the NYMC GMEC is formed.  
2. Members may consist of Program Directors, Associate Program Directors, program faculty, Program Coordinators, and Residents/Fellows (PGY-2 or higher) from NYMC-sponsored GME programs.  
3. An invitation for self-nomination is sent annually to all eligible parties.  
4. Residents/Fellows who self-nominate must be confirmed by their Program Director to be in good academic standing. 
5. Individuals who self-nominate are asked to confirm their willingness and ability to:

a. participate in an annual subcommittee training; 
b. participate in at least one Special Review over the academic year;
c. review and comment in a timely fashion on draft reports and recommendations for reviews in which they participated; and 
d. participate in subcommittee-related professional development and strategic planning activities.

6. Ex-officio members of the NYMC GMEC may also serve as subcommittee members at the invitation of the DIO.   
7. Special Review Subcommittee members must affirm their understanding of confidentiality appropriate to the Subcommittee’s work by signing a Special Review Subcommittee Confidentiality Statement.  
8. The DIO serves as the Chair of the Special Review Subcommittee.

B.  Special Review Process

1. Program Directors are notified by the DIO when their program has been selected for Special Review.  
2. The NYMC GME Office works with the program to determine a date(s) on which Special Review interviews will be conducted.  
3. The participants in such interviews are determined by the DIO. 
4. Such interviews usually include representatives from each PGY class and the program faculty, as well as program leadership and hospital leadership.  
5. The Subcommittee prioritizes conducting such interviews in person; however, interviews may be occasionally conducted virtually at the discretion of the DIO.  
6. After date(s) for Special Review interviews are determined, an invitation is extended to Special Review Subcommittee members to participate in the Special Review.  
7. No Subcommittee members from the program under Special Review may participate.  
8. Special Review Subcommittee members from different programs at the same primary clinical site are prioritized, as applicable.  
9. Reasonable efforts are made to have at least one program faculty Subcommittee member and one Resident/Fellow Subcommittee member participate in each Special Review.
10. Based on the reason(s) for the Special Review, or interviews with program personnel, the DIO may request program-related documents for review by the Subcommittee and/or a tour of clinical site facilities.  
11. When applicable, the DIO may arrange with the program to visit rotation site(s) outside of the primary clinical site and/or to interview individuals from such training sites. 
12. Special Reviews may be general or focused on a specific aspect of the program, as determined by the DIO.
13. After the completion of Special Review interviews and review of associated information, the NYMC GME Office drafts a Special Review report and recommendations for review and editing by the Subcommittee members participating in the review.  
14. The Subcommittee approved draft is provided to the Program Director, who is asked to prepare an action plan to address the findings and recommendations from the Special Review.  
15. The draft report, recommendations, and program action plan are presented to the NYMC GMEC for discussion, edits, and approval.  
16. The Program Director is asked to provide follow-up reports on the schedule recommended by the NYMC GMEC to address monitoring of outcomes and corrective actions, usually at approximately 3 months and 6 months.
17. The final report, recommendations, and action plan are distributed to the program’s leadership team, applicable hospital leaders, NYMC academic department chair, NYMC School of Medicine Dean, and other NYMC personnel as appropriate.

VI. EFFECTIVE DATE

This policy is effective immediately.

VII. POLICY MANAGEMENT

Executive Stakeholder: Dean of the School of Medicine
Oversight Office: Office of Graduate Medical Education