Beyond ACGME Compliance: Successful Development, Oversight, and Enhancement of Residency Programs

Jennifer L. Peel, PhD
Robert J. Nolan, MD

The graduate medical education committee (GMEC) is responsible for overseeing the quality of graduate medical education and the learning and working environment for ACGME-accredited programs. While there are required components to oversight (i.e., the annual program evaluation and special program review), GMECs have been allowed the flexibility to innovate an oversight structure that is appropriate for their individual programs and institution. This leaves some GMECs struggling to come up with a solid oversight process.

This book will provide readers with essential tools and processes to create a robust residency program oversight system for their institution that satisfies ACGME Institutional, Common, and Specialty Program Requirements under the Next Accreditation System (NAS) and which can be tailored to the unique characteristics of their educational environment.

Authors Jennifer L. Peel, PhD and Robert J. Nolan, MD are responsible for the design and implementation of program oversight in the NAS for 54 programs of various size and specialty at the University of Texas Health Science Center at San Antonio. They have developed an oversight and review process that can be replicated at institutions of all types and sizes.

Readers will learn how to:

• Develop a timeline for new program reviews
• Conduct a mock site visit before the scheduled 10-year site visit
• Complete the self-study, including a pre self-study review
• Identify actionable steps for improvement through the annual program evaluation

Published: January 2016

Page count: 206
Dimensions: 8.5x11
ISBN: 978-1-55645-871-2

Table of Contents

I. GMEC Oversight of ACGME-Accredited Residency Programs
     a. ACGME Requirements
     b. Program Oversight Policy Structure
     c. GMEC Oversight Toolbox for Continuous Program Improvement
     d. GMEC Program Oversight in the NAS Calendar
     e. What’s YOUR Cycle?

II. The New Program Review (NPR)
     a. NPR Protocol
     b. NPR Report Template
     c. Timeline for the NPR Process

III. The Annual Program Evaluation (APE)
     a. The Program Evaluation Committee (PEC)
     b. Accreditation Data System (ADS)
     c. APE Protocol
     d. The Online APE Form
     e. APE Meeting Minutes & Action Plan
     f. SWOT Analysis
     g. APE Report Template
     h. Timeline for the APE Process

IV. The Periodic Program Review (PPR)
     a. PPR Protocol
     b. PPR Report Template
     c. Timeline for the PPR Process

V. The Special Program Review (SPR)
     a. SPR Protocol
     b. SPR Report Template
     c. Timeline for the SPR Process

VI. The Pre Self-Study Review (PSSR)

VII. The Self-Study (SS)

VIII. The Mock Self-Study Visit (MSSV)

IX. The 10-Year Accreditation Site Visit (SV)

X. Strategies to Enhance the Oversight Process

About the Authors:

Jennifer L. Peel, PhD, is assistant dean for graduate medical education and professor of anesthesiology at the University of Texas Health Science Center at San Antonio (UTHSCSA). Along with her coauthor Dr. Nolan, she is responsible for the design and implementation of program oversight in the Next Accreditation System for 54 programs at UTHSCSA. They have also participated in more than 300 program reviews. She frequently presents on this topic at national and regional conferences.

Robert J. Nolan, MD, is an Associate Dean for GME and Professor of Pediatrics at University of Texas Health Science Center at San Antonio (UTHSCSA). Along with his coauthor Dr. Peel, he is responsible for the design and implementation of program oversight in the Next Accreditation System for 54 programs at UTHSCSA. They have also participated in more than 300 program reviews. He frequently presents on this topic at national and regional conferences.