Program Self-Study
Internal Review Protocol

UT College of MedicineChattanooga
Program Self Study
Internal Review Protocol

1. Educational Objectives of the Program and Six General Competency Areas

  1. What is the educational mission of this residency or fellowship program? Provide a narrative description of the program and the overall program objectives. Specifically address how the program is incorporating each of the six General Competency Areas.
  2. Attach a copy of the written goals and objectives of each major rotation, including written explanation and examples of how the program has incorporated the specific knowledge, skills, and attitudes required to provide patient education experiences for residents to demonstrate competency in each of the General Competency Areas: patient care skills, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning, and systems-based practice. Describe specifically the knowledge base and skills that must be acquired to demonstrate competency in each of the six areas and have they are evaluated.
  1. Describe the process used to determine the selection of hospitals or clinics for the educational components of the program. Describe the resident distribution at the teaching facilities used by this program (use percentages if residents spend time at more than one facility on a particular rotation). Attach a typical block schedule schedule and define the time period covered (monthly, quarterly, etc.)
  1. Describe the rationale for the current size of the residency program.
  1. What objective measurements are available for outcome assessment? If an in-service examination is used, describe the intervals at which the exam is given and provide a summary of the performance of the residents at each level. Provide any summary or available statistics on the performance of graduates on the specialty board examination. Complete the Assessment spreadsheet incorporated as part of the Self-Study.

2. Departmental Policies

  1. Attach a copy of the written departmental policy on the selection of residents and and a copy of the departmental policy on recruitment/eligibility of residents. These may be combined into one policy but should cover the areas of recruitment, selection, and eligibility. Note: If your program starts beyond the PGY-1 level, be sure your policy includes what pre-requisite training is required.
  1. Attach a copy of the written department policy on resident evaluation. The

Policy must specify how often the resident is formally evaluated and the process for giving feedback to the resident. Attach a copy of the departmental evaluation form used for resident evaluation.

Describe the process whereby residents are given an opportunity to evaluate supervising faculty and individual rotations. Attach a copy of the form used by residents to evaluate faculty as well as the form used to evaluate the rotation.

Describe the process whereby residents are given an opportunity to evaluate the total program in an anonymous manner. Attach a copy of any form used for this purpose.

  1. Attach a copy of the written departmental policy on resident promotion and

Dismissal.

  1. Attach a copy of the departmental policy on educational leave. Describe what financial support is provided by the department for attending meetings, board review courses or other educational activities.
  1. Attach a copy of the departmental policy on duty hours. Describe the call

schedule. Describe how the resident duty hours, including call, are monitored and how problems are addressed. Is moonlighting allowed and under what circumstances? Describe how moonlighting is monitored.

  1. Attach a copy of the departmental policy on resident supervision.
  2. Attach a copy of the minutes of the most recent departmental education committee.
  3. Attach a copy of the most recent annual program review report.
  4. Provide an example of at least program change or improvement that has resulted from the various evaluations, external metrics (such as board pass rates), and annual program review.

3. Program Quality and Program Requirements

  1. What is the current accreditation status of the program? When was the last site visit? When will the next visit occur? Attach a copy of the last ACGME accreditation letter?
  1. Provide the Panel with a detailed response to any citations or deficiencies denoted in the most recent accreditation letters from the Residency Review Committee (RRC), including specific actions taken to correct problems or clarify interpretation of requirements.
  2. What deficiencies exist currently that were not present at the time of the last site visit? How is the program addressing them?
  1. Describe the availability of clinical resources for the training program. Has the program been cited by the RRC for any deficiencies in procedures or case volume?
  1. How is the size of the residency determined? What is the maximum number of residents for which the program is approved? Where do most of the graduates of the program practice?
  1. How many faculty members does the department have? Attach a list of faculty denoting specialty/subspecialty and full-time and volunteer status. What is the required faculty-resident ratio? Is faculty supervision available at all sites? Is there faculty expertise available for all training program components? If not, elaborate regarding plans to correct these deficiencies. Do the clinical responsibilities of faculty interfere with teaching responsibilities? If so, how is program leadership addressing this problem?
  1. Attach a list of your current residents, identifying medical schools. Do you have unfilled positions? If so, please explain.
  1. Describe the departmental research and scholarly activities. Attach a list of scholarly activities, including research projects, presentations, and publications for the past three years, denoting which involve residents and which involve faculty (by name)
  1. Is resident research required for this program? Include a complete description of the Research/Scholarly Activity Requirement. How are research opportunities provided for residents? Describe other efforts to provide a scholarly environment for residents. Attach a copy of the educational conference schedule. Do faculty attend the conferences? Do faculty or residents develop the conference schedule? What additional resources are needed to provide a more scholarly environment for residents?
  1. Describe the departmental quality improvement activities and how residents are involved.
  1. Describe how residents are supervised and lines of authority. Do the residents confirm that supervision is available and appropriate?
  2. In reviewing the RRC requirements on the ACGME website, are there any new requirements? Attach a copy of the current program requirements. If new requirements have been added since the last site visit, identify them and indicate briefly how your program is meeting them.
  3. Discuss any future plans for changes in the residency program such as changes in the size, length or facilities utilized.

4. Financial Resources

  1. Attach a listing of your funding allocations (at each facility if applicable) that your program utilizes. Do these funding allocation match your curricular needs?
  1. Describe the level of resident support provided at the departmental level.
  1. Describe the departmental support available for teaching faculty; i.e., Powerpoint
    or presentation preparation, secretarial support, etc.
  1. Do you have adequate space for your training program? If not, describe your needs.

5. Summary

  1. Please provide any additional information that you feel should be considered by

The internal review panel and the GMEC.

  1. Does your program have any special needs that should be addressed at the

Institutional level?

  1. Describe any other future plans for your department that may affect your residency program.

Documents to attach:

  1. Written goals and objectives for each major rotation, identifying the competency areas associated with each one.
  2. Example of a resident block schedule for the program.
  3. Completed the outcome assessment spreadsheet (.xls file) to identify ways you are teaching and assessing each of the competencies.
  4. Departmental policy on the selection of residents.
  5. Departmental policy on the recruitment and eligibility of residents (may be included in #4 above).
  6. Departmental policy on resident evaluation.
  7. Form used by faculty to evaluate residents.
  8. Form used by residents to evaluate faculty.
  9. Form used by residents to evaluate each rotation.
  10. Form used by residents to evaluate the overall program.
  11. Departmental policy on resident promotion and dismissal.
  12. Departmental policy on educational leave.
  13. Departmental policy on duty hours.
  14. Departmental policy on resident supervision.
  15. Copy of minutes of the most recent departmental education committee meeting.
  16. Copy of the most recent annual program review report.
  17. Copy of the most recent RRC letter regarding accreditation status.
  18. List of departmental faculty, denoting specialty/subspecialty and full-time and clinical status.
  19. List of current residents, denoting medical school.
  20. List of departmental scholarly activity (including presentations, publications, and research projects) for the last two years. Be sure to denote which involve faculty and which involve residents (by name).
  21. Copy of the educational conference schedule.
  22. Copy of the current RRC program requirements.
  23. List of funding allocations for your program.

Revised 7/9/2008

Revised 7/9/2008
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