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					                    UCLA GRADUATE MEDICAL EDUCATION
                   RESIDENCY PROGRAM INTERNAL REVIEW
           Sponsoring Institution: David Geffen School of Medicine at UCLA

The Process: Thank you for agreeing to serve as a reviewer for the GMEC. Your role is very
important to the GMEC and is taken seriously. The goal of the internal review is to provide
information to our residency programs so that they can continue to improve and enhance their
programs, and to meet ACGME requirements. Please follow these steps:

     o   Examine all written materials and information provided by the program director and GME
         Office.

     o   Before asking the questions on this form, engage the program director and faculty in
         some conversation regarding “the general health of the program” or “taking the
         temperature of the program”. You are asked to comment on this at the end of the
         survey.

     o   Information gathered during this interview phase of the internal review should be
         documented on this Internal Review Form.

     o   The lead reviewer will complete this form and submit it to the administrative reviewer for
         additional input.

     o   The final internal review report should be submitted electronically by the lead reviewer to
         the GME Office (rziff@mednet.ucla.edu)

     o   The lead reviewer will present the findings of the internal review to the GMEC. At that
         time, the resident reviewer will also present resident findings.




              Program:
              Program Director:
              (name and academic title)
              Accreditation Status/Effective date:
              Next RRC Site Visit:
              ACGME assigned midpoint review date:
              Date of Internal Review:
              Date Discussed at GMEC Meeting:


I.   Internal Review Committee: List names, department and academic titles of review
     committee members
     1. Lead Reviewer
     2. Administrative Reviewer
     3. Resident Reviewer

II. Internal Review Process
     A. Inteviews: Separate interviews were conducted with:
        Program Director: list name
        Faculty members actively involved in resident education: list names and academic titles
        Peer selected residents: list names and PGY level

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   B. Information and Materials Reviewed
       The following information was reviewed as part of the internal review process:
          o ACGME Common Requirements, Specialty/subspecialty-specific Program and
               Institutional Requirements
          o UCLA GME Internal Review Self Study
          o ACGME Letter of Notification (LON) from previous ACGME review and progress
               report(s) sent to the respective RRC
          o Report from previous internal review of the program and follow-up
               correspondence
          o Result from the UCLA GME Annual Resident Survey
          o Results from the most recent ACGME resident survey

III. Previous RRC Citations
        1. List each citation exactly as in the ACGME notification letter.
        2. Were all citations adequately addressed?
              Yes                No If no, please comment
            Comment:
        3. Was the Program Director familiar with the citations and responses?
              Yes                No If no, please comment
            Comment:
           4. Were the faculty familiar with the citations and responses?
              Yes                No if no, please comment
            Comment:

IV. Previous Internal Review Concerns (major past concerns should be reviewed)
    Please list each internal review concern from past review:
       1. Has each concern been adequately addressed by the program?
               Yes        No If no, please comment:
       2. Were the faculty familiar with internal review concerns and how they were
          addressed?
               Yes        No If no, please comment:

V. Internal Review Committee Assessment of Program
    A. General Health of the Program (be sure to include program strengths and any
        concerns)

   B. Program Requirements
      Does the program comply with the
      1. ACGME Common program requirements?
                Yes      No If no, please comment:
      2. RRC Specialty/subspecialty-specific Program Requirements?
                Yes      No If no, please comment:
      3. ACGME Institutional Requirements?
                Yes      No If no, please comment:
      4. Are duty hours in compliance with institutional and program polices?
                Yes      No If no, please comment:
      5. Is there an annual program retreat with written improvement plans?
                Yes      No If no, please comment:
      6. Is there a semi-annual documented performance evaluation and meeting with the
               program director?
                Yes      No If no, please comment:
      7. Is a written final evaluation given which documents the trainee’s competence to
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            practice independently?
             Yes     No If no, please comment:
   8. Is there evidence of education by the program for faculty and house staff on resident
            fatigue?
             Yes     No If no, please comment:

C. Educational Program
    1. How effective are the Program’s Goals and Objectives in meeting the program
        requirements?
    2. How adequately do the goals and objectives reflect the ACGME six Core
        Competencies?
    3. Are there competency based goals and objectives for each rotation by year?
               Yes     No     This is a one year program If no, please comment:
        o If a one year program, are there goals and objectives for each activity/rotation?
               Yes     No If no, please comment:
    4. Do the competency based goals and objectives for each year of training reflect
        increasing competency development of residents?
               Yes     No If no, please comment:
    5. Is a block diagram of the training program presented reflecting a typical resident’s
        schedule for each year of training?
               Yes     No If no, please comment:
    6. Are the evaluation/assessment tools used by the program effective in assessing
        resident competency development?
               Yes     No If no, please comment:
    7. Do the evaluation methods provide multiple ways of assessing resident competency
        development?
               Yes     No If no, please comment:
    8. Do program evaluation measures, such as rotation reviews and end of year reviews,
        assist the program in modifying components of the residency educational program?
               Yes     No If no, please comment:
    9. Has the program developed a specific improvement plan based on the resident
        program evaluation measures?
               Yes     No If no, please comment:
    11. Has the program developed outcome measures for resident development?
               Yes     No If no, please comment:
    12. Has the program developed outcome measures for program development?
               Yes     No If no, please comment:
    13. Is a grid of the assessment of Core Competencies included?
               Yes     No If no, please comment:

D. Program Administration/Resources
   1. Are the Program’s educational resources adequate for the training program?
             Yes     No If no, please comment:
   2. Does the Program have a designated Program Coordinator?
             Yes     No If no, please comment:
   3. What is the time commitment of the Program Coordinator? (hours/week)
   4. Are the Program’s financial resources adequate for the training program?
             Yes     No If no, please comment:
   5. Is there a current PLA for each outside training site?
             Yes     No If no, please comment:

   E. Faculty Development
   1. Are the faculty members adequately familiar with the program curriculum?
            Yes     No If no, please comment:

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       2. Do the faculty members feel that they have contributed to development of the
          curriculum?
                 Yes     No If no, please comment:
       3. Are the faculty members familiar with the RRC program requirements as they apply
          to the curriculum and what is expected to be included in the curriculum?
                 Yes     No If no, please comment:
       4. Has there been education of the faculty on the ACGME six Core Competencies so
          they are adequately familiar with them?
                 Yes     No If no, please comment:
       5. Is there education for the faculty that directly focuses on enhancing their skills in the
          education of residents?
                 Yes     No If no, please comment:
       6. Are the faculty adequately familiar with the competency based assessment tools and
          do they feel comfortable in assessing the residents on their competency
          development?
                 Yes     No If no, please comment:
       7. Do the faculty members review the objectives and expectations of a rotation prior to
          the residents/fellows beginning the rotation?
                 Yes     No If no, please comment:


VI.     Overall Program Assessment from Internal Review Team

        A.     General assessment comments

        B.     Recommendations for Program Improvement: Please comment on each
               category listed below:
                 o Response to RRC Citations
                 o Compliance with ACGME/RRC Program Requirements
                 o Overall Educational Program, including competency based goals and
                    objectives and assessment
                 o Adequacy of Program Administration and Resources
                 o Adequacy of faculty development for education program


 Mechanisms for Follow Up: A letter will be sent from the Chair, GMEC, to the program
director, providing the results of the internal review and requesting a written follow-up.




Revised 1/09
Approved by GMEC: 8/25/08
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