Program Oversight and Review Policy

Scope

This policy was developed for SIU Medicine. SIU Medicine collectively applies to the SIU School of Medicine (SIU SOM), including the Federally Qualified Health Center (FQHC), and SIU HealthCare (SIU HC). These entities are collectively referred to as SIU in this document.

This document applies to SIU staff, faculty, trainees, agents, officers, directors, interns, volunteers, contractors, and any other individual or entity engaged in providing teaching, research and health care items and services at SIU. These individuals are collectively referred to as SIU personnel in this document.

Definitions 

The term “resident” is inclusive of all trainees at SIU SOM, whether training in a residency or fellowship program.  The term “program” is inclusive of all SIU residency or fellowship programs, whether accredited or non-accredited.

Purpose

GMEC oversight of program quality is an ongoing process. This includes the Annual 
Institutional Review (AIR), oversight of Annual Program Evaluations (APE), review of RRC 
letters, including any citations and progress reports, ACGME resident and faculty surveys, 
SIU End of Year Evaluations, monitoring of Non-Standard Training programs as related to 
ACGME requirements and other indicators of program quality as recognized by GMEC.
 

Procedure

Internal Review 

Each program in good standing will have an Internal Review every 4 years unless other 
review is performed. When a new program director begins, an Internal Review will be 
conducted 2 years after start date. Where appropriate, the GMEC may combine an Internal 
Review with a Special Review.

Special Review 

If there is an indication that a program needs additional oversight, the GMEC may institute a 
Special Review. 

Indicators for a Special Review may include, but are not limited to:

  • Accreditation status of warning, probation or proposed adverse action
  • Repeat or egregious RRC citations 
  • Any identified areas of concern from the ACGME resident or faculty survey
  • Significant drop in board pass rate

  •  Any founded report of serious violation of clinical and educational work hour 
    requirements, inadequate supervision, learner mistreatment or sub-optimal learning 
    environment

    A Special Review may be instituted by the GMEC, or upon request of program director or 
    department/division chair.

Protocol 

The Office of Graduate Medical Education (OGME) will recommend a chairperson to 
facilitate the Special Review. The Chair will then determine if additional committee members 
are needed, for example a resident and a faculty member. Special Review Committee 
members will not be from the GMEC program being reviewed and whenever possible will be 
from a different department.

The focus and scope of the special review will be at the discretion of the Special Review 
Committee members. The committee may focus on the specific performance trigger or 
expand the scope as warranted. 

OGME staff will prepare and distribute any surveys, questionnaires or request for materials 
deemed appropriate by the review committee. The committee will review the materials and 
meet with any appropriate residents, faculty or others. The Special Review Committee will 
submit a report to GMEC. The report will include, but is not limited to, the specific indicator 
that triggered the review, how the indicator or concern was investigated, goals for 
improvement and any corrective action. This report is shared with the program director prior 
to submitting to GMEC.

The program director will attend the GMEC meeting at which the special review report is 
being presented, and will be available to answer specific questions about the review. The 
GMEC may decide to accept, modify or refer back to the review committee their findings and 
recommendations.