Special Program Review Policy and Protocol

I. Purpose of policy

This policy defines the way in which the Quality and Accreditation Subcommittee (QAS) of the Graduate Education Medical Committee (GMEC) supports program quality improvement efforts for Accreditation Council for Graduate Medical Education (ACGME)-accredited graduate medical education programs at Dartmouth Hitchcock.

II. Policy scope

This policy applies to the Program Directors of ACGME-accredited training programs and to the QAS, GMEC, Designated Institutional Official and Graduate Medical Education (GME) Office staff at Dartmouth Hitchcock.

III. Definitions

Designated Institutional Official (DIO): The individual in a sponsoring institution who has the authority and responsibility for all of the ACGME-accredited GME programs.

Focused SPR: Special Program Review where the training program prepares an action plan to address focused issues/concerns, and does not require meetings with a panel.

Graduate Medical Education Committee (GMEC): The designated institutional oversight body for all ACGME-accredited residency and fellowship training programs at Dartmouth Hitchcock.

Quality and Accreditation Subcommittee (QAS): The subcommittee of the Graduate Medical Education Committee which is responsible for the development, implementation, and oversight of a quality improvement processes for ACGME-accredited graduate medical education training program at Dartmouth Hitchcock.

Resident: Any physician in an ACMGE-accredited graduate medical education program including residents and fellows.

Special Program Review (SPR): Mechanism for GMEC oversight of under-performing ACGME-accredited graduate medical education training programs.

Full (Team) SPR: Special Program Review performed by a panel that includes Program Director/Associate Program Director*, Resident*, Program Coordinator*, and GME Office staff representation (*from outside the section where the program under review resides).

IV. Policy statement

Initiating a Special Program Review
The following criteria are used by the QAS to trigger an SPR:

Internal Criteria	External Criteria
At the request of hospital, department, section, or program administration	Annual submission of Accreditation Data System (ADS) information: Pattern of Resident or faculty attrition ACGME Case Log reports indicating minimum requirements not met by recent graduates
Concerns identified from internal surveys	Annual ACGME Resident Survey Two or more categories with less than or equal to 50% compliance on any question A pattern of significant downward category trends since the last survey A rating of less than 4.0 in the category “Overall Evaluation” Survey completion rate below 70%
Concerns communicated to the GME office or QAS by Residents or faculty	Annual ACGME Faculty Survey Two or more categories with less than or equal to 50% compliance on any question** Pattern of significant downward category trends since the last survey Survey completion rate below 70%
Concerns identified by the GMEC or its subcommittees	Review Committee (RC) request for progress report
Programs with no Residents for 24 months	Board pass rate below 80%***
	Program with accreditation status of: Initial Accreditation with Warning Continued Accreditation with Warning Probationary Accreditation

**For a question with widespread low compliance (below 80%) across programs, the issue may be deferred to the GME Scorecard and addressed at a broader level, and therefore may not be considered in the SPR criteria.

***Per the ACGME Program Directors Guide to the Common Program Requirements, for a program to receive a citation related to board pass rates it would, (1) have to be in the lowest five percent of all programs in the specialty for board pass rate, and (2) have a board pass rate below 80 percent. Dartmouth Hitchcock Graduate Medical Education, and therefore the QAS, does not have access to specialty board pass rate data, and therefore must base SPR initiation on a pass rate below 80%. For programs that have recently completed an SPR related to board pass rates yet remain below 80% in subsequent years, the QAS may elect not to initiate another SPR as long as the pass rate is not decreasing.

Special Program Review Types
The QAS assesses which type of SPR is required to address the identified concern(s), based on criteria met:

Focused SPR; or
Full (Team) SPR

The initiation of each SPR type is addressed in the table below, however the QAS has discretion on which SPR type to initiate based on specific criteria and/or level of concern.

	Focused SPR	Full (Team) SPR
Initiation	Program meets single indicator from internal criteria, or external criteria 1-5	Program meets multiple indicators from internal criteria, and/or external criteria 1-5 and/or Program meets indicator from external criteria 6
Supervision	DIO or designee	DIO or designee
Reviewers	DIO or designee	Panel, which should consist of: Program director* Resident* Program coordinator* GME Office staff member(s) *from outside the section where the program under review resides
Documents	SPR Work Plan Final Report	Pre-SPR Work Plan SPR recommendations report Post-SPR Work Plan Final Report
Review Process	The DIO, or delegate, notifies the Program Director identifying the specific area of concern. The Program Director reviews the concern and completes an SPR work plan with corrective action, with submission to the QAS within 4 weeks of initial notification. The QAS reviews the SPR work plan and determines if a satisfactory plan is in place to resolve the trigger concern, or if additional follow-up or a Team SPR is required. The program provides the QAS with a follow-up progress update 90 days after submission of the SPR work plan, and in the next Annual Program Evaluation. The QAS completes a final report within two weeks of the Annual Program Evaluation deadline. The final report will outline quality improvement goals, corrective actions and the process for monitoring of outcomes.	The DIO, or delegate, notifies the Program Director identifying the specific area(s) of concern. The DIO, or designee, meets with program graduate(s) prior to departure to capture their voice(s) The Program Director reviews the concern(s) and completes a pre-SPR work plan with corrective action, submitting to the QAS within 4 weeks of initial notification. The assigned panel reviews the pre-SPR work plan and materials which document elements of the training program under review (see documentation list below). (a) The Resident panel member, DIO (or designee), and GME Office Accreditation Coordinator (or designee) meet with program Residents. The information gathered is blended with the voice of program graduate(s) (step 2) for the recommendations report. -OR- (b) The Program Director panel member, DIO (or designee), and GME Office Accreditation Coordinator (or designee) meet with Program Faculty. Based on feedback received from faculty, the QAS may elect to incorporate step 5a (resident meeting) into the process. The panel meets with program leadership, which should include: Department Chair/Section Chief, Program Director, Assoc. Program Director (if applicable), and Program Coordinator. The Accreditation Consultant, with feedback from the assigned panel, creates an SPR recommendations report within 2 weeks of final meeting. The QAS reviews the SPR recommendations report, which is then reviewed by the Program Director. The Program Director completes a post-SPR work plan, updating the original pre-SPR work plan and providing additional information as requested, within 4 weeks of receipt of the SPR recommendations report. The QAS reviews the post-SPR work plan and determines if a satisfactory plan is in place to resolve the concern(s) or if additional follow-up is required. The Program Director provides the QAS a follow-up progress update 90-days after submission of the post-SPR work plan and again in the next Annual Program Evaluation. The QAS completes a final report within two weeks of the Annual Program Evaluation deadline. The final report will outline quality improvement goals, corrective actions and outcomes monitoring.
GMEC Oversight	The QAS assigns, reviews, provides feedback on, and approves all work plans and reports generated by the SPR process. The QAS reports to the GMEC as required and at least quarterly.
Sharing Findings	The Program Director must share the results of the review with Residents and faculty in the program. Discussion of SPR action items at the Program Education Committee (PEC) must be documented as part of the Annual Program Evaluation (APE) process. Action item progress and outcomes will be tracked by the GME Office and QAS in the APE action items spreadsheet.

Team SPR documentation may include:

ACGME Accreditation Data Systems (ADS) summary
ACGME Graduate Resident Case Log – Minimums Report (if applicable)
Most recent Annual Program Evaluation (APE)
Previous SPR Reports and Work Plans within the last 3 years (if applicable)
ACGME Resident Survey results for past two academic years
ACGME Faculty Survey results for past two academic years
RC Accreditation Requirements
Relevant RC correspondence
Relevant program policies
Most recent board pass rate report for graduates
Other materials as necessary

SPR recommendations report must include

Name of the program reviewed
Program leadership roster
Panel members
Last RC site visit date
Current accreditation status
Start and end dates of the SPR
Quality improvement goals

Final report must include

Pre-SPR work plan (Full Team SPR only)
SPR recommendations report (Full Team SPR only)
Program defined corrective actions from SPR work plan (Focused SPR) or post-SPR work plan (Full Team SPR)
90-day and Annual Program Evaluation (APE) outcomes updates

Confidentiality

The SPR process is a quality assurance evaluation that is protected pursuant to NH RSA 151:13a and RSA 329:29a. A confidential cover page must accompany reports and work plans, indicating NH RSA 151:13a and RSA 329:29a quality assurance protection.
SPR reports and work plans are confidential and are not shared with program site visitors.
To confirm compliance with this policy document and ACGME Institutional Requirements, SPR reports are included in the Institutional Review Questionnaire (IRQ) and examined by the ACGME Institutional Review Committee at the time of periodic institutional accreditation evaluation to verify that we are following approved SPR policy, protocol, and procedure.

V. References

ACGME Institutional Requirements. (2022). Retrieved from ACGME.org: Institutional Requirements (acgme.org)

ACGME Program Director Guide to the Common Program Requirements. (2021). Retrieved from ACGME.org: program-director-guide---residency.pdf (acgme.org)

D-H Policy ID: 11318