ࡱ> SUR)` bjbj 7*{{%8$$BhNN"pppKKKdBfBfBfBfBfBfB$MDhFTBKKKKKBppBKdppdBKdB6:0^=pB df;$(B<B0B; G| GH^=^=z G=PKKKKKKKBBdKKKBKKKK$   SUNY Health Science Center at Brooklyn Downstate Medical Center GRADUATE MEDICAL EDUCATION POLICY AND PROCEDURE POLICY: ANNUAL INSTITUTIONAL REVIEW PURPOSE: To establish a formal, systematic process by which the GME Committee demonstrates effective oversight of the Sponsoring Institutions accreditation through an annual review and evaluation of institutional performance indicators in accordance with the Institutional Requirements of the ACGME (I.B.5) and any policies and procedures of the SUNY Health Science Center at Brooklyn (Downstate Medical Center) Graduate Medical Education Committee. POLICY: The Executive Subcommittee of the GME Committee is charged among other things with the following responsibilities: Review, monitor and assess accreditation status of sponsoring institution and its programs, and responses to citations, ACGME notifications and concerns Review results of CLER visits, and review and approve responses to CLER visit reports Address results of focused or special program reviews On behalf of GMEC, demonstrate Sponsoring Institution oversight of accreditation through an annual institutional review (AIR) This policy describes the procedure by which the Executive Subcommittee of the GMEC will fulfill its charge in conducting an Annual Institutional Review. PROCEDURE: At least one full meeting of the Executive Subcommittee will be dedicated to conducting the AIR. The AIR should be conducted during or before autumn of each academic year, preferably during September, unless rescheduled for other programmatic reasons. Beginning approximately one to two months prior to the review date, the Designated Institutional Official (DIO) in collaboration with the Chair of the Executive Subcommittee will: Establish and announce the date of the review meeting Inform the standing membership of the Executive Subcommittee of the review date and assure that the DIO, Chair of Executive Subcommittee, at least 2 Program Directors, and at least one (1) peer-selected resident representative participate in the review (this does not include post-graduate chief residents such as those in Internal Medicine and Pediatrics). Identify staff assisting with organizing the data collection, coordinating the review process, and report development. Compile the data and information, at a minimum those performance indicators that are listed below, to be considered in the review Results of most recent institutional self-study visit (or most recent accreditation site visit letter of notification) Results of ACGME surveys of residents/fellows and core faculty Notification of ACGME-accredited programs accreditation statuses and self-study visits Any other supporting information the committee may deem necessary Outcome of action plans resulting from prior AIRs At the time of the meeting, the Committee will review its charges and responsibilities, the institution history including past citations and previous years action plans, responses to prior action plans, and current performance indicators and outcome data such as that described above. Additional meetings may be scheduled, as needed, to continue to review data, discuss concerns and potential improvement opportunities, and to make recommendations. Written minutes will be taken of all meetings and submitted to GMEC. As a result of the information considered and resulting discussion, the Committee AIR will: identify any areas for improvement develop an action plan(s) to address areas for improvement include monitoring procedures for action plan(s) resulting from the review The AIR final report, action plan and DIO executive summary will be presented to and approved by the GME Committee The DIO will submit a written annual executive summary of the AIR to the Governing Body (the President) of the Sponsoring Institution. Approved by GMEC on June 18, 2014. 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