GME Annual Institutional Review Policy (AIR)
DEPT: MEDICAL EDUCATION
POLICY #: 8240.21
GOAL
To establish a written protocol for the Annual Institutional Review in accordance with ACGME requirements.
POLICY
1. The GMEC must demonstrate effective oversight of the Sponsoring Institution’s (Santa Barbara Cottage Hospital) accreditation through an Annual Institutional Review (AIR).
2. The GMEC must identify institutional performance indicators for the AIR (see below).
3. The DIO must annually submit a written executive summary of the AIR to the Governing Body. The written executive summary must include:
a) A summary of institutional performance on indicators for the AIR; and,
b) Action plans and performance monitoring procedures resulting from the AIR.
4. Annually, members of the GMEC will conduct and present the AIR. If a sub-committee of the GMEC is formed to conduct the review, that sub-committee will include at least one resident.
5. Institutional Performance Indicators
a) The AIR Report must include:
i. The most recent ACGME institutional letter of notification (when available);
ii. Results of ACGME surveys of residents/fellows and core faculty
iii. Each of its ACGME-accredited programs’ ACGME accreditation information, including accreditation statuses and citations.
b) The AIR Report may include review and discussion of:
i. GMEC responsibilities (from Institutional Requirements)
ii. Last ACGME accreditation letter
iii. CLER report (when available)
iv. Last annual report to Governing Body
v. In-house program survey results
vi. Use of data in decisions
vii. APE results and data use
viii. Clinical Experience and Education (Work Hour) compliance
ix. Policies (specifically Clinical Experience and Education (Work Hours), Supervision, Transition of Care, etc.)
x. Board passage rate data
xi. Graduate feedback (when available)
xii. Program Goals & Objectives
xiii. Resident QI and Patient Safety Projects
xiv. Selected ADS data
xv. Rotation schedule/block
xvi. Changes since last CLER or self-study visit
xvii. ACGME Citations/Responses xviii. Residency alignment with Institution mission
xviii: Residency alignment with Institution mission
c) The AIR Report will include a discussion of the 6 CLER Focus Areas (See ACGME CLER Pathways to Excellence documents):
i. Patient Safety
1. When available, the AIR committee will review
a. Number of resident recorded events
b. Training sessions
c. Open/closed recorded events
d. Risk meetings
e. Residents ability to report without fear
f. Engagement in standardized care transitions
ii. Health Care Quality
1. When available, the AIR committee will review
a. Current projects: title, residents/faculty, status, outcome
b. Potential projects: ideas, who may be interested, options
c. Didactic sessions: Title, date, audience, feedback
d. Education and engagement with institutional health care disparity initiatives: Results/outcomes of projects
e. Provision of data on quality metrics
iii. Teaming
1. When available, the AIR committee will review
a. Interprofessional learning activities on teaming
b. Demonstration of high-performance teaming including patient engagement and system support
iv. Supervision
1. When available, the AIR committee will review
a. Education on supervision
b. Culture of supervision
c. Roles of clinical staff members other than physicians in resident supervision
d. Patient perspectives on graduate medical education supervision
e. Monitoring of resident supervision and workload
f. Number of lapses
g. Procedure/protocol for reporting lapses
h. Communication channels
i. “Credentialing” database, who can do what, availability to support staff, training
v. Well-being
1. When available, the AIR committee will review
a. Specific efforts to promote the well-being of residents, faculty, and the clinical care team
b. Mechanisms for identification, early intervention, and ongoing support of residents and faculty members who are at risk of or demonstrating self-harm
c. Effectiveness of efforts to achieve well-being of the clinical care team
vi. Professionalism
1. When available, the AIR committee will review
a. Education on professionalism
b. Timeliness of assignment completion (faculty & resident evaluations, other assignments)
c. Reports of resident mistreatment
d. Other breaches of professionalism (conflict of interest, PHI breaches, use of copyrighted material, accurate reporting of work hours)
6. The AIR committee will prepare a written plan of action to document initiatives to improve performance in one or more of the areas listed above as well as delineate how they will be measured and monitored. The action plan will be reviewed and approved by the GMEC and documented in meeting minutes. The DIO will submit a written annual executive summary of the AIR to the Governing Body.
COTTAGE HEALTH POLICY
Original Policy Effective Date: 4/2014
Last Review Date: 1/2024
Last Revision Date: 1/2024
Owner Title: Designated Institutional Official (DIO)
Owner Approval Date: 1/2024
Committee Approval: Graduate Medical Education (GMEC)
Committee Approval Dates: 1/2024
VP Approval: CMO/VPMA
VP Approval Date: 1/2024
Previous Review Dates: 1/2021
Previous Revision Dates: 1/2018
