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Rose Marie Frey
Program Project Coordinator
RoseMarieFrey@stanfordhealthcare.org
650-723-6564 (Office)
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Forms
Special Review & the Special Review Committee (SRC)
ACGME Requirement
ACGME Institutional Requirements:
Requirement I.B.6 – Special Review process that:
- I.B.6.a).(1) establishes criteria for identifying underperformance; and,
- I.B.6.a).(2) results in a report that describes the quality improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes.
The Big Picture
The Special Review occurs when a program is underperforming or when GME conducts periodical reviews of a program.
During the Special Review, the Special Review Committee (SRC) interviews the following:
- program trainees
- program faculty
- program director
- program coordinator
- department chair/division chef
to generate a report for the Graduate Medical Education Committee (GMEC).
The GMEC review and approve the SRC recommendations for the program so that the program addresses the GMEC and SRC’s concerns.
Special Review Committee (SRC)
The Special Review Committee (SRC) is comprised of:
- 1 Faculty Representative
- 1 Resident Representative
- Designated Institutional Officer (DIO)
- GME Program Manager
Process
- The GME Accreditation Team notifies the program of the upcoming Special Review.
- Program schedules the Special Review with all its interviewees and notifies the accreditation team.
- The GME Accreditation Team searches for Special Review Committee (SRC) members for the review.
- Program gathers documents on the Special Review Checklist before the deadline, and notifies the accreditation team.
- Program schedules the Special Review with all its interviewees and notifies the accreditation team.
- The GME Accreditation Team searches for SRC members for the review.
- SRC reviews the program's documents.
- Special Review is conducted.
- SRC drafts a report to submit to GMEC for review.
- Program follows up with action items from the report.
- The GME Accreditation Team monitors the program's progress until the program improves program quality.
Document Checklist
Tips for Pre-, During, and Post-Review
Before the review:
- Notify the GME Accreditation Team when your program has scheduled the review
- Consult with GME Accreditation Team if you have any questions or concerns
- Remind everyone within your program of their designated time slot
After the review:
- If GME reaches out to the Program, the Program Director attends the GMEC Meeting to answer questions the committee has on the review.
- Program addresses the SRC recommendations.
Glossary
- Special Review (SR)
- Special Review Committee (SRC)