Program Internal

This module has been prepared to assist you in maintaining a quality training program for your residents. It contains important information that will help you conduct a continuous quality improvement process such as the program internal review. The following information is provided:

The April 2005 COPT Newsletter reported that the “AOA Board of Trustees, at its July 2003 meeting, approved a requirement for the initiation of an internal review process pending development by the COPT. This process has now been completed and approved by COPT.

The internal review is a mid cycle assessment of an AOA approved internship/residency program.

A program internal review is a continuous quality improvement strategy. If needed, changes to the program can be made based on the internal review thus, enhancing the quality within each program. In addition, this review will enable the program to perform better on their next AOA on-site review.

This review will take place at approximately mid approval cycle. For example, if your program were given 5-year approval, your internal review would take place in 2 ½ years. This requirement goes into effect after the next on-site program review beginning July 1, 2005.

The Medical Education Committee will designate an internal review committee. An internal team, which includes a resident from within the training institution or OPTI, will conduct this review. This team will review compliance with all AOA standards. Copies of reviews and recommendations are not to be made available to the external reviewers.

A program director from another specialty will chair the team. Members could include the DME, a faculty from another specialty, resident from another specialty, an OPTI representative, and a medical education office staff.

Date	Activity
Date of recent AOA inspection (After July 1, 2005)	AOA inspection
Date of receipt of most recent AOA inspection report	File report/deficiencies.
Mid-approval cycle	The Medical Education Committee (MEC) designates a program internal review (PIR) committee. The PIR committee conducts its initial meeting to discuss AOA inspection report and deficiencies.
Specified time after initial meeting	The PIR committee conducts a one-day program internal review. Include interviews with the program director, representatives from the faculty, interns/residents in the program (no less than 50%) and other individuals deemed appropriate by the committee. Refer to the PIR Template (Appendix A).
Specified time after the one-day internal review	The PIR committee conducts a debriefing.
Specified time after debriefing	The PIR committee prepares a written report. Refer to the PIR Report Template (Appendix B). This must be presented to and reviewed by the MEC to monitor the areas of noncompliance and recommend appropriate action. PIR committee should also submit a copy of the written report to the OPTI Chief Academic Officer.

Medical Education Committee - responsible for the development, implementation, and oversight of the internal review process. Designates an internal review committee to include program director from another specialty who chairs the internal review committee, faculty from another specialty/department, residents/fellows from within the institution but from programs other than the one being reviewed, and a representative of the institution’s accredited OPTI.

Program Director from another specialty – chairs the program internal review committee, serves as the facilitator of the initial meeting, internal review, and debriefing, and monitors the completion of the PIR Report.

Resident/fellow from within the institution but from programs other than the one being reviewed – participates in initial meeting, internal review, and debriefing.

Faculty from another specialty/department – participates in initial meeting, internal review, and debriefing.

Medical Education Staff – participates in initial meeting, internal review, and debriefing. Provides logistical support.

Other: CORE Assistant Dean – acts as a representative of the institution’s accredited OPTI and participates in initial meeting, internal review, and debriefing.

Description of how the internal review process was carried out, including the list of the groups/individuals who were interviewed:

Sufficient documentation or discussion of the specialty’s Program Requirements and the AOA’s Institutional requirements to demonstrate that a comprehensive review was conducted and was based on the OPTI’s internal review protocol.

A list of the areas of noncompliance or any concerns or comments from the previous AOA accreditation letter with a summary of how the program and/or institution addressed each one.