Special Review Policy

Purpose

This policy defines underperformance in ACGME-accredited programs and outlines the process for conducting a special review in accordance with the ACGME Institutional Requirements listed below.

• 1.15. The GMEC must demonstrate effective oversight of underperforming program(s) through
  a Special Review process. (Core)
  
  • 1.15.a. The Special Review process must include a protocol that: (Core)
    • 1.15.a.1. establishes a variety of criteria for identifying underperformance that includes, at a minimum, program accreditation statuses of Initial Accreditation with Warning, Continued Accreditation with Warning, and adverse accreditation statuses as described by ACGME policies; and, (Core)
    • 1.15.a.2. results in a timely report that describes the quality improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes, including timelines. (Core)

Policy

1. Criteria for Review – TIER 1:
   The GMEC must conduct a special review when a program receives any of the following ACGME accreditation statuses:
   1. Initial Accreditation with Warning
   2. Continued Accreditation with Warning
   3. Probationary Accreditation
   4. Accreditation Withheld
   5. Withdrawal of Accreditation (including expedited)
2. Criteria for Review – TIER 2:
   The GMEC may initiate a special review based upon criteria including, but not limited to the following:
   1. Significant concerns related to the ACGME Resident/Fellow or Faculty Survey
   2. Reports of concerns by a resident/fellow to the GME Office or the Designated Institutional Official (DIO)
   3. Trends, such as persistent or recurring issues identified in the ACGME Letter of Notification across review cycles and ACGME Survey data
   4. Complaints against a program to the ACGME
   5. Concerns about new or extended citations or Areas For Improvement (AFIs) or failure to address citations or AFIs
   6. Concerns about board pass rates
   7. Failure to submit timely or accurate data to the ACGME
   8. Issues with underperformance of a program related to any ACGME-monitored or internal metrics
   9. At the request of the DIO or GMEC Executive Committee
   10. A request by program stakeholders such as a program director, residents/fellows, department lead for a special review*
       
       *These requests will be reviewed by the DIO and the GMEC Executive Committee to determine necessity and appropriateness.

Procedure

1. Timeline
   • Once the criteria for the review are met, the discussion will be added to the upcoming GMEC meeting agendas for discussion and vote.
   • If the GMEC votes in favor of conducting a special review of a program, the program will be notified following the GMEC meeting.
   • If the special review is time-sensitive, an electronic vote will be conducted.
2. Special Review Team
   A special review team composed of GMEC representatives is convened to perform the review of the program. The special review team includes the DIO or Associate DIO (ADIO), a GMEC-voting program director, and a resident/fellow representative of the GMEC — none of whom may be members of the program under review. The Chair of the special review team is the GMEC-voting program director. A program coordinator who is a GMEC member and not affiliated with the program under review may also be invited to participate, as deemed necessary. Additional members may be recommended by the GMEC, provided they are not affiliated with the program under review.
3. Interviews
   At a minimum, the interviews conducted must include:
   1. The Chair of the special review team and DIO or ADIO, with all available residents/fellows by PGY level.
   2. Resident/Fellow representatives of the GMEC, with peer-selected resident/fellows from the program to be reviewed (1-2 from each class), conducted together or separately based on availability.
   Other interviews that may occur include:
   3. Chair of the special review team and DIO or ADIO, with core faculty members.
   4. Program coordinator from the GMEC, with program coordinator from the program.
   5. GME Office team members as administrative reviewers, with program coordinator from the program, to review requested documentation.
   6. Others, as deemed necessary by the special review team.
   
   The program coordinator from the program under review will coordinate interviews with the GME Office.
4. Review of Documentation
   The DIO will determine the materials and data to be reviewed during the special review.
   The special review team will conduct a special review by reviewing materials, data, and other information requested by the special review team through interviews with identified individuals. As requested, the program coordinator will facilitate the distribution of materials to the GME Office.
5. Reporting
   The special review team will prepare a Findings and Action Report to be presented to the GMEC for review and approval.
   At a minimum, the report must include:
   1. A description of the criteria of concern and findings regarding each concern.
   2. Quality improvement goals to address identified concerns.
   3. The process for the GMEC to monitor outcomes of corrective actions to be implemented by the program.
      The Special Review Findings and Action Report is completed by the Chair of the special review team, with input from all team members, and submitted to the DIO and GMEC for discussion and comments. The special review team will then meet with program leadership in a collaborative discussion to identify quality improvement goals and address identified concerns.
      The report is confidential and will not be shared outside of the GMEC; however, it will be shared with the program following GMEC review. The DIO will encourage the program to include residents/fellows and faculty in the development of action plans.
6. Monitoring of Outcomes
   Based on the Special Review Findings and Action Report, the program director, with support from the DIO/ADIO, will develop and present an action plan to the GMEC to address all noted concerns. The DIO may request updates to the action plan based on GMEC feedback, and the GMEC may request follow-up meetings with residents/fellows and/or faculty to monitor progress.
   The program director will provide written updates to the DIO for documentation purposes, in accordance with the monitoring section of the report. Progress on each action item will be recorded in the GMEC minutes. The GMEC may request more frequent updates or additional follow-up as needed.
   Action plan updates will conclude with the completion of the action items. The GMEC will then vote on one of the following actions:
   1. The action plan has been successfully completed with no additional GMEC reports needed.
   2. The action plan will be updated, with continued updates required as requested by the GMEC.

Attachment A: Special Review Action Plan Template

GMEC Approved Date: June 2, 2026
Next Review Date: Spring 2027