ACGME Institutional Requirements for Internal Reviews:
ACGME requires that the "GMEC must develop, implement, and oversee an internal review process." The University of Colorado Denver Graduate Medical Education Committee complies with this requirement as detailed in the GME Internal Review Process.
INTERNAL REVIEW PROCESS FOR ACGME PROGRAMS – Flow Chart
IRC = Internal Review Committee (Primary/Secondary faculty person(s), fellow/resident,
DIO, Director of Compliance, Director of Accreditation & Education)
Internal Review Process Flow Chart: Expanded (Printable) Version
Program Schedule of Internal Review Dates:
An internal review will be scheduled for all ACGME programs as close as possible to the approximate date for the internal review as detailed on each program’s ACGME accreditation notification letter.
Required Forms and Documentation to be Completed by the Program Director:
Your responses in the below documentation will be reviewed by the Internal Review Committee and integrated into the report prepared for the GMEC. The internal review report will be presented at the GMEC meeting following the internal review.
Program directors are responsible for completing and submitting the following to the GME Director of Compliance 2-3 weeks before their program’s internal review date.
1. Program Information Form (PIF) -www.acgme.org/acgmeweb/
a. Part 1 Common PIF – log into ACGME WebADS to complete, generate, and download
b. Part 2 Specialty/Sub-specialty PIF (go to the ACGME website, select Review
Committees, select specialty/sub-specialty)
c. Please note: some specialties are moving toward the entire PIF being completed in WebADS.
2. Checklist of Required Program Documentation – please download and print.
This is a comprehensive list of all documentation that must be submitted to the GME office
2-3 weeks before the scheduled internal review date.
Program Documentation Review Meeting:
The GME Director of Compliance will meet with the Program Coordinator 2-3 weeks prior to the internal review date to review the program’s resident and graduate files, PLAs, resident/fellow handbook, policies, and all other required documents as detailed in the program documentation review checklist.
For questions regarding internal reviews, please contact Tammy Samuels, MPA, GME Director of Compliance (303)-724-6033.