Annual Institutional Review (AIR) Protocol

LOUISIANA STATE UNIVERSITY SCHOOL OF MEDICINE-NEW ORLEANS

Annual Institutional Review Protocol (AIR)

Effective Date:  July 1, 2017

Approved by GMEC: April 15, 2016

1. Purpose:

The ACGME requires that all institutions which sponsor ACGME accredited GME programs have an organized process to demonstrate effective oversight of the institution through an Annual Institutional Review (AIR) process (I.B.5). The Graduate Medical Education Committee is responsible for the development, implementation, and oversight of the annual review process.  The AIR is to assess the quality of our programs and institution by monitoring and requesting follow up on over 24 program and institutional performance indicators chosen by GMEC. The culmination of the analysis of these indicators is an Executive Summary delivered to the Organized Medical Staff each year.

1. Policy:

It is the Graduate Medical Education Committee’s responsibility to ensure that the process shall be in accordance with ACGME standards.  The GMEC identifies the need and process as stipulated in those standards.

• Annual Institutional Review Process:

1. Reviewers

The Annual Institutional Review Performance Indicators will be compiled by the DIO, Director of Accreditation, GME Statistician and other GME Staff and Program Leadership as deemed necessary throughout the year.  This team will identify any deficiencies in the institution in meeting performance indicators and required areas and make suggestions for addressing the. The team will develop initial action plans for monitoring and present to the GMEC for review, additional recommendations, action items, and approval.

The GMEC receives annual reports of each of the performance indicators (see below) throughout the year and the Annual Executive Summary in January of each year prior to it being presented to the Organized Medical Staff. In response to presentation of each of the performance indicators GMEC may develop additional action plans requiring time specified follow up reporting.

1. Timing and Reporting

Due to the volume of material reviewed and the staggered and episodic reporting of that date to the institution, AIR will represent an ongoing performance improvement activity of the institution under the direction of GMEC. As data for each of the performance indicators becomes available it will be presented to GMEC according to the GMEC schedule and will be centrally collected in one repository (AIR Binder) for each academic year.

1. Reporting of the Annual Executive Summary

The information from this central repository will be used to create the Annual Executive Summary for presentation to GMEC in January and the OMS in February of the year following the previous AY.

1. Performance Indicators
2. AIR reports / Action Plans / Follow up (see also Program Files)
3. ACGME Notification of Institutional Accreditation
4. Institutional Roll Ups
5. Resident End of Year (Survey Monkey – Institutional) Survey
6. Program Strengths –(Survey Monkey – Institutional) Text
7. Program Areas to Improve –(Survey Monkey – Institutional) Text
8. Hospital deficiencies –(Survey Monkey – Institutional) Text
9. WebADS – Institutional Aggregate Data – Resident / Faculty Surveys
10. ACGME Resident Surveys – Program Data
11. ACGME Faculty Data – Program Data
12. Annual Performance Review – Aggregate Data
13. Citations (see also Inst Roll Ups)
14. Liaison Survey
15. Resident Exit Survey
16. Educational and Clinical Work Hours Report
17. EQuIP Annual Report
18. Common Program Requirements Yearly Compliance
19. CLER Visit Results
20. Match Data – by specialty / in-out state/offer-fill/
21. Manpower data
    1. Total Payroll
    2. Historical by Program

• Historical by Site

1. Running Total bar graph – All and NO only
2. Public Private
3. % Metro NO ( NO only)

• IMGs and visa types

1. Notification of Programs’ Accreditation Status and Self Study Results
2. Institutional Self Study Results
3. Special Focused Program Reviews Data

1. Changes in Program Leadership
2. Changes in Participating Sites
3. Changes in Resident Complement