Program

Annual Institutional Review (AIR)

and Annual Program Evaluation (APE) Policy

Institution and Program Quality Oversight

Purpose

In compliance with the ACGME Institutional and Common Program Requirements, the Graduate Medical

Education Committee (GMEC) sets forth this policy to establish oversight of the UACOM-T’s accreditation

through an annual institutional review process, and of the quality of the learning and working environment,

its participating sites, and educational activities.

The ACGME Institutional Requirements (2021) state:

I.A.5.b).(2) The Designated Institutional Officer (DIO) must oversee submissions of the Annual Update for each

program and the Sponsoring Institution to the ACGME (Core);

I.B.4.a) GMEC responsibilities include oversight of:

I.B.4.a).(1) ACGME accreditation and recognition statuses of the Sponsoring Institution and each of

its ACGME-accredited programs; (Outcome)

I.B.4.a).(2) the quality of the GME learning and working environment within the Sponsoring

Institution, each of its ACGME-accredited programs, and its participating sites; (Outcome)

I.B.4.a).(3) the quality of educational experiences in each ACGME-accredited program that lead to

measurable achievement of educational outcomes as identified in the ACGME Common and specialty-

/subspecialty-specific Program Requirements; (Outcome)

I.B.4.a).(4) the ACGME-accredited program(s)’ annual program evaluation(s) and Self-Study(ies);

(Core)

I.B.5. The GMEC must demonstrate effective oversight of the Sponsoring Institution’s accreditation through

an Annual Institutional Review (AIR) (Outcome).

I.B.5.a) The GMEC must identify institutional performance indicators for the AIR to include, at a minimum:

(Core)

I.B.5.a).(1) the most recent ACGME institutional letter of notification; (Core)

I.B.5.a).(2) results of ACGME surveys of residents/fellows and core faculty members; and, (Core)

I.B.5.a).(3) each of its ACGME-accredited programs’ ACGME accreditation information, including

accreditation and recognition statuses and citations. (Core)

I.B.5.b) The DIO must annually submit a written executive summary of the AIR to the Sponsoring Institution’s

Governing Body. The written executive summary must include: (Core)

I.B.5.b).(1) a summary of institutional performance on indicators for the AIR; and, (Core)

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I.B.5.b).(2) action plans and performance monitoring procedures resulting from the AIR. (Core)

The ACGME Common Requirements (Residency, Fellowship, One-Year Fellowship, 2023) state:

V.C.1. The program director must appoint the Program Evaluation Committee to conduct and document the

Annual Program Evaluation as part of the program’s continuous improvement process. (Core)

V.C.1.e) The Annual Program Evaluation, including the action plan, must be distributed to and discussed with the

residents and the members of the teaching faculty, and be submitted to the DIO. (Core)

Process for AIR

1. In April of each academic year, the Associate Dean of Graduate Medical Education (GME) will create a GMEC

subcommittee to perform the AIR. This subcommittee will be comprised of GMEC members, including a resident

member, and other key constituents or representatives as needed.

2. The GMEC subcommittee will review institutional performance data including:

• New Institutional/Common Program Requirements for changes in the upcoming academic year

• GME mission statement

• Institutional ACGME resident, faculty and well-being surveys (including 3-year trends)

• Institutional accreditation status

• Institutional citations/areas of improvement

• Institutional milestones reports

• Previous year’s Executive Summary, including identified AIR goals and progress toward meeting those goals

• Sponsored programs’ accreditation statuses

• Sponsored programs’ citations/areas of improvement

• Review of programs in special review

• Program APEs and identified action plans, and progress toward meeting action plan goals

• Self-Study reports (when applicable)

• Resident Grievance(s)

• CLER report and response(s)

• Quantity and quality of exceptionally qualified trainees

• GME office annual survey results

• Other relevant material as applicable

3. A SWOT/PDSA will be performed to identify short-/mid-/long-term goals for the upcoming year.

• Goals will be in SMARTIE format.

• Goals will include steps for implementing the action plan, quantitative metrics to be used, and a plan to

monitor for achievement and sustainability of the goals.

4. A written executive summary of the AIR will be prepared by the Associate Dean for GME and the DIO.

5. The AIR processes, identified institutional performance indicators, and the Executive Summary will be reviewed

and approved by the GMEC annually.

6. After review by the GMEC, the finalized Executive Summary will be submitted to the UACOM-T’s Governing

Body (the Arizona Board of Regents), the Academic Management Council (AMC), and a UACOM-T General Faculty

Meeting annually.

7. The institutional AIR goals will be entered in ADS by the ACGME deadline annually.

Process for the APE

1. In April of each academic year, the GME office will release the APE Summary Form through New Innovations.

2. At a minimum, PEC meetings should be held in June/July of each year. Programs are encouraged to hold more than

one PEC meeting throughout the year to review relevant data as needed.

3. The PEC will review annual program data, perform a SWOT/PDSA analysis, and develop an APE that includes

goals and an action plan for the upcoming year.

• Program goals will be in SMARTIE format.

• Goals will include steps for implementing the action plans, quantitative metrics to be used, and a plan to

monitor for achievement and sustainability of the goals.

4. After the APE is completed, the APE will be presented to faculty and trainees at a minimum (and other stakeholders

as needed) for prompt review and feedback.

5. After incorporating feedback into the APE, the APE Summary Form will be completed and submitted through New

Innovations to the GME office for review. APE Summary Forms will be submitted in August of each year to allow

time for review and feedback.

6. The APE Summary Form will be reviewed by the GME office staff, and feedback will be provided to the program.

7. After the GME office has approved the APE Summary Form in New Innovations, the finalized APE should be

distributed to faculty and trainees at a minimum, and to other stakeholders as needed.

8. APE action plans will be entered in the Major Changes section during the annual program update in ADS. The

annual update must be completed and finalized in ADS at least one week prior to the deadline. This allows time for

DIO review and approval, as required in the ACGME institutional requirements [

I.A.5.b).(2)].

9. The GMEC will review APEs annually and may employ a variety of methods to provide additional oversight and

support, and to help identify and overcome potential barriers in reaching program goals. This may include providing

specific, written feedback on the APE, performing focus groups with trainees, or 1:1 meetings with program

leadership.

July 2013

Reviewed July 2015, January 2017

Revised April 2023; GMEC-approved May 2023