Internal Reviews


Internal reviews (IRs) are an important function of the GME Office. All VUMC GME programs must participate in reviews according to the target dates set by the ACGME (for ACGME programs) or the Associate Dean (for non-ACGME programs). For ACGME programs, they are a mandatory part of accreditation.

This IR is similar to a practice session for your next accreditation site visit and each institution follows different protocols for how these reviews are completed. Unlike a site visit, this process is designed to help your program. The IR process determines how well you follow the program requirements, how you have responded to the citations and recommendations in your last accreditation letter and internal review, how satisfied your residents are with the program, and many other topics.

The IR committee reviewing the program is composed of:

  • Associate Dean, GME and DIO
  • Administrative Director, GME
  • Outside program faculty
  • Outside program resident

After review of your materials and interviews with the program director, faculty and residents the internal review committee makes recommendations for your program in a formal report. This report is internal and unavailable to your site visitor, but documentation of the date must be provided.


The following information provides guidelines to ensure timely compliance with program internal review procedures.

The GME Office IR coordinator will email the program director and coordinator no less than 90 days before the target date of the IR. The email will contain a scheduling request for the IR and necessary. The program must coordinate with Megan to find a date convenient to both Dr. Terhune and the program.

The scheduling email will come with the IR documents to be filled out by the program and instructions. The program should fill out the IR documents and submit them to the GME Office no later than two weeks before the date of the internal review so that the committee has time to review them. Be sure to look over them as soon as you receive them. 

The reviewed program’s attendees at the internal review must be:

  • Program Director and associate PD (if there is one) – Time required: first hour
  • Program faculty other than PD - Time required: next half-hour
  • House staff (at least one peer-elected resident from each level) - Time required: last half-hour

The program must ensure that its representatives are present and on time.

Before the IR, the IR committee will review the materials you submit, as well as resident surveys, ACGME and GME Office correspondence, and program requirements. At the IR, they will interview the various program participants and discuss the documents with them.

About a month after the IR committee meets with your program, you will receive a report documenting the observations and analysis of the IR committee. It will include helpful recommendations for improvement and will likely ask that you follow up with a progress report a few months later.

For questions, contact