Graduate Medical Education Departmental Policy
Policy Title: Annual Institutional Review (AIR)
Policy Number: 43.3
Effective Date: September 16, 2015
To establish a formal, systematic process by which the Graduate Medical Education Committee (GMEC)
demonstrates effective oversight of the Sponsoring Institution’s accreditation. This is partially achieved
through an annual review and evaluation of institutional performance indicators in accordance with the
Institutional Requirements of the ACGME (I.B.5); and any policies and procedures of the UW Health
II. PROGRAMS AFFECTED
This policy applies to all Graduate Medical Education (GME) programs sponsored by the University of
Wisconsin Hospitals and Clinics Authority (UWHCA).
A. The term “resident” refers to residents and fellows.
B. Program(s) will refer to UWHC sponsored ACGME-accredited program(s).
C. UW Health: For the purpose of this policy, the term “UW Health” shall mean University of
Wisconsin Hospitals and Clinics Authority, which is the sponsoring institution of the ACGME-
accredited training programs. “UW Health” is the trade name of University of Wisconsin
Hospitals and Clinics Authority and its affiliates.
The GMEC must demonstrate effective oversight of the Sponsoring Institution’s accreditation through an
Annual Institutional Review (AIR). The GMEC must identify institutional performance indicators for the
AIR, which includes:
A. results of the most recent institutional self-study visit;
B. results of ACGME surveys of residents and core faculty members;
C. notification of each of its ACGME-accredited programs’ accreditation statuses and self-study
D. outcome of action plans resulting from prior AIRs.
The AIR must include monitoring procedures for action plans results from the review. The DIO must
submit a written annual executive summary of the AIR to the UW Hospitals and Clinics Authority Board.
A. At least one full meeting of the GMEC will be dedicated to conducting the AIR.
B. The AIR should be conducted during or before autumn of each academic year, preferably during
August, unless rescheduled for other programmatic reasons.
C. Beginning approximately one to two months prior to the review date, the Designated
Institutional Official (DIO) in collaboration with the Chair of GMEC will:
a. Establish and announce the date of the review meeting;
b. Inform GMEC membership of the review date and assure that the DIO, Chair of the GMEC,
at least 2 Program Directors, and at least one (1) peer-selected resident representative
participate in the review (this does not include post-graduate chief residents such as those in
Internal Medicine and Pediatrics);
c. Identify staff assisting with organizing the data collection, coordinating the review process,
and report development;
d. Compile the data and information to be considered in the review. This should include the
performance indicators listed in section IV above and any other information requested by the
D. At the time of the meeting, the Committee will review: its charges and responsibilities; the
institutional history, including: past citations, previous year’s action plans, responses to prior
action plans, current performance indicators, and outcome data such as that described above.
E. Additional meetings may be scheduled, as needed, to continue to review data, discuss concerns
and potential improvement opportunities, and to make recommendations.
F. Written minutes will be taken of all meetings.
G. As a result of the information considered and resulting discussion, the Committee will:
a. identify any areas for improvement,
b. develop an action plan(s) to address areas for improvement,
c. include monitoring procedures for action plan(s) resulting from the review.
5. The AIR final report, action plan, and executive summary will be presented to GMEC for approval.
6. The DIO will submit the final AIR report and the executive summary to the Governing Body
(UWHCA Board) of the Sponsoring Institution.
Sr. Management Sponsor: Susan L. Goelzer, M.D., M.S., Designated Institutional Official
Author: Director, Graduate Medical Education and Medical Staff Administration
Approval Committee: Graduate Medical Education Committee
Approved by GMEC on September 16, 2015.
Susan L. Goelzer, M.D., M.S.
Professor of Anesthesiology, Internal Medicine and Population Health Sciences
Designated Institutional Official
Associate Dean for Graduate Medical Education
Previous Revision Date: New
Next Revision Due: 9/16/2018