1. CORE 45-Day Corrective Action Plan Review Process PTRC Decision Letter to PD PTRC Decision Letter to PD Program Director formulates CAP DME conducts 1 st review of CAP CORE CAO triages CAP CASC actions AOA/specialty college review CAPCom review 30 Days 45 Days The CAO may forward non-substantive 45-Day CAPs to AOA after review; this action is approved at CASC en bloc Non-substantive infers citations associated with a five year accreditation award or citations of a clerical/reporting nature 45-Day CAPs requiring substantive action are reviewed by CAPCom during monthly CASC reference group meetings CASC acts on acceptable CAPs that are then forwarded to AOA; unacceptable CAPs are returned via the CAO to the program for further refinement CASC action is documented for OPTI accreditation purposes

2. CORE 180-Day Corrective Action Plan Review Process PTRC 45-Day CAP Acceptance Letter to PD PTRC 45-Day CAP Acceptance Letter to PD Program Director implements CAP (creates documentation & records outcomes) Program Director implements CAP (creates documentation & records outcomes) DME conducts review of implemented CAP (documentation & outcomes) CORE CAO triages CAP CASC actions CAPCom review 120 Days 60 Days The CAO may forward selected 180-Day CAPs directly to CASC after review; this action is approved at CASC en bloc Selected 180-Day CAPs include citations associated with a five year accreditation award or citations of a clerical/reporting nature 180-Day CAPs requiring substantive action are reviewed by CAPCom during monthly CASC reference group meetings CASC acts on acceptable CAPs; unacceptable CAPs are returned via the CAO to the program for further refinement CASC action is documented for OPTI accreditation purposes Process initiates if 45-Day CAP did not include evidence of implementation

3. Explanation of Terms CASC – CORE Academic Steering Committee OPTI GME committee CAP – Corrective Action Plan CAO – Chief Academic Officer DME – Director of Medical Education PD – Program Director CAPCom – Corrective Action Plan Committee CAP review committee PTRC – Program and Training Review Committee