Section 3
Evaluation and
Assessment
Processes
Effective:
July 2005
Revised:
February 2014, May
2014, February 2015,
August 2017
Policy 3.5.
Program Evaluation
Committee and
Annual Program
Evaluation
Responsibility:
Designated
Institutional Official
Program Evaluation Committee (PEC) and
Annual Program Evaluation (APE)
Policy
The ACGME requires that all GME programs implement formal
processes of program curriculum planning and program evaluation. It is
the responsibility of the Program Director to appoint a Program
Evaluation Committee (PEC), which is to participate actively in both
aspects of the program.
PEC membership – The Program Evaluation Committee must be
composed of at least
three program faculty members (in addition to the
Program Director and/or Associate Program Director)* and should
include at least one resident (unless there are currently no trainees in
the program); must have a written description of its responsibilities
(please see the Responsibilities of the Program Evaluation Committee
(PEC) template attached to this policy).
*Faculty members of the PEC must be either core or key faculty (as
defined by the ACGME Specialty Specific Program Requirements) or
faculty responsible for a significant curricular component of the program.
PEC meeting frequency - The PEC must meet at least annually
to
conduct the APE. However, more frequent meetings are recommended
to facilitate a process of continuous program improvement.
PEC responsibilities – the PEC is required to participate actively in the
following:
• Program planning, developing, implementing, and evaluating
educational activities of the program
• Reviewing and making recommendations for revision of competency-
based curriculum goals and objectives
• Addressing areas of non-compliance with ACGME standards; and
• Reviewing the program annually using evaluations of faculty,
residents, and others, as specified below.
• Documentation of formal, systematic evaluation of the curriculum at
least annually, and
• Preparation of a written Annual Program Evaluation (APE). This
report will be formulated using a template in New Innovations.
• Submit the APE to the GME Office for review by the Compliance and
Accreditation Standing Committee of the GME Committee.
APE parameters – essential specific parameters to be monitored,
tracked, and incorporated into the APE include all of the following:
• Program goals and objectives
• Resident performance
• Faculty development
• Graduate performance, including performance on the certification
examination
• Program quality – as assessed by residents’ confidential written
evaluations of the program (at least once/year), faculty members’
confidential written evaluations of the program (at least once/year),
and other program evaluation results
• Supervision, transitions of care and progressive responsibility
• Wellness initiatives
• Policies, protocols and procedures
• Previous years APE and Action Plans
• If applicable, Periodic Program Review Report and Action Plan or
Special Review Report and Action Plan
• When new deficiencies are identified, or prior deficiencies are noted
to recur, the group should prepare an explicit plan of action
PEC documentation – the written work product of the PEC includes the
following:
• APE report (New Innovations)
• Meeting minutes - Minutes of PEC meetings should be documented.
Please see the Program Evaluation Committee (PEC) Minutes
template attached to this policy
• Documentation of faculty/resident review of Action Plan - The PEC
minutes and action plan should be reviewed and approved by the
teaching faculty and documented in faculty meeting minutes. It is
suggested that the action plan be reviewed with the residents and
appropriate staff
Annual Program Evaluation (APE)
Minutes & Action Plan
Program
Date
Date of the APE meeting:
Date Minutes & Action Plan were reviewed and Approved by teaching faculty:
Please attach the minutes of the meeting where the Minutes & Action Plan were reviewed and
approved.
Academic Year reviewed:
Faculty Members of the PEC in attendance:
Resident/Fellow Members of the PEC in attendance:
Other Members of the PEC in attendance:
Question 1: Program description
Provide a brief description of your residency/fellowship program, as you would to
an applicant or a prospective faculty member. Discuss any notable information
about this program. (Maximum 250 words)
Question 2: Program aims
Based on information gathered and discussed during the APE, what are the
program’s aims? (Maximum 150 words)
Question 3: Program activities to advance the aims
Describe current activities that have been or are being initiated to promote or
further these aims. (Maximum 250 words)
Areas reviewed:
Resident performance
Supporting documents:
Faculty development
Supporting documents:
Graduate performance
Supporting documents:
Program quality
Supporting documents:
Supervision, transitions of care and progressive responsibility
Supporting documents:
Wellness initiatives:
Supporting documents:
Policies, Protocols & Procedures
Supporting documents:
SWOT Analysis
Strengths
Weaknesses
Opportunities
Threats
Responsibilities of the Program Evaluation Committee (PEC) Template
Responsibilities of the Program Evaluation Committee (PEC)
The PROGRAM Program Evaluation Committee (PEC) will participate in:
• planning, developing, implementing, and evaluating educational activities of the
program;
• reviewing and making recommendations for revision of competency-based
curriculum goals and objectives;
• addressing areas of non-compliance with ACGME standards; and,
• reviewing the program annually using evaluations of faculty, residents, and others, as
specified below.
The PEC will be composed of NUMBER faculty and NUMBER residents. The PEC will
document formal, systematic evaluation of the curriculum at least annually, and is
responsible for rendering a written and Annual Program Evaluation (APE).
The PEC will monitor and track each of the following areas:
• resident performance
• faculty development
• graduate performance, including performance of program graduates on the
certification exam;
• program quality (residents and faculty must have the opportunity to evaluate the
program confidentially and in writing at least annually, and the program must use
the results of residents’ and faculty members’ assessments of the program together
with other program evaluation results to improve the program);
Responsibilities of the Program Evaluation Committee (PEC) Template
• supervision, progressive responsibility and transition of care;
• wellness initiatives;
• policies, protocols and procedures; and
• progress on the previous year’s action plan.
The PEC will meet annually, at a minimum, and will communicate as appropriate with the
PROGRAM Clinical Competency Committee (CCC) about resident Milestone performance
trends that are indices of program quality.
The PEC will keep minutes of all meetings using the template provided by the GME Office.