Graduate Medical Education Program Evaluation Committee / Annual Program Evalutaion Policy

Category: Graduate Medical Education

Effective Date: September 10, 2020

Last Review/Revision Date:

Prior Revisions: 07/01/2015 (original)

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Title: Graduate Medical Education Program Evaluation Committee / Annual Program Evaluation Policy

Reference(s): ACGME Common Program Requirements (focused revision effective July 1, 2020); ACGME

Manual of Policies and Procedures (effective June 13, 2020)

I. Purpose

A. To establish, in accordance with the Common Program Requirements (CPRs), that all

Accreditation Council for Graduate Medical Education (ACGME) accredited programs

must have a Program Evaluation Committee (PEC) appointed by the program director to

conduct and document the Annual Program Evaluation (APE) as part of the program’s

continuous improvement process that functions in compliance with both the common and

program-specific requirements.

B. To define that the goal of the PEC is to evaluate the program’s performance and plan for

improvement in the APE by utilizing outcome parameters and other data to assess the

program’s progress toward achievement of its goals and aims.

II. Policy:

A. Each PEC must have a written description of its responsibilities, including its current

membership, which must be updated in New Innovations and the ACGME Accreditation Data

Systems (ADS) website annually.

B. The PEC functions in an advisory role by meeting at least annually (or as specified by the

relevant ACGME Review Committee) to review and document an APE that is an objective,

comprehensive evaluation of the program focused on required components, with an

emphasis on program strengths and self-identified areas for improvement. The Committee

must function objectively and in a manner that promotes the highest levels of professionalism

with the goal of continuous quality improvement.

C. At a minimum, the PEC will:

1. Act as an advisor to the program director, through program oversight [V.C.1.b).(1)];

2. Review the program’s self-determined goals and progress toward meeting them

[V.C.1.b).(2)];

3. Guide ongoing program improvement, including development of new goals, based

upon outcomes [V.C.1.b).(3)]; and,

4. Review the current operating environment to identify strengths, challenges,

opportunities, and threats as related to the program’s mission and aims

[V.C.1.b).(4)].

D. Each PEC must be composed of at least two program faculty members, at least one of

whom is a core faculty member, and at least one resident/fellow (“resident”) [V.C.1.a)] and

meet at least annually (or as specified by the relevant ACGME Review Committee).

E. The PEC should consider the following elements in its assessment of the program as part of

the APE [V.C.1.c)]:

1. curriculum [V.C.1.c).(1)];

2. outcomes from prior Annual Program Evaluation(s) [V.C.1.c).(2)] ;

3. ACGME letters of notification, including citations, Areas for Improvement (AFIs), and

comments [V.C.1.c).(3)];

4. quality and safety of patient care [V.C.1.c).(4)];

5. aggregate resident and faculty [V.C.1.c).(5)]:

a. well-being [V.C.1.c).(5).(a)] ;

b. recruitment and retention [V.C.1.c).(5).(b)] ;

c. workforce diversity [V.C.1.c).(5).(c)] ;

d. engagement in quality improvement and patient safety [V.C.1.c).(5).(d)] ;

e. scholarly activity [V.C.1.c).(5).(e)] ;

f. ACGME Resident and Faculty Surveys [V.C.1.c).(5).(f)] ; and,

g. written evaluations of the program [V.C.1.c).(5).(g)].

6. aggregate resident [V.C.1.c).(6)]:

a. achievement of the Milestones [V.C.1.c).(6).(a)];

b. in-training examinations (where applicable) [V.C.1.c).(6).(b)];

c. board pass and certification rates [V.C.1.c).(6).(c)]; and,

d. graduate performance [V.C.1.c).(6).(d)].

7. aggregate faculty [V.C.1.c).(7)]:

a. evaluation [V.C.1.c).(7).(a)]; and,

b. professional development [V.C.1.c).(7).(b)].

F. The PEC must evaluate the program’s mission and aims, strengths, areas for improvement,

and threats [V.C.1.d)].

G. The annual review, including the action plan, must [V.C.1.e)]:

1. be distributed to and discussed with the members of the teaching faculty and the

residents [V.C.1.e.(1)]; and,

2. be submitted to the DIO [V.C.1.e.(2)].

H. There is no mandatory role for the program director; however, s/he may serve as the chair of

the PEC, or s/he may appoint another faculty member as chair.

I. PEC meeting minutes should document discussion of the elements noted in V.C.1.c). This

document should also include the timing & location of the meeting, attendance, and

documentation of the program’s mission and aims, strengths, areas for improvement, and

threats.

J. The program must complete a Self-Study prior to its 10-Year Accreditation Site Visit [V.C.2.]

and submit this to the DIO [V.C.2.a)].

1. The Self-Study is an objective comprehensive evaluation of the residency program,

with the aim of improving it.

2. Outcomes of the documented APE can be integrated into the 10-year Self-Study

process.

3. Underlying the Self-Study is this longitudinal evaluation of the program and its

learning environment, facilitated through sequential APEs that focus on the required

components, with an emphasis on program strengths and self-identified areas for

improvement.

4. Details regarding the timing and expectations for the Self-Study and the 10-Year

Accreditation Site Visit are provided in the

ACGME Manual of Policies and Procedures.

5. Additional Self-Study Tools regarding the Self-Study process and how to prepare for

the visit are available on the ACGME website.