PRESENTED BY:Michael T. Flannery, M.D., F.A.C.P.

Professor of MedicineGME Internal Review Director

ACGME EVALUATION REQUIREMENTS

RESIDENT EVALUATION

FORMATIVE EVALUATION

Faculty must evaluate resident performance during each rotation and document this evaluation at completion of the assignment.

ROTATIONAL – COMPETENCY/LEVEL SPECIFIC

FORMATIVE EVALUATIONS1.) Competence in patient care2.) Medical Knowledge3.) Practice-based learning and improvement4.) Interpersonal and communication skills5.) Professionalism6.) Systems-based practice

FORMATIVE EVALUATIONS1.) 360 degree evaluation use multiple evaluators (e.g.,

Faculty, peers, patients, self, and other professional staff).

2.) Document progressive resident performance improvement appropriate to education level (semiannual).

3.) Provide each resident with documented semiannual evaluation of performance with feedback.

4.) The evaluations of resident performance must be accessible for review by the resident.

RESIDENT SEMIANNUAL EVALUATIONResident Name: _______________________________PGY Year: _____________________________________Reviewer’s Name circle (PD/APD):________________ Date:_______________ Check off all appropriate areas and note any discussion with

the resident REVIEW ITEMS

__Review Self Assessment*:__Review Rotational Evaluations*:__Review Ambulatory Preceptor Evaluation* (every 6 months:)

REVIEW LIST (CONTINUED)__Review 360 Evaluations*:__Review Case Logs:__Review Surgical Logs (program vs individual variation):__Review Simulation Activities:__Review and Attach Scholarly Activities:__Review CEX’s*:__Review ITE’s*:Y/N Moonlighting: GME form completed Y/N: Interferes with

clinical education Y/N* = Areas that involve main review of ACGME Core Competencies

RESIDENT SEMIANNUAL EVALUATION (CONTINUED)

DISCUSSION/ACTION ITEMS__Quality Improvement/Patient Safety:__Reception/Review of Goals/Objectives Prior to Rotations:__Transitions of Care:__Fatigue:__Supervision Policies:__Duty Hours:__Required Conference Attendance:__Interdisciplinary Team Involvement:__Participation on Committees and document (residency, departmental, hospital,

graduate medical, etc.):

_____________________ ________________________Resident’s Signature Reviewer’s Signature

RESIDENT SEMIANNUAL EVALUATION (CONTINUED)

OTHER REQUIRED FILE INFORMATION

__Curriculum Vitae:__USMLE Data:__ACLS Documentation:__Licensing Information:__ECFMG Data (if appropriate)

SUMMATIVE EVALUATION The Program Director must provide a

summative evaluation for each resident upon completion of the program. This evaluation must become part of the resident’s permanent record maintained by the institution, and must be accessible for review by the resident in accordance with institution policy.

SUMMATIVE EVALUATION(CONTINUED)

1.) Document the resident’s performance during the final period of education.

2.) Verify that the resident has demonstrated sufficient competence to enter practice without direct supervision.

SUMMATIVE EVALUATION DATE:______

I have reviewed Dr._____________ performance in the final __ months of his residency/fellowship (circle) matriculation and found him/her competent in the six core competencies which are superior/average/below average (circle) in relation to his/her peers. Dr.______________ has successfully completed his/her residency/fellowship and can enter ______________ (insert field of training) practice independently and competently without direct supervision.

Program Director_______________________Resident/Fellow________________________

FACULTY EVALUATION1.) At least annually, the program must evaluate

faculty performance as it relates to the educational program.

2.) This evaluation must include at least annual written confidential evaluations by the residents.

FACULTY EVALUATION (CONTINUED)

3.) These evaluations should include a review of the faculty’s:A.) Clinical teaching abilitiesB.) Commitment to educational programC.) Clinical knowledgeD.)ProfessionalismE.) Scholarly activities

ANNUAL FACULTY EVALUATION (Attachment to New Innovations Faculty summary which reviews

ACGME competencies and resident/fellow comments.)YEAR:Checklist (discussion with commentary):Clinical teaching abilities:Commitment to educational program:Clinical Knowledge:Professionalism:Scholarly activities:Faculty Development attended:Date & Signatures of Program Director and Faculty

PROGRAM EVALUATION & IMPROVEMENT

The program must document formal, systematic evaluation of the curriculum at least annually. The program must monitor and track each of the following areas:

1.) Resident performance2.) Faculty development3.) Graduate performance, including performance of

program graduates on the certification examination4.) Program quality. Specifically:

PROGRAM EVALUATION & IMPROVEMENT Program Quality ContinuedA.) Residents and faculty must have the opportunity

to evaluate the program confidentially and in writing at least annually.

B.) The program must use the results of residents’ assessments of the program together with other program evaluation results to improve the program.

PROGRAM EVALUATION & IMPROVEMENT (CONTINUED)

If deficiencies are found, the program should prepare a written plan of action to document initiatives to improve performance in the areas listed in section V.C. 1. the action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes.

USF MORSANI COLLEGE OF MEDICINE ANNUAL PROGRAM REVIEW

Program:___________________Review Date:________________

Attendance: (specific roles)Program Director:Program Coordinator:Faculty Member (s):Residents/Fellows (by PGY year)Other:

USF MORSANI COLLEGE OF MEDICINE ANNUAL PROGRAM REVIEW

DATA REVIEWED: Prior Year Annual Program Review and status of any

issues identifiedCurrent Goals/Objectives reviewed – and modified as

needed (every three years minimum)ACGME Annual Resident Survey (Current Year vs. Prior

Year)Faculty/Resident Annual Surveys of the ProgramPost-graduate Surveys

USF MORSANI COLLEGE OF MEDICINE ANNUAL PROGRAM REVIEW

RESIDENT/FELLOW PERFORMANCE/EVALUATIONS:Review of evaluationsPOST-GRADUATE PERFORMANCE:Review of graduates performance on certification examThree year rolling pass rate and how many took the examination [> 80%]PROGRAM QUALITY:With measures (program and faculty evaluations)Improvements to be implemented

USF MORSANI COLLEGE OF MEDICINE ANNUAL PROGRAM REVIEW

FACULTY DEVELOPMENT:Describe needs/activitiesAnnual Feedback from New Innovations dataAny specific GME and program-directed activity

CURRENT DEFICIENCIES/CITATIONS:Add action on prior deficiencies/citationsNote: Minimum of one annual meeting required (but more

necessary i.e., due to abnormal resident survey, for instance)

NAS (Next Accreditation System)

CURRENT EVALUATION: (ADS) update ACGME resident survey Case Log Clinical experience data Data on graduates’ performance on

certifying board examination.

NAS (Next Accreditation System)

NEW EVALUATION ELEMENTS:

Educational Milestone data from semiannual resident evaluations (phase one specialties submit reports in 12/13 and 6/14)

Faculty survey (scheduled for implementation in 2012/2013)

Scholarly activity report form that replaces the detailed faculty curricula vitae presently used (only PD will need full CV)

ACGME EVALUATION REQUIREMENTSWhat you will receive via e-mail:Talk w/slidesEvaluation form templates

1. Resident Semiannual Evaluation2.Summative Evaluation3.Annual Faculty Evaluation4.USF Morsani College of Medicine Annual Program Review

LinksCommon Program Requirements (CPR) http://www.acgme.org/acgmeweb/Portals/0/dh_dutyhoursCommonPR07012007.pdfNext Accreditation System FAQ’s:

http://www.acgme-nas.org/assets/pdf/NASFAQs.pdf