ACGME EVALUATION REQUIREMENTS

Report
PRESENTED BY:
Michael T. Flannery, M.D., F.A.C.P.
Professor of Medicine
GME Internal Review Director
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 EVALUATIONS
1.) Competence in patient care
2.) Medical Knowledge
3.) Practice-based learning and improvement
4.) Interpersonal and communication skills
5.) Professionalism
6.) Systems-based practice
FORMATIVE EVALUATIONS
1.) 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
EVALUATION
Resident 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 EVALUATION
1.) 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 abilities
B.) Commitment to educational program
C.) Clinical knowledge
D.)Professionalism
E.) 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 performance
2.) Faculty development
3.) Graduate performance, including performance
of program graduates on the certification
examination
4.) Program quality. Specifically:
PROGRAM EVALUATION &
IMPROVEMENT
Program Quality Continued
A.) 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 identified
 Current 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 Program
 Post-graduate Surveys
USF MORSANI COLLEGE OF MEDICINE
ANNUAL PROGRAM REVIEW
RESIDENT/FELLOW PERFORMANCE/EVALUATIONS:
Review of evaluations
POST-GRADUATE PERFORMANCE:
Review of graduates performance on certification exam
Three 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/activities
Annual Feedback from New Innovations data
Any specific GME and program-directed activity
CURRENT DEFICIENCIES/CITATIONS:
Add action on prior deficiencies/citations
Note: 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
REQUIREMENTS
What you will receive via e-mail:
 Talk w/slides
 Evaluation form templates
1. Resident Semiannual Evaluation
2.Summative Evaluation
3.Annual Faculty Evaluation
4.USF Morsani College of Medicine Annual Program Review
 Links
Common Program Requirements (CPR)
http://www.acgme.org/acgmeweb/Portals/0/dh_dutyhoursCommo
nPR07012007.pdf
Next Accreditation System FAQ’s:
http://www.acgme-nas.org/assets/pdf/NASFAQs.pdf

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