GME Evaluation Policy

POLICY #: 8240-17


To establish uniform evaluation policies and procedures regarding residents, faculty, and residency programs.


1. Each ACGME-accredited residency program will establish a Clinical Competency Committee as well as a Program Evaluation Committee. All Santa Barbara Cottage Hospital Graduate Medical Education training programs are required to use an electronic evaluation system. (i.e. E*Value). In accordance with ACGME Common Program Requirements programs must follow the evaluation criteria outlined below.

2. Resident Evaluation:

a. The Program Director must:

i. Appoint the Clinical Competency Committee. At a minimum the Clinical Competency Committee must be composed of three members of the program faculty. Others eligible for appointment to the committee include faculty from other programs and non-physician members of the health care team.

ii. There must be a written description of the responsibilities of the Clinical Competency Committee (CCC). The CCC should review all resident evaluations semi-annually; prepare and assure the reporting of Milestones evaluations of each resident semi-annually to ACGME; and, advise the program director regarding resident progress, including promotion, remediation, and dismissal.

3. Formative Evaluation

a. The Faculty must:

i. Evaluate trainee performance in a timely manner during each rotation or similar educational assignment, and document this evaluation at completion of the assignment.

b. The Program must:

i. Provide objective assessments of resident competence in patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice based on the specialty-specific Milestones;

ii. Use multiple evaluators (i.e. faculty, peers, patients, self, other professional staff);

iii. Document progressive resident performance improvement appropriate to educational level; and,

iv. Provide each resident with documented semiannual evaluation of performance with feedback. Overall reviews of the trainee’s progress will be conducted at least semi-annually by program faculty with responsibility for monitoring the overall academic progress of all residents in the training program (see Clinical Competency committee). Trainees who make satisfactory progress as determined by the program director will be promoted and given increased graded responsibilities.

v. The evaluations of resident performance must be accessible for review by the resident, in accordance with institutional policy.

4. Summative Evaluation: The specialty-specific Milestones must be used as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of program.

a. The program director must:

i. Provide a final summative evaluation for each trainee who completes the program. This evaluation must document the trainee’s performance during the final period of education, and should verify that the trainee has demonstrated sufficient competence to enter practice without direct supervision. The final evaluation must be part of the trainee’s permanent record.

ii. Written evaluations must be available to the residents to enable them to assess their progress and improve performance.

5. Faculty Evaluation

a. The program must evaluate faculty performance as it relates to the educational program at least annually.

b. The evaluations should include a review of the faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism and scholarly activities.

c. This evaluation must include annual written confidential evaluations by the trainees.

6. Program Evaluation and Improvement

a. The Program Director must:

i. Appoint the Program Evaluation Committee (PEC). The PEC must be composed of at least two program faculty members and should include at least one resident. The PEC must have a written description of its responsibilities.

ii. The PEC should participate actively in: planning, developing, implementing, and evaluating all significant 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.

b. The program, through the PEC, must:

i. Document formal, systematic evaluation of the curriculum at least annually, and is responsible for rendering a written and Annual Program Evaluation (APE).

ii. The program must monitor and track each of the following areas:

1. trainee performance;

2. faculty development;

3. graduate performance, including performance of program graduates on the certification examination;

4. program quality, and

a. residents and faculty must have the opportunity to evaluate the program confidentially and in writing at least annually and;

b. the program must use the results of the trainees’ and faculty members’ assessments of the program together with other program evaluation results to improve the program.

5. progress on the previous year’s action plan(s).

iii. The PEC must prepare a written plan of action to document initiatives to improve performance in one or more of the areas listed above as well as delineate how they will be measured and monitored. The action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes.


RECOMMENDED BY: A. Gersoff, MD DATE: 11/14
APPROVED BY: E. Wroblewski, MD DATE: 1/18
DATE REVIEWED: 1/12, 11/14, 1/18