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. MedHub). In accordance with ACGME Common Program Requirements programs must follow the evaluation criteria outlined below.

2. Resident Evaluation:

A) Feedback and Evaluation

i. Faculty members must directly observe, evaluate, and frequently provide feedback on resident performance during each rotation or similar educational assignment.

ii. Evaluation must be documented at the completion of the assignment.

1. For block rotations of greater than three months in duration, evaluation must be documented at least every three months.

2. Longitudinal experiences, such as continuity clinic in the context of other clinical responsibilities, must be evaluated at least every three months and at completion.

iii. The Program must provide an objective performance evaluation based on the Competencies and the specialty-specific Milestones, and must:

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

2. Provide that information to the Clinical Competency Committee for its synthesis of progressive resident performance and improvement toward unsupervised practice.

iv. The program director or their designee, with input from the Clinical Competency Committee, must:

1. Meet with and review with each resident their documented semi-annual evaluation of performance, including progress along the specialty-specific Milestones;

2. Assist residents in developing individualized learning plans to capitalize on their strengths and identify areas for growth; and,

3. Develop plans for residents failing to progress, following institutional policies and procedures.

v. At least annually, there must be a summative evaluation of each resident that includes their readiness to progress to the next year of the program, if applicable.

vi. The evaluations of a resident’s performance must be accessible for review by the resident.

B) Final Evaluation:

i. The program director must provide a final evaluation for each trainee who completes the program.

1. The specialty-specific Milestones, and when applicable the specialty-specific Case Logs, must be used as tools to ensure residents are able to engage in autonomous practice upon completion of the program.

2. This final evaluation must:

a. become part of the trainee’s permanent record maintained by the institution, and must be accessible for review by the resident, in accordance with institutional policy;

b. verify that the resident has demonstrated the knowledge, skills, and behaviors necessary to enter autonomous practice;

c. consider recommendations from the Clinical Competency Committee; and,

d. be shared with the resident upon completion of the program.

C) A Clinical Competency Committee must be appointed by the program director.

i. At a minimum, the Clinical Competency Committee must include three members of the program faculty, at least one of whom is a core faculty member.

1. Additional members must be faculty members from the same program or other programs, or other health professionals who have extensive contact and experience with the program’s residents.

ii. The Clinical Competency Committee must:

1. Review all resident evaluations at least semi-annually;

2. Determine each resident’s progress on achievement of the specialty-specific Milestones; and,

3. Meet prior to the residents’ semi-annual evaluations and advise the program director regarding each resident’s progress.

3. Faculty Evaluation

A) The program must have a process to evaluate each faculty member’s performance as it relates to the educational program at least annually.

i. This evaluation must include a review of the faculty’s member’s clinical teaching abilities, engagement with the educational program, participation in faculty development related to their skills as an educator, clinical performance, professionalism and scholarly activities.

ii. This evaluation must include written, anonymous, and confidential evaluations by the trainees.

B) Faculty members must receive feedback on their evaluations at least annually.

C) Results of the faculty educational evaluations should be incorporated into program-wide faculty development plans.

4. Program Evaluation and Improvement

A) The Program Director must appoint the Program Evaluation Committee (PEC) to conduct and document the Annual Program Evaluation as part of the program’s continuous improvement process.

i. The PEC must be composed of at least two program faculty members, at least one of whom is a core faculty member, and include at least one resident.

ii. Program Evaluation Committee responsibilities must include:

1. Acting as an advisor to the program director, through program oversight;

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

3. Guiding ongoing program improvement, including development of new goals, based upon outcomes; and,

4. Review of the current operating environment to identify strengths, challenges, opportunities, and threats as related to the program’s mission and aims.

iii. The Program Evaluation Committee should consider the following elements in its assessment of the program:

1. Curriculum

2. Outcomes from prior Annual Program Evaluation(s);

3. ACGME letters of notification, including citations, Areas for Improvement, and comments;

4. Quality and safety of patient care;

5. Aggregate resident and faculty:

a. Well-being;

b. Recruitment and retention;

c. Workforce diversity;

d. Engagement in quality improvement and patient safety;

e. Scholarly activity;

f. ACGME Resident and Faculty Surveys; and,

g. Written evaluations of the program.

6. Aggregate resident:

a. Achievement of the Milestones;

b. In-training examinations (where applicable);

c. Board pass and certification rates; and,

d. Graduate performance.

7. Aggregate faculty:

a. Evaluation; and,

b. Professional development.

iv. The Program Evaluation Committee must evaluate the program’s mission and aims, strengths, areas for improvement, and threats.

v. The annual review, including the action plan, must:

1. Be distributed to and discussed with the members of the teaching faculty and the residents; and,

2. Be submitted to the DIO.

B) The program must complete a Self-Study prior to its 10-Year Accreditation Site Visit.

i. A summary of the Self-Study must be submitted to the DIO.


RECOMMENDED BY: A. Gersoff, MD DATE: 11/14
APPROVED BY: E. Wroblewski, MD DATE: 8/19, 1/21
DATE REVIEWED: 1/12, 11/14, 1/18, 8/19, 1/21