GME Evaluation Policy

GOAL:

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

POLICY:

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.

PROCEDURES:

1. Resident Formative and Summative Evaluation

The faculty must:

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

The program must:

• Evaluate resident competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice;
• Use multiple evaluators (i.e. faculty, peers, patients, self, other professional staff);
• Document progressive resident performance improvement  appropriate to educational level; and,
• 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.  Trainees who make satisfactory progress as determined by the program director will be promoted and given increased graded responsibilities.

The program director must:

• Provide a final summative evaluation for each trainee who completes the program. This evaluation must include a review of 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. 

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

 

2. Faculty Evaluation

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

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

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

 

3. Program Evaluation
   (Annual Educational Effectiveness Review – AEER)

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

• Trainee performance;
• faculty development;
• graduate performance, including performance of program graduates on the certification examination and;
• program quality, specifically:
  • residents and faculty must have the opportunity to evaluate the program confidentially and in writing at least annually and;
  • the program must use the results of the trainees’ assessments of the program together with other program evaluation results to improve the program

Representative program personnel (i.e., at least the program director, representative faculty, and one resident) must be organized to review program goals and objectives, and the effectiveness with which they are achieved. This group must conduct a formal documented meeting at least annually for this purpose.

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