Evaluation Policy
Scope
The policy applies to all ACGME-accredited residency and fellowship programs at DHMC.
Purpose
- The ACGME Institutional Requirements, Program Requirements, and Common Program Requirements require a policy on resident, faculty and program evaluation.
- Each GME program must develop and maintain academic requirements for the educational development of the residents in that program. In order to progress academically in the program, the resident must meet those academic requirements.
Policy Guidelines
Assessment of Learning
DHMC recognizes learning on a continuum from novice to advanced beginner to competent at a level expected of a new practitioner. Each training program provides assessment of trainee learning in consideration of this continuum, aligned with basic RRC requirements as to the scope and number of both formative and summative evaluations.
Each residency program must utilize measures to assess residents' competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Mechanisms are developed and updated to provide regular and timely performance feedback to residents. This process involves the use of assessment results to achieve progressive improvements in residents' competence and performance consistent with graduated roles and responsibilities as assigned.
Evaluation of Residents
Written assessments of learning focus on a trainee's ability to perform up to defined expectations as outlined in the program curriculum. Behavioral expectations are outlined in the DHMC Code of Ethical Conduct and include the recording of procedures in case logs if required by the ACGME Residency Review Committee (RRC), and the timely and accurate reporting of duty hours. Programs must use multiple evaluators (e.g. faculty, peers, patients, self, and other professional staff). At scheduled intervals during the training year, written formative evaluations are provided to the trainee. At the conclusion of a training year, and at the end of the training program, written summative evaluations are provided to the trainee via a documented face-to-face meeting with the program director or their designee. Evaluations of resident performance must be readily accessible for review by the resident. The standards of evaluation must be applied equitably to all residents and assure due process.
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 institutional policy. The final summative evaluation must document the resident's performance during the final period of education, and verify that the resident has demonstrated sufficient competence to enter practice without direct supervision.
Evaluation of Faculty
Each residency program must monitor the educational effectiveness of faculty and attending physicians. At least annually, residents are asked to provide written or electronic evaluations of individual faculty members. These evaluations should include a review of the faculty's clinical teaching abilities, clinical knowledge, professionalism, and interpersonal and communication skills. These evaluations are confidential.
Evaluation of Program
At prescribed intervals, residents are asked to provide written or electronic feedback about the program including curriculum, working environment, scholarly milieu, evaluation systems, and other features. These evaluations are confidential. Each residency program uses these resident assessments, combined with faculty input, to evaluate the educational effectiveness of the training program. Programs are expected to utilize the GME office template for the Annual Program Evaluation and Improvement Plan to guide and document this annual improvement process. All programs must submit a completed Program Evaluation and Improvement Plan to the GME office on an annual basis.
Resident Quality Assurance Files
All residency programs participate in the medical center-wide quality assurance system. Performance evaluations of residents are coordinated and administered by Residency Program Directors. Performance evaluations are reflective of academic knowledge and patient care/clinical skills and are to be used in making decisions about promotion, program completion, remediation, and any disciplinary action. These evaluations are considered to be confidential and privileged (by New Hampshire laws RSA 151:13a and RSA 329:29a).
Related Policies and Reference Material
- ACGME Common Program Requirements at: http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf
Specific section applicable to this policy:
V. A-C - Institutional Annual Program Evaluation and Improvement template.
