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Residents In This Section

Evaluation Policy

I. Purpose of Policy

The purpose of this policy is the expectation that each Graduate Medical Education (GME) Residency and Fellowship Program must develop and maintain academic requirements for the educational development of the residents in that program per the Accreditation Council for Graduate Medical Education (ACGME) Institutional and Common Program Requirements.

II. Policy Scope

This policy applies to all residents and fellows participating in ACGME-accredited residency and fellowship programs at Dartmouth-Hitchcock (D-H).

III. Definitions

Resident: Any physician in an accredited graduate medical education program, including interns, residents and fellows.


IV. Policy Statement

  1. Assessment of Learning
    • D-H 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 Residency Review Committee (RRC) requirements as to the scope and number of both formative and summative evaluations.

    • Each residency program must utilize measures to assess resident’s 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 performance consistent with graduated roles and responsibilities as assigned.

    • In addition, the Program Director must appoint a Clinical Competency Committee (CCC) with composition as defined by the Common Program Requirements.


  2. Formative Evaluation of Residents
    • The faculty must evaluate resident performance in a timely manner during each rotation or similar educational assignment, and document this evaluation at the completion of the assignment.

    • Programs must:
      • Provide objective assessments of competence of 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;
      • Use multiple evaluators (e.g. faculty, peers, patients, self, and other professional staff);
      • Document progressive resident performance improvement appropriate to educational level; and,
      • Provide each resident with documented semi-annual evaluation of performance with feedback. Evaluations of resident performance must be readily accessible for review by the resident.


  3. 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 the program.

    • The Program Director must:
      • Provide a summative evaluation for each resident upon completion of the program which becomes part of the resident’s permanent record maintained by the institution that must be accessible for review by the resident in accordance with institutional policy;
      • 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.


  4. Evaluation of Faculty and Program
    • Per the ACGME Common Program Requirements the following evaluation must remain confidential:
      • Resident Evaluation of Faculty
        • At least annually, each program must evaluate faculty performance as it relates to the educational program. These 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 at least annual written confidential evaluations by the residents.
      • Resident Evaluation of Program
        • At least annually, residents must have the opportunity to evaluate the program confidentially and in writing. Each training program must use these resident assessments, combined with confidential faculty input, to evaluate the educational effectiveness of the training program as part of the mandatory Annual Program Evaluation (APE) process.

    • The Program and the GME Office make every effort to ensure that resident submission of, and program management of, these two types of evaluation supports the expectation of confidentiality to the greatest extent possible. To that end, the following steps are routinely in effect:
      • These two evaluation types must be submitted and managed electronically in all training programs. Use of paper evaluation forms is not permitted.
      • The GME Office maintains central control of the electronic Residency Management System (RMS) settings related to the resident evaluation of the faculty to ensure that the following information is routinely suppressed:
        • Identity of evaluator
        • Subject participation dates
        • Date(s) of specific activity
        • Due date range for the evaluation
        • Activity site
      • The RMS “Low Score Trigger” is only applied for evaluations of the resident. It is not utilized to resident evaluations of the faculty.
      • Program level download of Resident Evaluation of Faculty data for the purpose of generating cumulative summaries must occur no more frequently than every six (6) months. Programs with fewer than six (6) residents, as well as programs with rotational blocks longer than two (2) months, must only download this data once per year to minimize the possibility of a temporal association of an evaluation to a specific resident.


  5. Program Evaluation and Improvement
    • Programs must appoint a Program Evaluation Committee (PEC) with composition and responsibilities as defined in the Common Program Requirements. The program, through the PEC, must document formal, systematic evaluation of the curriculum at least annually, and is responsible for rendering a written, APE using the standard institutional APE template.

    • Resident Quality Assurance Files
      • Performance evaluations of residents are coordinated and administered by 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).

V. References

ACGME Common Program Requirements


D-H Policy ID: 11305

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