Evaluation Policy

I. Purpose of policy

The purpose of this policy is to define the evaluation standards for Residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited programs at Dartmouth-Hitchcock (D-H).

II. Policy scope

This policy applies to Residents, Program Directors, Faculty and staff in ACGME-accredited residency and fellowship programs at Dartmouth-Hitchcock (D-H).

III. Definitions

Resident: Any physician in an ACGME-accredited graduate medical education program including Residents and Fellows.

IV. Policy statement

All training programs must manage evaluations through the Residency Management System (RMS).

  1. Evaluations of Residents
    • In order to maximize learning development for Residents, regular, timely, and meaningful verbal and written feedback is required.
    • All programs are responsible for the regular evaluation of each trainee’s progress. The evaluation system must consist of both formative and summative evaluations.
    • Evaluations of Resident performance must be readily accessible for review by the Resident.
    1. Formative Evaluation of Residents: The faculty must evaluate Resident performance, via the RMS, in a timely manner, during or at the end of each rotation or similar educational assignment.
      • Programs with block/rotation schedules: Evaluations must be completed at the end of each block/rotation.
      • Programs with longitudinal schedules: Evaluations must be completed at least quarterly (every three [3] months).

      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 semiannual evaluation of performance with feedback.
    2. Summative Evaluation of Residents: The Program Director must provide a final 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
      • 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.
      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.
    3. Resident Evaluation of Peers: Residents should be evaluated by their peers, through an evaluation administered through the RMS, at least annually.
      • Evaluations, while not anonymous, will include a confidential comment box.
      • Comments included in the box will not be shared verbatim with the Resident being evaluated.
  2. Evaluations of Faculty: At least annually, each program must evaluate faculty performance as it relates to the educational program, through an evaluation administered through the RMS.
    • Evaluations must include confidential written evaluation by Residents.
    • Evaluations must include a review of the faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities.
    • The GME Office determines program level RMS electronic evaluation settings related to the Resident Evaluation of Faculty. Programs may not make modifications to evaluation settings. The RMS “Low Score Trigger” will not be applied and the following information will be suppressed from view by the faculty being evaluated:
      • Identity of evaluator
      • Subject participation dates
      • Date(s) of specific activity
      • Due date range for the evaluation
      • Activity site
    • In order to minimize the possibility of a temporal association of an evaluation to a specific Resident, program level download of Resident Evaluation of Faculty data for the purpose of generating cumulative summaries must adhere to the following criteria:
      • Programs with fewer than six (6) Residents must download data on an annual basis (once each year).
      • Programs with rotational blocks longer than two (2) months must download data on an annual basis (once each year).
      • All other programs may download data no more frequently than every six (6) months.
  3. Evaluations of the Program
    1. Resident Evaluation of Program: At least annually, Residents must have the opportunity to evaluate the program confidentially and in writing.
      • Evaluations must be submitted and managed electronically through the RMS.
      • Training programs must use these Resident assessments to evaluate the educational effectiveness of the training program as part of the mandatory Annual Program Evaluation (APE) process.
    2. Faculty Evaluation of Program: At least annually, faculty must have the opportunity to evaluate the program confidentially and in writing.
      • Evaluations must be submitted and managed electronically through the RMS.
      • Training programs must use these faculty assessments to evaluate the educational effectiveness of the training program as part of the mandatory APE process.

V. References

ACGME Institutional Requirements. (2015). Retrieved from ACGME.org.

Common Program Requirements. (2016). Retrieved from ACGME.org.

D-H Policy ID: 11305