ACGME EVALUATION REQUIREMENTS

1. ACGME EVALUATION REQUIREMENTS PRESENTED BY: Michael T. Flannery, M.D., F.A.C.P. Professor of Medicine GME Internal Review Director

2. RESIDENT EVALUATION FORMATIVEEVALUATION Faculty must evaluate resident performance during each rotation and document this evaluation at completion of the assignment. ROTATIONAL – COMPETENCY/LEVEL SPECIFIC

3. FORMATIVE EVALUATIONS 1.) Competence in patient care 2.) Medical Knowledge 3.) Practice-based learning and improvement 4.) Interpersonal and communication skills 5.) Professionalism 6.) Systems-based practice

4. FORMATIVE EVALUATIONS 1.) 360 degree evaluation use multiple evaluators (e.g., Faculty, peers, patients, self, and other professional staff). 2.) Document progressive resident performance improvement appropriate to education level (semiannual). 3.) Provide each resident with documented semiannual evaluation of performance with feedback. 4.) The evaluations of resident performance must be accessible for review by the resident.

5. RESIDENT SEMIANNUAL EVALUATION Resident Name: _______________________________ PGY Year: _____________________________________ Reviewer’s Name circle (PD/APD):________________ Date:_______________ Check off all appropriate areas and note any discussion with the resident REVIEW ITEMS __Review Self Assessment*: __Review Rotational Evaluations*: __Review Ambulatory Preceptor Evaluation* (every 6 months:)

6. REVIEW LIST (CONTINUED) __Review 360 Evaluations*: __Review Case Logs: __Review Surgical Logs (program vs individual variation): __Review Simulation Activities: __Review and Attach Scholarly Activities: __Review CEX’s*: __Review ITE’s*: Y/N Moonlighting: GME form completed Y/N: Interferes with clinical education Y/N * = Areas that involve main review of ACGME Core Competencies

7. RESIDENT SEMIANNUAL EVALUATION (CONTINUED) DISCUSSION/ACTION ITEMS __Quality Improvement/Patient Safety: __Reception/Review of Goals/Objectives Prior to Rotations: __Transitions of Care: __Fatigue: __Supervision Policies: __Duty Hours: __Required Conference Attendance: __Interdisciplinary Team Involvement: __Participation on Committees and document (residency, departmental, hospital, graduate medical, etc.): _____________________ ________________________ Resident’s Signature Reviewer’s Signature

8. RESIDENT SEMIANNUAL EVALUATION (CONTINUED) OTHER REQUIRED FILE INFORMATION __Curriculum Vitae: __USMLE Data: __ACLS Documentation: __Licensing Information: __ECFMG Data (if appropriate)

9. 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 institution policy.

10. SUMMATIVE EVALUATION(CONTINUED) 1.) Document the resident’s performance during the final period of education. 2.) Verify that the resident has demonstrated sufficient competence to enter practice without direct supervision.

11. SUMMATIVE EVALUATION DATE:______ I have reviewed Dr._____________ performance in the final __ months of his residency/fellowship (circle) matriculation and found him/her competent in the six core competencies which are superior/average/below average (circle) in relation to his/her peers. Dr.______________ has successfully completed his/her residency/fellowship and can enter ______________ (insert field of training) practice independently and competently without direct supervision. Program Director_______________________ Resident/Fellow________________________

12. FACULTY EVALUATION 1.) At least annually, the program must evaluate faculty performance as it relates to the educational program. 2.) This evaluation must include at least annual written confidential evaluations by the residents.

13. FACULTY EVALUATION (CONTINUED) 3.) These evaluations should include a review of the faculty’s: A.) Clinical teaching abilities B.) Commitment to educational program C.) Clinical knowledge D.)Professionalism E.) Scholarly activities

14. ANNUAL FACULTY EVALUATION (Attachment to New Innovations Faculty summary which reviews ACGME competencies and resident/fellow comments.) YEAR: Checklist (discussion with commentary): • Clinical teaching abilities: • Commitment to educational program: • Clinical Knowledge: • Professionalism: • Scholarly activities: • Faculty Development attended: Date & Signatures of Program Director and Faculty

15. PROGRAM EVALUATION & IMPROVEMENT The program must document formal, systematic evaluation of the curriculum at least annually. The program must monitor and track each of the following areas: 1.) Resident performance 2.) Faculty development 3.) Graduate performance, including performance of program graduates on the certification examination 4.) Program quality. Specifically:

16. PROGRAM EVALUATION & IMPROVEMENT Program Quality Continued A.) Residents and faculty must have the opportunity to evaluate the program confidentially and in writing at least annually. B.) The program must use the results of residents’ assessments of the program together with other program evaluation results to improve the program.

17. PROGRAM EVALUATION & IMPROVEMENT (CONTINUED) If deficiencies are found, the program should prepare a written plan of action to document initiatives to improve performance in the areas listed in section V.C. 1. the action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes.

18. USF MORSANI COLLEGE OF MEDICINE ANNUAL PROGRAM REVIEW Program:___________________ Review Date:________________ Attendance: (specific roles) Program Director: Program Coordinator: Faculty Member (s): Residents/Fellows (by PGY year) Other:

19. USF MORSANI COLLEGE OF MEDICINE ANNUAL PROGRAM REVIEW DATA REVIEWED: • Prior Year Annual Program Review and status of any issues identified • Current Goals/Objectives reviewed – and modified as needed (every three years minimum) • ACGME Annual Resident Survey (Current Year vs. Prior Year) • Faculty/Resident Annual Surveys of the Program • Post-graduate Surveys

20. USF MORSANI COLLEGE OF MEDICINE ANNUAL PROGRAM REVIEW RESIDENT/FELLOW PERFORMANCE/EVALUATIONS: Review of evaluations POST-GRADUATE PERFORMANCE: Review of graduates performance on certification exam Three year rolling pass rate and how many took the examination [> 80%] PROGRAM QUALITY: With measures (program and faculty evaluations) Improvements to be implemented

21. USF MORSANI COLLEGE OF MEDICINE ANNUAL PROGRAM REVIEW FACULTY DEVELOPMENT: Describe needs/activities Annual Feedback from New Innovations data Any specific GME and program-directed activity CURRENT DEFICIENCIES/CITATIONS: Add action on prior deficiencies/citations Note: Minimum of one annual meeting required (but more necessary i.e., due to abnormal resident survey, for instance)

22. NAS (Next Accreditation System) CURRENT EVALUATION: • (ADS) update • ACGME resident survey • Case Log • Clinical experience data • Data on graduates’ performance on certifying board examination.

23. NAS (Next Accreditation System) NEW EVALUATION ELEMENTS: • Educational Milestone data from semiannual resident evaluations (phase one specialties submit reports in 12/13 and 6/14) • Faculty survey(scheduled for implementation in 2012/2013) • Scholarly activity report form that replaces the detailed faculty curricula vitae presently used (only PD will need full CV)

24. ACGME EVALUATION REQUIREMENTS What you will receive via e-mail: • Talk w/slides • Evaluation form templates 1. Resident Semiannual Evaluation 2.Summative Evaluation 3.Annual Faculty Evaluation 4.USF Morsani College of Medicine Annual Program Review • Links Common Program Requirements (CPR) http://www.acgme.org/acgmeweb/Portals/0/dh_dutyhoursCommonPR07012007.pdf Next Accreditation System FAQ’s: http://www.acgme-nas.org/assets/pdf/NASFAQs.pdf