Annual Program Evaluation

Scope

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Policy Statement

The ACGME requires that all residency and fellowship programs conduct an annual systematic review of their programs.

The program director must appoint the Program Evaluation Committee (PEC) to conduct and document the Annual Program Evaluation as part of the program’s continuous improvement process.  The PEC must be composed of at least two program faculty members, at least one of whom is a core faculty member, and should include at least one resident.

Program Evaluation Committee responsibilities must include:

1. acting as an advisor to the program director, through program oversight;
2. review of the program’s self-determined goals and progress toward meeting them;
3. guiding ongoing program improvement, including development of new goals, based upon outcomes; and,
4. review of the current operating environment to identify strengths, challenges, opportunities, and threats as related to the program’s mission and aims.

The Program Evaluation Committee should consider the following elements in its assessment of the program:

1. curriculum;
2. outcomes from prior Annual Program Evaluation(s);
3. ACGME letters of notification, including citations, Areas for Improvement, and comments;
4. quality and safety of patient care;
5. aggregate resident and faculty:
   1. well-being;
   2. recruitment and retention;
   3. workforce diversity;
   4. engagement in quality improvement and patient safety;
   5. scholarly activity;
   6. ACGME Resident and Faculty Surveys; and,
   7. written evaluations of the program
6. aggregate resident:
   1. achievement of the Milestones;
   2. in-training examinations (where applicable);
   3. board pass and certification rates; and,
   4. graduate performance.
7. Aggregate faculty:
   1. evaluation; and,
   2. professional development.

The Program Evaluation Committee must evaluate the program’s mission and aims, strengths, areas for improvement, and threats.

The PEC must prepare a written plan of action to document initiatives to improve performance in one or more of the areas listed above, as well as delineate how they will be measured and monitored. The annual review, including the action plan, must be distributed to and discussed with the members of the teaching faculty and the residents and be submitted to the DIO.  The aggregated results of the APE must also be reported to the IUSM Graduate Medical Education Committee (GMEC) via the Annual Program Evaluation Summary in MedHub. 

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Reason for Policy

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Procedures

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Definitions

ACGME is the Accreditation Council for Graduate Medical Education. 

A resident is an IUSM resident or fellow, or a non-IUSM resident or fellow electively rotating through IUSM and provides clinical care as part of a GME program. 

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Implementation

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Oversight

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History

1. Policy gme-adm-0021 approved by GMEC and published on 12 June 2013. 
2. Policy reviewed, updated, and approved by GMEC on 16 April 2014. 
3. Policy updated for formatting 02 March 2018. 
4. Policy updated for formatting 27 June 2018.
5. Policy updated 25 August 2022.
6. Policy updated for formatting 04 November 2022.

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