Evaluation Policy & Procedure

1. Each graduate medical education program determines its methods of evaluation (i.e. clinical, in-service, chart review, observed clinical exam, and oral exams) consistent with sound pedagogical practice and the requirements of its Residency Review Committee (RRC) and/or medical specialty board.
2. Each program must establish a committee for resident evaluation that monitors the progress of each resident and makes recommendations to the Program Director. This committee should meet at least two times per year. This committee or a departmental sub-committee serves as the first step in the program's academic appeals process.
3. Each program should institute an advisory system assigning each resident to an advisor. This advisor will become a liaison between the resident and the evaluation committee and will meet for follow-up with the residents at least twice yearly.
4. The Chairman/Program Director or designee must meet with each resident at least semiannually to review progress and discuss future promotion in the residency program.
5. All meetings related to formal evaluation between resident and representatives of program must be documented, signed and dated by resident and representative, and placed in resident's academic file immediately. (See academic file policy)
6. If a resident is subject to any type of corrective or disciplinary action (suspension, letter of warning, probation, termination, non-renewal of contract), the Office of the Associate Dean for GME must be notified. (See Due Process Policy Below)
7. A Resident Promotion Form must be completed at the end of the academic year for each resident.
8. In discussing adverse actions with residents, the Program Director or designee must outline specific problem areas, define with the resident the methods that will be used to address these, and determine a timetable for improvement. Clear criteria for determining improvement must be articulated. A follow-up meeting should be scheduled to determine status. These meetings must be documented and signed by both parties and placed in the resident's evaluation file with a copy to the GME Office. (See Due Process Policy).
9. All evaluation documentation should be available for direct review in the department and/or in an RMS office, by the resident when requested.

Evaluations of Resident Performance

1. Evaluations should be in writing and completed at the end of each month or rotation or when appropriate. Evaluations should be discussed with the resident. All evaluations that are marginal or unsatisfactory, must be discussed with the resident in an exit interview at the end of the rotation and signed by both the resident and the evaluator or referred to the program’s resident evaluation committee for review and action.
2. Programs are required to prepare evaluation forms that address core competencies and areas of knowledge, skills and attitude and contain space for comments at each evaluation point. The form should also have an overall evaluation rating and space for defining strengths and weaknesses and suggestions for future improvement. There should be space for the resident’s signature and the date of review. An updated copy of the form must be on file in the GME Office. An electronic or web-based equivalent of this system is acceptable and preferred. The institution provides access to a Residency Management System, currently New Innovations, to support programs in web-based evaluations and procedures tracking.
3. Completed evaluation forms should be returned by the evaluator to the departmental office within a reasonable time after the resident completes the evaluation period. Faculty compliance with completing evaluations should be monitored and deficiencies addressed.
4. The forms should be reviewed for completeness by the Program Director or designee and followed-up in cases of inadequate documentation particularly for unfavorable assessments. In cases where the evaluator has not sufficiently documented his/her evaluation, the evaluator should be called by the Program Director to correct deficiencies. (i.e. no comments for below average performance, inconsistency between written and numerical evaluation).
5. Residents should be evaluated using multiple tools in multiple settings by multiple evaluators. At a minimum, this should include multisource 360 degree assessments, directly observed performance assessments (mini CEX, OSCE, SCO), professionalism and interpersonal and communication skills assessments, manual skill/procedure performance assessment and objective tests of knowledge.
6. Residents should perform self-assessments and develop guided individualized improvement plans under the mentorship of faculty.

Resident Evaluation of Program and Faculty

Residents must be given the opportunity to evaluate their program and teachers at least once a year. This evaluation must be confidential and anonymous.

Faculty Evaluation of Program

Faculty must be given the opportunity to evaluate the program at least once a year.

Annual Review of Program Effectiveness

An annual review of the program involving residents, faculty and program leadership and using reliable outcome measures to assess program effectiveness in competency-based education and assessment must be conducted, documented and result in an action plan addressing areas for improvement. Documentation of this Annual Review of Program Effectiveness must be submitted to the GMEC as part of the program’s Annual Report to the GMEC.

Approved by GMEC 1996
Revisions approved by GMEC 6/16/10