University of South Alabama Hospitals

Graduate Medical Education Committee

Annual Program Evaluation and Action Plan

Academic Year FROM YEAR– TO YEAR

Program Name:

Date of Program Evaluation Meeting:

Number of Residents/Fellows in Program:

Number of Key Clinical Faculty listed on the PIF

Key Clinical Faculty (KCF) members are attending physicians who dedicate, on average, 15 hours per week throughout the year to the program.

Program Director Signature:

ACGME Common Program Requirements (V.C.) requires a 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; and 4. Program quality.

Please complete this form and return to the GME Office by June,YEAR, including all attachments.

The program review can be part of the annual faculty meeting, the department education committee, or faculty education meeting. All faculty and residents must have the opportunity to evaluate the program confidentially and in writing at least annually, which may be done via New Innovations. Please contact the GME Office for further instruction on this module.

The following key teaching faculty members participated in the annual meeting:

The following residents/fellows participated in the meeting:

  1. Educational Component/Review of Curriculum for Effectiveness
  2. Program goals/objectives are distributed to faculty and residents annually

Yes No

  1. Each assignment/rotation at each PGY level has competency based goals & objectives

Yes No

  1. Program Letter’s of Agreement for all required and elective sites current

Yes No

(Agreements must have current PD, current Site Director, and rotation length by

PGY levels and goals/objectives by competency)

a)Please identify any new sites or sites no longer used

  1. Conferences

a) Is attendance taken at required conferences for faculty and residents?

Yes No

b)Average attendance of residents at required conferences as listed on the PIF

%

  1. Transition of Care (CPR VI.B.):

Does the program monitor an effective and structured hand-over process?

Yes No If yes, how?

  1. Clinical Quality Improvement/Patient Safety Program

Describe at least one quality improvement activity or project in which residents participated, including the outcome and how it improved patient outcomes. (If you need more space, please attach the QI project description including the outcome).

  1. Resident Participation in Scholarly, Educational and Professional Activities
  2. Scholarly Activities

1.Number of articles authored/coauthored by residents for 2011-2012

2.Number of presentations at professional meetings by residents for 2011-2012

  1. Committee Participation

List all committees with resident participation (For example, Patient Safety, Education/Curriculum, QI, etc.)

Committee Name / Resident Name(s) / PGY Level(s) / Program/Dept/Hospital/Other / Comment
  1. Do all residents participate in interdisciplinary teams?

Yes No

  1. Evaluation
  2. Residents are evaluated on their performance following each learning experience.

Yes No

  1. Residents are evaluated semi-annually and evaluation is in the residents’ file.

YesNo

  1. Evaluations are in New Innovations.

YesNo

  1. Multisource evaluations are used. (Ex. Nurses, Allied Health, Peer, Patients)

YesNo

  1. Final summative evaluation verifies that the resident has “demonstrated sufficient competence to enter practice without direct supervision”.

YesNo

  1. Faculty and residents have the opportunity to evaluate the program confidentially and in writing at least annually

YesNo

  1. Residents confidentially evaluate faculty

YesNo

  1. Residents confidentially evaluate rotations

YesNo

  1. Duty Hour Monitoring and Supervision
  2. How does the program monitor compliance with duty hours? (Please attach a copy of your program duty hourpolicy including the monitoring process).
  1. How does the faculty provide appropriate supervision of residents in patient care activities? (Please attach a copy of your program Supervision Policy ensuring oversight and graded authority and responsibility CPR VI.D.3).
  1. ACGME Citation/Resident Survey Responses
  2. Using the program Plan of Action submitted and approved by the GMECresponses to citations have been updated in WebADS as of

Date

  1. Overall Program
  2. Board Pass Rates for residents graduating during last three academic years. Please provide national comparison if available.

Academic Year ending / Number of residents completing the program / Number of residents taking 1st stage of Board exam for 1st time / Number of 1st time takers who passed 1st stage of Board exam / National 1st time pass rate / Number of residents taking 2nd stage of Board exam for 1st time / Number of 1st time takers who passed 2nd stage of Board exam
June 30, 2012
June 30, 2011
June 30, 2010
  1. In-Training Exams

a)Results of ITE (Shelf, PRITE, etc.) by PGY level, if applicable

PGY Level / Exam Results / National Comparison Data
1
2
3
4
5
6
7

b)How is this information used to improve the program?

  1. Faculty Professional Development

1.Key Clinical Faculty* CV’s , for this academic year, are current in WebADS

Yes No

2.Number of Key Clinical Faculty who participated in faculty development programs?

#

3.What program activities are in place to support faculty teaching effectiveness?

*Per ACGME – Key Clinical Faculty (KCF) members are attending physicians who dedicate, on average, 10 hours per week throughout the year to the program.

  1. Program Strengths and Weaknesses

What are the residency educational and professional development strengths and weaknesses?

  1. Areas for Improvement:

List the areas for improvement in your program.

  1. Program Action Plan for Improvement

Attach your program’s plan for improvement or describe below. Please include improvement goals for conferences, rotations/assignments, curriculum, etc. Identify your timeline for the actions and how you will measure improvement.

  1. Program Changes/Resources Needed

Please identify any changes in complement or change in participating sites.

Required Attachments:

  1. Program specific duty hour monitoring process
  2. Program specific supervision policy

Used with permission from University of Colorado, Denver, Graduate Medical Education