Evaluation Policy

Description of requirements and expectations regarding evaluation of University at Buffalo- (UB) sponsored, Accreditation Council for Graduate Medical Education- (ACGME) accredited training programs, as well as residents/fellows and faculty in those programs.

UB-sponsored, ACGME-accredited programs must adhere to all applicable ACGME Institutional, Common, and Specialty-Specific requirements pertaining to evaluation, as well as local requirements determined by the UB Graduate Medical Education Committee (GMEC) and/or the Office of Graduate Medical Education (UB GME).

ACGME Common Program Requirements (Residency) Effective 7/1/2022 (V.A.1. – Background and intent)

Feedback: ongoing information provided regarding aspects of one’s performance, knowledge, or understanding.

Formative evaluation: monitoring resident learning and providing ongoing feedback that can be used by residents to improve their learning in the context of provision of patient care or other educational opportunities.

Summative evaluation: evaluating a resident’s learning by comparing the residents against the goals and objectives of the rotation and program, respectively.

• Programs must use the current Residency Management System (RMS), MedHub, to build and deliver evaluations.
  • In cases where alternate means of evaluation are used, UB GME must be consulted or these evaluations must be entered in the RMS in a timely fashion.
• Evaluations should be reviewed by the Program Director or designee(s) (e.g., Associate Program Director, faculty mentor, program administrator, etc.) at least monthly when available.
  • The Program Director must notify UB GME as soon as possible of any evaluations possibly indicating discrimination, harassment, other significant breaches of professionalism, and/or serious concerns about the program. See the UB GME Discrimination and Harassment Policy for additional information.
• Resident/fellow files must be maintained according to the UB GME Record Retention, Disposal and Data Security Policy.
• Unsatisfactory evaluations of a resident/fellow must be discussed in a timely manner with that resident/fellow.
  • See the UB GME Academic Action Policy for additional information.
• Annual Summative and Final Summative Evaluations of residents/fellows must be completed by the Program Director in a timely fashion, using the form(s) provided by UB GME in the RMS, at the end of each resident’s/fellow’s year of training.
  • Annual Summative Evaluations must be completed for residents/fellows not in their final year of training.
  • Final Summative Evaluations must be completed for residents/fellows in their final year of training
  • A program may obtain approval in advance to use an alternate form in the RMS, which must be vetted by UB GME to ensure, at minimum, that ACGME-required language is used as follows:
    • For Annual Summative Evaluation (if applicable): “This resident/fellow has [or has not] demonstrated readiness to progress to the next year of the program.”
    • For Final Summative Evaluation: “This resident/fellow has [or has not] demonstrated the knowledge, skills, and behaviors necessary to enter autonomous practice.”
• The Annual Program Evaluation (APE) must be completed by the program director or designee(s) in the RMS using the form provided by UB GME.
  • Use of this form ensures program compliance with requirements and facilitates review of program data by the UB GMEC.

ACGME Common Program Requirements (Residency) Effective 7/1/2022 (V.-V.C.2.a))

• Evaluation
  • Resident Evaluation
    • Feedback and Evaluation
      • Faculty members must directly observe, evaluate, and frequently provide feedback on resident performance during each rotation or similar educational assignment. (Core)
      • Evaluation must be documented at the completion of the assignment. (Core)
        • For block rotations of greater than three months in duration, evaluation must be documented at least every three months. (Core)
        • Longitudinal experiences, such as continuity clinic in the context of other clinical responsibilities, must be evaluated at least every three months and at completion. (Core)
      • The program must provide an objective performance evaluation based on the Competencies and the specialty- specific Milestones, and must: (Core)
        • use multiple evaluators (e.g., faculty members, peers, patients, self, and other professional staff members); and, (Core)
        • provide that information to the Clinical Competency Committee for its synthesis of progressive resident performance and improvement toward unsupervised practice. (Core)
      • The program director or their designee, with input from the Clinical Competency Committee, must:
        • meet with and review with each resident their documented semi-annual evaluation of performance, including progress along the specialty-specific Milestones; (Core)
        • assist residents in developing individualized learning plans to capitalize on their strengths and identify areas for growth; and, (Core)
        • develop plans for residents failing to progress, following institutional policies and procedures. (Core)
      • At least annually, there must be a summative evaluation of each resident that includes their readiness to progress to the next year of the program, if applicable. (Core)
      • The evaluations of a resident’s performance must be accessible for review by the resident. (Core)                                            [The Review Committee may further specify under any requirement in V.A.1.-V.A.1.f)]
    • Final Evaluation
      • The program director must provide a final evaluation for each resident upon completion of the program. (Core)
        • The specialty-specific Milestones, and when applicable the specialty-specific Case Logs, must be used as tools to ensure residents are able to engage in autonomous practice upon completion of the program. (Core)
        • The final 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; (Core)
          • verify that the resident has demonstrated the knowledge, skills, and behaviors necessary to enter autonomous practice; (Core)
          • consider recommendations from the Clinical Competency Committee; and, (Core)
          • be shared with the resident upon completion of the program. (Core)
      • A Clinical Competency Committee must be appointed by the program director. (Core)
        • At a minimum, the Clinical Competency Committee must include three members of the program faculty, at least one of whom is a core faculty member. (Core)
          • Additional members must be faculty members from the same program or other programs, or other health professionals who have extensive contact and experience with the program’s residents. (Core)
      • The Clinical Competency Committee must:
        • review all resident evaluations at least semi-annually; (Core)
        • determine each resident’s progress on achievement of the specialty-specific Milestones; and, (Core)
        • meet prior to the residents’ semi-annual evaluations and advise the program director regarding each resident’s progress. (Core)
  • Faculty Evaluation
    • The program must have a process to evaluate each faculty member’s performance as it relates to the educational program at least annually. (Core)
      • This evaluation must include a review of the faculty member’s clinical teaching abilities, engagement with the educational program, participation in faculty development related to their skills as an educator, clinical performance, professionalism, and scholarly activities. (Core)
      • This evaluation must include written, anonymous, and confidential evaluations by the residents. (Core)
    •  Faculty members must receive feedback on their evaluations at least annually. (Core)
    • Results of the faculty educational evaluations should be incorporated into program-wide faculty development plans. (Core)
  • Program Evaluation and Improvement
    • The program director must appoint the Program Evaluation Committee to conduct and document the Annual Program Evaluation as part of the program’s continuous improvement process. (Core)
      • The Program Evaluation Committee must be composed of at least two program faculty members, at least one of whom is a core faculty member, and at least one resident. (Core)
    • Program Evaluation Committee responsibilities must include:
      • acting as an advisor to the program director, through program oversight; (Core)
      • review of the program’s self-determined goals and progress toward meeting them; (Core)
      • guiding ongoing program improvement, including development of new goals, based upon outcomes; and, (Core)
      • review of the current operating environment to identify strengths, challenges, opportunities, and threats as related to the program’s mission and aims. (Core)
    • The Program Evaluation Committee should consider the following elements in its assessment of the program:
      • curriculum; (Core)
      • outcomes from prior Annual Program Evaluation(s); (Core)
      • ACGME letters of notification, including citations, Areas for Improvement, and comments; (Core)
      • quality and safety of patient care; (Core)
      • aggregate resident and faculty:
        • well-being; (Core)
        • recruitment and retention; (Core)
        • workforce diversity; (Core)
        • engagement in quality improvement and patient safety; (Core)
        • scholarly activity; (Core)
        • ACGME Resident and Faculty Surveys; and, (Core)
        • written evaluations of the program. (Core)
      • aggregate resident:
        • achievement of the Milestones; (Core)
        • in-training examinations (where applicable); (Core)
        • board pass and certification rates; and, (Core)
        • graduate performance. (Core)
      • aggregate faculty:
        • evaluation; and, (Core)
        • professional development. (Core)
    • The Program Evaluation Committee must evaluate the program’s mission and aims, strengths, areas for improvement, and threats. (Core)
    • The annual review, including the action plan, must:
      • be distributed to and discussed with the members of the teaching faculty and the residents; and, (Core)
      • be submitted to the DIO. (Core)
  • The program must complete a Self-Study prior to its 10-Year Accreditation Site Visit. (Core)
    • A summary of the Self-Study must be submitted to the DIO. (Core)

Established:  1994
Reviewed by GMEC: 08/94; 03/02; 08/13; 06/17; 06/22