GME Policy Manual

POLICY#:       I.4
SECTION:     SELECTION/PROMOTION PROCESS
SUBJECT:     PERFORMANCE EVALUATION

I. PURPOSE

To establish a general guideline within which each program can provide a house officer with periodic evaluations as required by the ACGME, University, CIR or RRC specific to each Program.

II. SCOPE

This applies to all housestaff in all postgraduate training programs.

III. DEFINITIONS

Housestaff-refers to all interns, residents and subspecialty residents (fellows) enrolled in a University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School postgraduate training program. An individual housestaff member may be referred to as a house officer.

IV. RESPONSIBILITIES/REQUIREMENTS

A. Each house officer shall be continuously evaluated for his/her academic performance as follows:

1.       Formative Evaluation

The faculty must evaluate in a timely manner the residents whom they supervise. In addition, the residency program must demonstrate that it has an effective mechanism for assessing resident performance throughout the program, and for utilizing the results to improve resident performance.

a) Assessment should include the use of methods that produce an accurate assessment of residents' competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.

b) Assessment should include the regular and timely performance feedback to residents that includes at least semiannual written evaluations. Such evaluations are to be communicated to each resident in a timely manner, and maintained in a record that is accessible to each resident.

c) Assessment should include the use of assessment

results, including evaluation by faculty, patients, peers, self, and other professional staff, to achieve progressive improvements in residents' competence and performance.

2.      Final Evaluation

The program director must provide a final evaluation for each resident who completes the program. This evaluation must include a review of the resident's performance during the final period of education, and should verify that the resident has demonstrated sufficient professional ability to practice competently and independently. The final evaluation must be part of the resident's permanent record maintained by the institution.

3.     Other measures of performance to be considered in assessing academic growth include but are not limited to the following:

a. Standardized examinations
b. Required certifications, such as ACLS
c. In-service examinations
d. Quality of research, presentations, publications, etc.
e. Success in achieving assigned goals, including remediation goals.

4. Personal communications between program director and faculty or other persons in a supervisory role. (In order for such communications to be used meaningfully in evaluation, oral communications must be documented, with a copy placed in the house officer's file and another copy provided to the house officer. However, documentation of such communication may occur for the first time when an evaluation form is completed.)

5. Periodic review of each house officer's progress in the program by the program director in which all of the above performance measures will be discussed.

B. Each residency program must have in place a system of evaluation used to assess the academic performance of housestaff on a continuing basis; this system must be followed uniformly for all housestaff in the program. This serves to enhance the education process and keep trainees apprised of their progress.

C. The Program Director will assume responsibility for establishing the mechanism and frequency of performance evaluations in compliance with the ACGME essentials for the specific program. This is monitored through the GME internal review process.

D. The Program Director will inform the housestaff annually of the departmental procedure and schedule for performance evaluations.

E. Documentation of periodic performance evaluations shall be maintained in the house officer's academic record.

F. In order to continue in a residency program, a housestaff officer must make satisfactory academic progress as determined in accordance with the residency program's evaluation system.

G. All academic matters, including in-training exams should be considered in determining whether a house officer is making satisfactory academic progress. Academic matters include acquisition of knowledge related to the discipline as well as all aspects of the development of clinical and professional skills necessary for effective functioning as a health care professional. Of particular importance as academic issues are areas such as patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice.

Approved by GMEC on 2/23/99 and Amended on 5/13/08