Policies,Administrative,UWHC,Department Specific,Graduate Medical Education (GME)

Evaluation of Residents and Faculty (43.7)

Evaluation of Residents and Faculty (43.7) - Policies, Administrative, UWHC, Department Specific, Graduate Medical Education (GME)


Graduate Medical Education Departmental Policy
Policy Title: Evaluation of Residents and Faculty
Policy Number: 43.7
Effective Date: November 18, 2015
Version: New

The purpose of this policy is to establish University of Wisconsin Hospitals and Clinics Authority
(UWHCA) Graduate Medical Education Committee (GMEC) expectations and highlight relevant
ACGME Common Program Requirements (CPRs) required for robust resident and faculty evaluation
systems for GME programs.


This policy applies to all Graduate Medical Education (GME) programs sponsored by the UWHCA.


A. The term “resident” refers to residents and fellows.
B. Program(s) will refer to ACGME-accredited program(s) sponsored by UWHC.
C. UW Health: For the purpose of this policy, the term “UW Health” shall mean University of
Wisconsin Hospitals and Clinics Authority, which is the sponsoring institution of the ACGME-
accredited training programs. “UW Health” is the trade name of University of Wisconsin
Hospitals and Clinics Authority and its affiliates.
D. Evaluation and assessment: Although the terms evaluation and assessment are often used
interchangeably in education literature, assessment can be used to refer to measuring or gathering
information about a resident’s competence or performance, and evaluation to making a judgment
about competence or performance. Assessment is often used to describe formative measures,
while evaluation generally describes higher stakes decisions at a point in time.
E. “Written” may refer to a printed or electronic document.


All UW Health GME programs must develop and implement a robust evaluation system that will be used
to determine resident promotion and successful program completion. The evaluation system must meet
the minimum requirements of the ACGME as outlined in the Common Program Requirements (CPRs)
and any further specifications outlined in the specialty program requirements.

A. Resident Evaluation: Resident performance assessment must include both formative evaluation
[CPR V.A.2.] and summative evaluation [CPR V.A.3.].
1. Formative Evaluation/Assessment:
a. Faculty must evaluate resident performance in a timely manner during each rotation or
similar educational assignment, and document this evaluation at completion of the

assignment [CPR V.A.2.a]. For programs that do not have defined rotations, formative
written evaluations by faculty must be conducted and provided to residents at least
quarterly. Evaluations should be completed using the MedHub Residency Management
b. The formative evaluation process must be structured such that the program can provide
reliable assessments of competence in patient care, medical knowledge, practice-based
learning and improvement, interpersonal and communication skills, professionalism, and
systems-based practice, based on the specialty-specific Milestones [CPR, V.A.2.b.1] and
include the use of multiple evaluators (e.g., faculty, peers, patients, self, and other
professional staff) [CPR, V.A.2.b.2].
c. The program must use this formative evaluation to document progressive resident
performance improvement appropriate to the educational level [CPR, V.A.2.b.3].
d. In addition, the program must provide each resident with documented semiannual
evaluation of performance with feedback [CPR, V.A.2.b.4]. The semiannual evaluation
may be conducted by the program director or designee, and must be considered as a part
of the promotion process in accordance with the program’s established promotion
2. Summative Evaluation:
a. The program director must provide a summative evaluation for each resident upon
successful completion of the specialty program expectations [CPR V.A.3.b]. This
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 the UW
Health GME Resident Files and Retention Policy [CPR V.A.2.b.1].
b. The final summative evaluation must document the resident’s performance during the
final period of education (i.e. the last six months of training) [CPR V.A.3.b.2] and verify
that the resident has demonstrated sufficient competence to enter practice without direct
supervision [CPR V.A.3.b.3].
c. Specialty-specific milestones must be used as one of the tools to ensure residents are able
to practice core professional activities without supervision upon completion of the
program [CPR V.A.2.a].
d. Final summative evaluations for all residents will be stored in MedHub as part of the
resident permanent file.
3. Clinical Competency Committee: The program director must appoint a Clinical Competency
Committee (CCC), which is responsible for reviewing all resident evaluations semiannually,
preparing and assuring the reporting of Milestone data to the ACGME on a semiannual basis,
and advising the program director of resident progress, including promotion, remediation and
dismissal [CPR V.A.1.]. The composition, roles and responsibilities of the CCC are described
further in the Common Program Requirements [CPR V.A.1.].

B. Faculty Evaluation: At least annually, the program director must evaluate faculty performance
as it relates to the educational program [CPR V.B.1.]. These evaluations should include a review
of the faculty’s clinical teaching abilities, commitment to the educational program (demonstrated
by active participation in and support of resident educational activities), clinical knowledge,
professionalism, and scholarly activities [CPR V.B.2.]. Finally, the evaluation must include at
least annual written confidential evaluations by the residents [CPR V.B.3.].


The purpose of the following guidelines is to provide program directors background information and
specific suggestions for implementing the expectations defined in the policy.

A. Resident Evaluations
1. Formative Evaluations: Formative assessment, or assessment for learning, documents
resident progressive development over time and informs the on-going learning process for the
resident, the faculty, the program director, and the institution. Assessment tools document
this development and should be aligned with the published goals and objectives and the
relevant specialty-specific milestones for each rotation/educational assignment, program
clinical and procedural objectives, and, as applicable, to the specialty specific Entrustable
Professional Activities (EPAs).
a. Goals of Formative Evaluation:
ξ Provide a transparent evaluation system based on the goals and objectives of each
rotation or educational assignment, and on the published specialty-specific
ξ Maximize resident learning development through frequent, timely, meaningful
feedback to provide multiple individual data points as evidence for promotional
ξ Support a learning environment that nurtures individual growth and development.
ξ Provide data to continuously improve the learning, teaching, curriculum, evaluation
instruments, and program outcomes.
b. To meet these goals, programs are expected to use a multi-faceted approach with multiple
instruments, evaluators, and observations. These instruments include direct observation
assessments (for clinics, consults, procedures, and/or labs), end-of-
rotation/shift/assignment evaluations, multi-source feedback, evaluations of presentations
at conference, semi-annual meeting assessments, portfolios and self-reflections on
learning, in-house training exams, case/procedure logs, as well as other educational
instruments that reflect the progress and performance expectations in the specialty area
and within the ACGME competencies.
c. Case and Procedure Logs: As case and procedure logs record the number of cases or
procedures performed, they document an aspect of training and practice that leads to
competent performance in the medical, diagnostic, and surgical procedures essential for
the area of practice. Considered in combination with direct observation assessments of
procedures, the logs and evaluations of the procedures together provide evidence of
d. Frequency of Documented Formative Assessment and Evaluation: A sufficient number
and variety of documented assessments should be completed semiannually by a number
of faculty and other members of the health care team and/or program to ensure reliable
judgments can be made by the CCC.
e. Program directors are responsible for ensuring that faculty complete resident assessment
and evaluation forms in MedHub in a timely manner (ACGME recommends within two
weeks of the end of the rotation/educational assignment or quarter).
2. Semiannual Evaluation of Performance
a. The program director (or designee) should meet semiannually with each resident to
review all documented performance records, plans and evidence of scholarly activity (if
applicable), case and procedure logs and other performance indicators, including the most
recent CCC milestone report and any performance concerns generated by the CCC, if
b. During the semiannual meeting, residents will be asked to reflect on their performance
and progress, and make plans with the director (or designee) to address current and future
training needs. Based on the collection of work (i.e. portfolio), evidence of experience
and work accomplished, the program director (or designee) will provide guidance and
academic advice to enable the resident to meet program performance expectations. These

semiannual meetings should provide the basis for residents to develop self-evaluation
skills and the foundations for life-long learning.
c. A summary of the semiannual evaluation must be provided to the resident in writing,
signed by the resident to confirm receipt, and a copy filed in the residents file in
3. Accessibility of Evaluations: To provide transparency and fairness, all evaluation
instruments must be distributed and explained to residents at the beginning of the training
year, rotation, or educational experience (along with the relevant goals and objectives) and
whenever there are revisions or changes to the evaluation instruments or processes. In
addition, all completed, documented evaluations of resident performance must be accessible
to residents on MedHub or in their files.
4. Final Summative Evaluation: Program directors will provide a final summative evaluation,
which includes documentation of performance during the final period of training (i.e. the last
six months). This evaluation must indicate that each graduating resident has demonstrated
sufficient competence to enter practice without direct supervision.
a. From ACGME CPRs, [V.A.3.] on Summative Evaluation:
ξ “The specialty-specific milestones must be used as one of the tools to ensure
residents are able to practice core professional activities without supervision upon
completion of the program. (Core)
ξ “The program director must provide a summative evaluation for each resident upon
completion of the program. (Core)
ξ “This evaluation must:
(i) 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; (Detail)
(ii) document the resident’s performance during the final period of education, and,
(iii) verify that the resident has demonstrated sufficient competence to enter practice
without direct supervision.” (Detail)
b. Summative evaluations should be completed within four weeks of completion of all
training requirements. These documents must be stored in MedHub in the resident’s
permanent file, will be accessible to the resident (upon request), and may vary in form by

B. Faculty Development in Assessment: Faculty must be trained in the use of all assessment tools
in order to achieve greater reliability and, ultimately, validity with the instruments. In-depth
training sessions can be useful, along with shorter, continuous training on the appropriate use and
interpretation of the forms. From ACGME Frequently Asked Questions about the Next
Accreditation System: “Evaluation is a core faculty member competency, but most faculty
members will need added training in the evaluation process.... They will initially need to discuss
the milestone narratives and reach a common agreement of their meaning.”

C. Faculty Evaluation: Faculty performance in the educational program can be assessed in a
variety of ways, depending on the emphasis and expectations of the program. Most of the items
listed below are required as a part of the ACGME Annual Program Update in ADS:
1. Faculty clinical teaching abilities as reflected in evaluations from:
a. Conference presentations and organized clinical discussions (e.g. M&Ms, Case
Presentations, journal club)
b. Resident/fellow confidential assessments of individual faculty (minimum of 4
c. Other assessments, variable by program, such as 360 degree assessments; peer

assessments, rounding effectiveness, debrief assessments, mentoring/advising
2. Commitment to the educational program. Examples vary by program:
a. Participation in educational committees (e.g. CCC, Program Evaluation Committee,
Curriculum Committee) or as a faculty advisor for a resident committee.
b. Participation as a faculty mentor for a resident.
c. Attendance and participation at educational program retreats, faculty meetings, and/or
d. Attentiveness to completing assessments of residents in a timely (within days) and
thoughtful manner. [Percentage of faculty that complete written evaluations of residents
within 2 weeks.]
e. Quality of comments on evaluation forms: The number of individualized, specific,
behaviorally-based comments written to residents on assessment tools can be an indicator
of faculty commitment to the educational program.
f. Readiness to support the program director and residents on projects (e.g. QI Projects,
g. Number of residents mentored and collaborating with in scholarly activity
3. Scholarly activities: The Faculty Scholarly Activity Template in ADS must be updated
annually. The annual reporting areas in the ADS template include:
a. Pub Med ID numbers
b. Number of conference presentations (abstracts, posters, and presentations)
c. Number of other presentations (such as grand rounds), materials developed, or work
presented in non-peer review publications
d. Number of chapters or textbooks published
e. Number of grants with leadership
f. Leadership roles in national medical organizations or served as reviewer or editorial
board member for a peer-reviewed journal
g. Teaching of formal courses: responsibility for seminar, conference series, course
coordination for any didactic training.


Sr. Management Sponsor: Susan L. Goelzer, M.D., M.S., Designated Institutional Official
Author: Director, Graduate Medical Education and Medical Staff Administration
Approval Committee: Graduate Medical Education Committee 11-18-15


Susan L. Goelzer, M.D., M.S.
Professor of Anesthesiology, Internal Medicine and Population Health Sciences
Senior Medical Director for GME/Designated Institutional Official
Associate Dean for Graduate Medical Education

Revision Details:
Previous Revision Date: New
Next Revision Due: 10/21/2018