Annual report requirement/Core Competencies
December 22, 2005
The ACGME requires a systematic review of the educational effectiveness of all programs at least annually. This is contained in the ACGME Common Program Requirements, VII.C., which states:
1. Representative program personnel (i.e., at least the program director, representative faculty, and one resident) must be organized to review program goals and objectives, and the effectiveness with which they are achieved. This group must conduct a formal documented meeting at least annually for this purpose.  In the evaluation process, the group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution, and the residents’ confidential written evaluations. If deficiencies are found, the group should prepare an explicit plan of action, which should be approved by the faculty and documented in the minutes of the meeting.
2. The program should use resident performance and outcome assessment in its evaluation of the educational effectiveness of the residency program. Performance of program graduates on the certification examination should be used as one measure of evaluating program effectiveness. The program should maintain a process for using assessment results together with other program evaluation results to improve the residency program.
These annual reports should be submitted to Dr. Sandlow by the end of July.  All programs, including the subspecialties and programs with no current residents, are included. The GME Office will send out the criteria to the programs.
The regular Internal Review report does not appear to meet the requirements.  However, a Curriculum Committee report might meet the requirements, if a resident is on the committee.
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Sample format:
Annual Review of the Residency Program in ______________________
For Academic Year ___________
Date of meeting:
Location of meeting:
Present at the meeting (a minimum of at least one in each category must be present):
Program director:
- Representative faculty: (Name and title)
- Resident (Name and PGY)
Program goals and objectives:
- Review of goals and objectives
- Effectiveness with which goals and objectives are achieved
Educational Effectiveness of the program evaluation:
- Resident performance
- Outcome assessment
- Performance of program graduates on the certification examination
The program should maintain a process for using assessment results together with other program evaluation results to improve the residency program.
The group must take into consideration:
- Written comments from the faculty
- The most recent report of the GMEC of the sponsoring institution
- The residents' confidential written evaluations
If deficiencies are found:
- Plan of action
- Describe in detail
- Approved by faculty
- Document in the minutes of the meeting