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Program Evaluation and Improvement Self-Assessment and Annual Program Internal Review Policy



The educational effectiveness of a program must be evaluated at least annually in a systematic manner as required by the Section V.C.1 of ACGME Common Program Requirements. An annual self-assessment by the Program is a process different and separate from the “midpoint” program internal review carried out by the GMEC - Education and Research Committee (ERC).



  • Self-assessment will involve (i.e., at least the Program Director and/or Associate Program Director, representative faculty and at least one (1) resident from each year level).
  • Self-assessment process will be verified at the Education and Research Committee meetings and during the Internal Review of the program.


  1. Residents and faculty must have the opportunity to evaluate the program confidentially and in writing at least annually, and
  2. The program must use the results of residents’ assessments of the program together with other program evaluation results to improve the program.
  3. If deficiencies are found, the program should prepare a written plan of action to document initiatives to improve performance in the areas listed in Section V.C.1. The action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes.
  4. The Education and Research Committee will monitor the effectiveness of action plans for improvement.

The Program Evaluation and Improvement Self-Assessment should include at least:

  • Recommendations from the last Internal Review or Accreditation Letter Progress Report
  • Review of Program Dashboard Indicator/Metric
  • Program goals and objectives and the effectiveness with which they are achieved
  • Competency/Outcomes Curriculum Enhancements
  • Duty Hour compliance
  • Policy reviews up to date
  • Faculty Performance
  • % evaluations returned from core faculty
  • Faculty Development
  • Resident performance-probation/remediation
  • Resident Satisfaction and Work Environment Survey
  • ACGME Web Based Resident Survey
  • Exit Interview Survey.

Approved by Education and Research Committee 06/03/09

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