V.C.1. The program director must appoint the Program Evaluation Committee (PEC)to conduct and document the Annual Program Evaluation as part of the program's continuous improvement process. (Core)
V.C.1.a) 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)
V.C.1.ab) The Program Evaluation Committee responsibilities must include:
V.C.1.ab).(1) acting as an advisor to the program director, through program oversight; (Core)
V.C.1) must be composed of at least two program faculty members and should include at least one resident.b).(2) review of the program's self-determined goals and progress toward meeting them; (Core)
V.C.1.ab).(2) must have a written description of its responsibilities3) guiding ongoing program improvement, including development of new goals, based upon outcomes; and, (Core)
V.C.1.b).a).(3)should participate actively in:(4) review of the current operating environment to identify strengths, challenges, opportunities, and threats as related to the program's mission and aims. (Core)
V.C.1.c) The Program Evaluation Committee should consider the following elements in its assessment of the program:
V.C.1.c).(1) curriculum; (Core)
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2) outcomes from prior Annual Program Evaluation(s); (Core)
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3) ACGME letters of notification, including citations, Areas for Improvement, and comments; (Core)
V.C.1.c).(4) quality and safety of patient care; (Core)
V.C.1.c).(5) aggregate resident and faculty:
V.C.1.c).(5).(a) well-being; (Core)
V.(3C.1.c).(5).(b) reviewing and making recommendations for revision of competency-based curriculum goals and objectives; (Detailrecruitment and retention; (Core)
V.C.1.ac).(35).(c) addressing areas of non-compliance with ACGME standards; and, (Detailworkforce diversity; (Core)
V.C.1.ac).(35).(d) reviewing the program annually using evaluations of faculty, residents, and others, as specified below. (Detailengagement in quality improvement and patient safety; (Core)
V.C.1.c).(5).(e) scholarly activity; (Core)
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.1.c).(5).(f) ACGME Resident and Faculty Surveys; and, (Core)
V.C.1.c).(6) aggregate resident:
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.1.c).(6).(a) achievement of the Milestones; (Core)
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.1.c).(6).(b) in-training examinations (where applicable); (Core)
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1.c).(6).(c) board pass and certification rates; and, (Core)
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1.c).(6).(d) graduate performance. (Core)
V.C.21.dc).(7) aggregate faculty:
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.c).(7).(a) evaluation; and, (Core)
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c).
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(7).(
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b) professional development. (Core)
V.C.21.e)progress on the previous year's action plan(s)d) The Program Evaluation Committee must evaluate the program's mission and aims, strengths, areas for improvement, and threats. (Core)
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e) The annual review, including the action plan, must:
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1.e).(1) be distributed to and discussed with the members of the teaching faculty and the residents; and, (Core)
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(2) be submitted to the DIO. (Core)