Medical College of Wisconsin Affiliated Hospitals, Inc.
PROGRAM EVALUATION COMMITTEE(S)
Each MCWAH Program must evaluate its program through an Annual Program Review and each Program must have a committee that assists the Program Director in a quality and advisory capacity in the evaluation of housestaff performance. These two evaluation functions may be performed by one program committee or two distinct Program committees.
Annual Program Review Committee (APRC)
1. An Annual Program Review Committee must conduct an Annual Program Review. This review must be a formal and systematic evaluation of the Program’s curriculum and quality of education.
2. At minimum, the membership of the Annual Program Review Evaluation Committee shall be comprised of the Program Director, a representative number of program faculty and a senior level housestaff.
3. The Annual Program Review must include a review of the following:
a. Overall performance of housestaff (e.g., in-service exam results, procedure logs, summary evaluations of housestaff);
b. Faculty development (e.g., CME activities, activities directed toward improving teaching abilities and professionalism);
c. Graduate performance (e.g., certification examination results, survey of graduates);
d. Confidential written housestaff evaluation of the Program (e.g., ACGME Resident Survey, MCWAH Housestaff Survey, housestaff evaluation of rotations); and
e. Confidential written faculty evaluation of the Program (e.g., MCWAH Faculty Survey).
f. The previous year’s improvement action plan to evaluate whether the identified improvements were achieved.
4. Based on the review and evaluation, the Committee shall prepare a written improvement plan of action for the Program.
5. The Committee must maintain written meeting minutes. These minutes must include the written improvement plan of action for the upcoming year. The minutes must be submitted to MCWAH’s Designated Institutional Official (DIO) & Executive Director.
6. The improvement plan of action must be presented to and approved by the Program’s faculty.
Housestaff Evaluation Committee (HEC)
Each program must establish a program Housestaff Evaluation Committee (HEC) that serves in a quality review and advisory capacity to the Program Director.
1. The HEC must meet to review and discuss the performance of the Program’s housestaff at least annually.
2. The HEC shall also meet on an ad hoc basis to assist the Program Director in evaluating an individual’s performance or behavior.
3. If there is a separate evaluation committee from the Annual Program Review Committee, the voting membership of the HEC shall be comprised of the Program Director, a representative number of faculty and senior level housestaff as appropriate. The Department Chair (or the Division Chief for fellowships in large departments) should not attend HEC meetings so that s/he may objectively evaluate any housestaff complaint or grievance.
4. The committee must maintain written meeting minutes.
This policy was approved by the MCWAH Graduate Medical Education Council on July 18, 2011.