Graduate Medical Education

Annual Program Evaluations (APE)

 

According to the ACGME Common Program Requirements, section V.C.2., the program, through the Program Evaluation Committee (PEC), must document formal, systematic evaluation of the curriculum at least annually, and is responsible for rendering a written Annual Program Evaluation (APE).

 

In addition, the program must monitor and track each of the following areas: resident performance; faculty development; graduate performance, including performance of program graduates on the certification examination; program quality; and policies, protocols and procedures.

 

The PEC must prepare minutes and a written plan of action, using the required Annual Program Evaluation Minutes (APE) and Action Plan template to document initiatives to improve performance as well as delineate how they will be measured and monitored. The action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes.

 

The APE Process (See sample timeline)

 

Programs will be assigned a date by which the program component APE process must be complete.  This specific assigned date will recur yearly to facilitate long-term planning.  The multi-step process is outlined below:

 

  1. The program will receive a reminder notification 90 days in advance from the GME Office of the due date for completion of the program component of the APE process.*
  2. The program must update ADS.
  3. The program completes the APE form in New Innovations.
  4. The PEC conducts the APE Meeting.
  5. The program submits the Annual Program Evaluation Minutes (APE) and Action Plan (through New Innovations) by the assigned due date.
  6. An Annual Program Evaluation Report and Action Plan is generated and reviewed by the GMEC Compliance & Accreditation Subcommittee.  The subcommittee either:

    a.  Accepts the report and action plan

    b.  Asks for clarification/additional documentation

    c.  Determines the need for a Special Program Review (SPR)

  7. The Annual Program Evaluation Report and Action Plan is presented to the GME Executive Committee and to the GMEC.
  8. Program leaders meet with GME Faculty for debrief (core programs, only).

 

APE Materials

At a minimum, the following materials (documenting resident performance, faculty development, graduate performance and program quality) should be reviewed as part of the program component of the APE process:

  • Completed New Innovations Annual Program Evaluation form
  • Most recent ACGME Letter of Notification
  • Most recent ACGME Resident and Faculty Survey summaries
  • Core faculty development activities
  • Previous Annual Program Evaluation (APE) Minutes and Action Plans
  • Milestone patterns/trends suggesting the need for faculty development or curricular revision
  • Resident/Fellow quality improvement activities
  • Resident/Fellow scholarly activities
  • Faculty scholarly activities
  • Ongoing “wellness” activities

 

 

 

Program APE Meeting

The program APE meeting should be conducted by the PEC within 90 days of the due date for completion of the program component of the APE process.  The format for the meeting must be a SWOT (strengths, weaknesses, opportunities and threats) analysis of the program based on the materials provided and the participants’ knowledge of the program’s activities and processes.

 

APE Action Plan

An action plan must be created from the results of the SWOT analysis and documented using the Annual Program Evaluation (APE) Minutes and Action Plan Template. The action plan must be reviewed and approved by the teaching faculty and documented in meeting minutes of a faculty meeting.  The action plan should be distributed to all residents/fellows.

 

GMEC Oversight

The GMEC Compliance & Accreditation Subcommittee will review the Annual Program Evaluation Report and Action Plan at its monthly meeting as designated by the GME Program Oversight Calendar and either:

 

    a.  Accepts as submitted

    b.  Asks for clarification/additional documentation

    c.  Determines the need for a Special Program Review (SPR)

 

The Annual Program Evaluation Report and Action Plan will be presented to the GME Executive Committee and to the GMEC.

 

*The month that completed Annual Program Evaluation Minutes and Action Plan must be submitted to the GME Office is predetermined and illustrated in the GMEC Program Oversight Calendar.