ANNUAL PROGRAM EVALUATION (APE) AND IMPROVEMENT REPORT
Academic Year 2014-2015
The ACGME requirement is that all programs must perform a formal annual self-evaluation. The program must monitor and track program quality, resident performance, faculty development, graduate performance and action plans.Program:
Date of Review:
Committee Members: The Program Director must appoint the Program Evaluation Committee (PEC) which must be composed of at least two program faculty members and at least one resident
Faculty Member:
Faculty Member:
Resident Member:
Others (Optional): / Please list all other Members
Is there a written description of the PEC responsibilities? / Yes
No
Program Aim (Why does your program exist):
PROGRAM QUALITY
Number of Positions Approved by the ACGME:
Number of Positons Filled:
Number of Other Learners Rotating with the Residents:
Increase in compliment approved by the ACGME: / Temporary Increase
Permanent Increase
ACGMENotification Letter: / Date:
Cycle Years
Number of Citations:
Number of Areas for Improvement:
Commendations:
Citation #1 Description: / Citation corrected, no further intervention required
Continuing of current efforts adequate, no new actions
necessary
New action plan necessary: (Please describe)
Citation #2 Description: / Citation corrected, no further intervention required
Continuing of current efforts adequate, no new actions
necessary
New action plan necessary: (Please describe)
(Add/delete rows as necessary)
Quality of Candidates Recruited:
Number of Positions Available:
Number of Positions Filled: / Through the Match:
Through the SOAP:
Number of Positions Filled by LCME & AOA graduates:
Program Stability:
Resident Attrition Rate:
Faculty, PD Attrition Rate:
Resident Transfer Rate:
Summary of Resident Overall Evaluation of Program (taken from the resident annual evaluation of the program):
Summary of Faculty Overall Evaluation of Program (taken from the faculty annual evaluation of the program):
Annual PD Evaluation of Faculty Performed: / Yes / No
Program Requirements:
New ACGME Program Requirements were reviewed, if applicable. / Yes / No
No Program changes required
List new requirements requiring programmatic changes:
(Please describe)
Clinical Competency Committee Appointed / Yes / No
Milestones Evaluations entered in ACGME site prior to deadline / Yes / No
Overall educational goals for program and competency-based goals and objectives for each rotation at each PGY level were reviewed. / Yes / No
No changes required in Overall Goals and/or Goals &
Objectives
New Overall goals and/or Goals & Objectives necessary
to meet Program changes: (Please describe)
GME and Program Policy & Procedure Manual Reviewed. / Yes / No
No changes required in Policy & Procedure Manual
Changes in Policy & Procedures necessary: (Please
describe)
Supervision Policy
Reviewed / Yes / No
No changes required in Supervision Policy
Changes in Policy & Procedures necessary: (Please
describe)
Transition of Care Policy Reviewed / Yes / No
No changes required in Transition of Care Policy
Changes in Policy & Procedures necessary: (Please
describe)
Program Letters of Agreement reviewed / Yes / No
No changes required in current PLAs
New PLAs necessary: (Please describe)
List the participating institutions for your program.
Has the Program Director met with the appropriate personnel of the participating institution this year? List any concerns:
Program rotation evaluations reviewed. / Yes / No
No changes required in rotations
Aspects of rotations that require change: (Please
describe)
Program didactic curriculum reviewed. / Yes / No
No changes required in the didactic curriculum
Aspects of didactic curriculum that require change:
(Please describe)
ACGME Resident Survey summary data reviewed. / List major non-compliant issues:
No changes prompted by survey results
Changes required to address survey non-compliant
areas: (Please describe)
Were survey findings discussed with residents? / Yes / No
Duty Hour violation reports and program duty hour monitoring system reviewed. / Total number of violations for the year:
No changes required
Changes to improve duty hour compliance: (Please
describe)
Review of program educational resources and financial support. / List specific deficits in resources and program support:
No changes required
Changes to improve program support: (Please describe)
Please provide a brief update of any major changes to the program:
RESIDENT PERFORMANCE
In-Training/Mock Oral Examination Results:
Program Results / National Data
PGY 1
PGY 2
PGY 3
PGY 4
PGY 5
PGY 6
Scholarly Activities:
Submitted project for IRB review:
Received IRB approval:
Number of articlessubmitted for publication:
Number of articles accepted for publication:
Number of articles published:
Number of abstracts, posters, presentations given at National & Regional conferences:
Number of chapters or textbooks published:
Number of lectures or presentations (grand rounds) given:
Participated in basic science or clinical outcomes research:
Other (Please describe):
Resident Case-Procedure-Office Volume Logs:
Number of residents meeting volume requirements:
Number of residents below volume requirements:
No changes required in Program
Changes in Program and/or Resident
rotation/focus to address deficits:
(Please describe)
Quality Improvement Activities:
Number of residents involved in the following:
- Hospital Committees
- Medication Safety
- Disease or condition-specific quality improvement projects
- Infection Control/Surgical Infection Prevention
- Fall Prevention
- Rapid Response Teams
- Multidisciplinary Rounds
- Implementation of EMR
- Implementation of Protocols/Guidelines
- Root Cause Analysis
- QI Research Project
- Other (Please describe)
FACULTY DEVELOPMENT
Scholarly Activities:
Submitted project for IRB review:
Received IRB approval:
Number of articles submitted for publication:
Number of articles accepted for publication:
Number of articles published:
Number of abstracts, posters, presentations given at National & Regional conferences:
Number of chapters or textbooks published:
Number of lectures or presentations (grand rounds) given:
Number of grants for which faculty member had a leadership role:
Number of faculty with an active leadership role (such as serving on committees or governing boards) in national medical organizations or reviewer or editorial board members for peer review journals:
Other (Please describe)
Development Activities:
Did the Program offer Faculty Development? / Yes / No
Percentage of faculty participating in faculty development:
Number of Faculty attending CME conferences to improve teaching abilities:
Unmet Needs: Please identify future faculty development needs:
Academic Productivity:
Percentage of Faculty presenting at Resident Conferences:
Quality Improvement Activities:
Number of faculty involved in the following:
- Hospital Committees
- Medication Safety
- Disease or condition-specific quality improvement projects
- Infection Control/Surgical Infection Prevention
- Fall Prevention
- Rapid Response Teams
- Multidisciplinary Rounds
- Implementation of EMR
- Implementation of Protocols/Guidelines
- Root Cause Analysis
- QI Research Project
- Other (Please describe)
Resident Evaluation of Faculty (taken from the resident’s annual evaluation of the faculty:
Teaching Ability:
Supervision:
Education:
Overall Score:
GRADUATE PERFORMANCE
Number of residents completing program:
Number of graduating residents staying in Kansas
On-time graduation rate:
Graduate Board Pass Rate: / Number Eligible / Number Took Exam / NumberFirstTimePass
Graduating Year 2014:
Graduating Year 2013:
Graduating Year 2012:
Summary of Graduate Survey (if required):
PROGRESS ON PREVIOUS YEAR’S ACTION PLAN(S)
Area / Action / Measurement / Status
Resident Performance
Faculty Development
Graduate Performance
Program Quality
PROGRAM IMPROVEMENT ACTION PLAN
(In at least one area)
Area / Action / Measurement / Monitoring Mechanism
Resident Performance
Faculty Development
Graduate Performance
Program Quality
What help would you like from the GMEC in achieving your action plans?
Date approved by Faculty: ______
Date approved by GMEC: ______
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