The ACGME wants to assure full integration of the competencies and their assessment with learning and clinical care. Program improvement activities can occur as part of educational retreats, departmental Clinical Competency Committees; as well as feedback from internal review reports.

With the implementation of Phase III of the ACGME Outcomes Project, programs must now document the framework for program improvement that includes:

  • Internal Program Evaluations
  • External Program Evaluations
  • National Benchmarks

Internal Program Evaluations include:

  • Performance on in-training examinations compared to national averages
  • Rolling board certification pass rates (if available)
  • Residents' evaluations of the educational program (annual and confidential)
  • Alumni surveys
  • Patient satisfaction surveys
  • Systematic identification by faculty and residents of areas in need of educational improvement
  • Aggregate performance on program assessment tools

External Program Evaluation Methods include:

  • Clinical Practice Indicators or Hospital Core Quality Measures by program
  • Practice indicators collected by program or institution
  • Resident surveys (e.g., annual Needs Assessment Survey completed by residents)
  • Active improvement plans developed and implemented as a result of internal review and/or site review
  • Cycle length and number of citations by GMEC and ACGME

National Specialty Specific Benchmarks:

  • National specialty specific benchmarks or thresholds
  • Specialties are encouraged to develop competency based program requirements with threshold for passing