Applies to: WSU Elson S. Floyd College of Medicine Graduate Medical Education (GME) Sponsoring Institution and all accredited post-graduate medical training programs (i.e. residency or fellowship) and non-accredited clinical fellowship programs sponsored by the College of Medicine.
Date: January 17, 2023
1.0 Policy Statement
It is the WSU College of Medicine GME policy that all Accreditation Council for Graduate Medical Education (ACGME) programs sponsored by Elson S. Floyd College of Medicine have a clinical competency committee (CCC) that functions in compliance with ACGME requirements.
2.0 Definitions
Accreditation Council for Graduate Medical Education (ACGME)
Accredits Sponsoring Institutions and residency and fellowship programs, confers recognition on additional program formats or components, and dedicates resources to initiatives addressing areas of importance in graduate medical education.
Clinical Competency Committee (CCC)
A required body comprising three or more members of the active teaching faculty that is advisory to the program director and reviews the progress of all residents or fellows in the program.
Designated Institutional Official (DIO)
The individual in a sponsoring institution who has the authority and responsibility for oversight and responsibility of all of the ACGME accredited programs.
Graduate Medical Education Committee (GMEC)
An institutional committee of the College of Medicine charged with the responsibility of monitoring and advising on all aspects of institutional, residency, and fellowship education as required by the ACGME.
Program Director (PD)
The individual designated with authority and accountability for the operation of a residency/fellowship program.
Trainee
A physician in training at an ACGME accredited graduate medical education program, the term includes Interns, Residents, and Fellows or other trainee enrolled in an educational program whose education falls under the purview of the College of Medicine Office of
Graduate Medical Education.
3.0 Responsibilities
GMEC and DIO.
4.0 Procedures
The goal of the Clinical Competency Committee (CCC) is to provide broad input from several individuals to assist the program director in making evaluative decisions regarding the performance and abilities of trainees in their program.
All accredited programs must create a CCC which meets at least semi-annually and maintains written minutes of each meeting. A CCC must be appointed by the program director. At a minimum, the CCC must include three members of the program faculty, at least two of whom are core faculty members. Additional members must be faculty members from the same program or other programs, or other health professionals who have extensive contact and experience with the program’s Trainees.
The Clinical Competency Committee must:
- Review all Trainee evaluations at least semi-annually
- Determine each Trainee’s progress on achievement of the specialty-specific Milestones
- Meet prior to the Trainees’ semi-annual evaluations and advise the program director regarding each Trainee’s progress
- Require residents to submit a self-assessment at least annually
- Function as an advisory role to the Program Director and advise on each Trainee’s progress
- Systematically review each Trainee’s assessments, adherence to policies and procedures and other available information
- Function objectively and in a manner that promotes the highest levels of professionalism and confidentiality
- Determine each Trainee’s progress on achievement of Milestones
- Include multiple forms of assessment and multiple sampling utilizing multiple assessors
- Include core methods of assessments such as direct observation, multi-source feedback, in-service examination, QI project, procedure log, longitudinal evaluations, patient survey, audit of clinical performance, and simulation
- Advise the PD regarding the Trainee’s developmental progression towards competence which may include promotion, recommendations to place the resident on a formal plan for performance improvement, or dismissal
- Undergo training and faculty development in assessment practices and the use of and interpretation of data
- Prepare a report summarizing the Committee’s recommendations and rationale for recommending any adverse action from each meeting
- Keep Trainee and program performance data and discussions strictly confidential
The program director has final responsibility for Trainee evaluation and promotion decisions.
It is strongly suggested that the PD, chair, and members of the CCC review the ACGME CCC Guidebook before developing the CCC and at least annually throughout the CCC’s tenure. Program specific CCC requirements can be found in Section V.A. of each program’s specialty-specific ACGME Program Requirements.
Guidelines for Program Consideration
The CCC is a shared mental model in which decisions are consensus based. It is not a voting committee and serves in an advisory role to the PD. The CCC may determine a review method, see ACGME CCC Guidebook (e.g., a CCC member reviews evaluations for a Trainee in advance and makes a recommendation, which the CCC discusses.) For each Trainee, the CCC should decide the narrative for each Milestone that best fits the Trainee. The PD shares CCC recommendations and meets with the Trainee.
Consideration should be given to the number of members sufficient for frank discussion. Members should be dedicated to education and may include representatives from major sites, subspecialists, and junior & senior faculty. The PD should be a member of the CCC.
5.0 Related Policies
- GME Grievance and Due Process Policy
- GME Renewal and Promotion Policy
- ACGME Clinical Competency Committees Guidebook
6.0 Revision History
GMEC Approval: February 18, 2020
Revision/Review Date(s): January 17, 2023
Responsible Office: WSU College of Medicine Sponsoring Institution
Policy Contact: Designated Institutional Official
Supersedes: N/A