Clinical Competency Committee – Roles and Responsibilities


Department of Neurological Surgery – Residency Program Policy

Policy: Clinical Competency Committee – Roles and Responsibilities

Program Chair: Michael Rosner, MD

Last Revision: March 11, 2020

PURPOSE: The George Washington Residency Program in Neurological Surgery, as required by ACGME, utilizes a Clinical Competency Committee (CCC) in its evaluation of resident Performance. This document serves as the written description of its responsibilities. (Common Program Requirements, V.A.1.b)

COMMITTEE MEMBERSHIP: The Program Director shall appoint the CCC (CPR, V.A.1) which consists of the following members with terms as stipulated:

Committee Role Program Role Term
Chairperson Program Chairman Duration of role as Chairman
Member Core Faculty 3 years
Member Core Faculty 3 years
Member Site Director HCH Duration of role as site director
Member Site Director HCH Duration of role as site director
Member Site Director CNMC Duration of role as site director
Secretary Program Coordinator Duration of role as program coordinator



  • Review all evaluations of the residents semi-annually
  • Prepare and assure the reporting of Milestone evaluations for each resident semi-annually to the ACGME. (V.A.I.b.1.b)
  • Advise the Program Director with regards to resident promotion, remediation and dismissal. (V.A.I.b.1.c)

The committee will meet each December and June to review each resident according to the applicable milestones for their performance during the previous six months. For example, clinical milestones for pediatric neurosurgery are only applicable for rotations with pediatric services (CNMC). Milestones for non-clinical core competencies are applicable to every resident on every rotation.

All deliberations of the committee will be confidential, and minutes of the committee shall record the date and time of the meeting, members present/not-present/excused, and only reflect decisions made by consensus opinion of the meeting without individually identifiable commentary.

The chairperson of the committee shall work in conjunction with the secretary to produce:

  • Minutes of the meeting
  • Individual Milestone Reports for each Resident
  • Report of the committee with recommendations for promotion, remediation and dismissal of residents.

Reports of progress on milestones shall represent the consensus opinion of the committee regarding the resident’s progress. The PD will use these recommendations to report the residents’ performance to ACGME. 

The Program Director will share a copy of the completed Milestones assessment at their semi-annual evaluation meeting (to be scheduled within 30 days of the CCC meeting). The Resident and Program Director will countersign the ACGME milestones summary, and a copy will be retained in the resident file.

Remediation & Non-Promotion:

The CCC may recommend remediation or non-promotion based on resident performance as measured by the ACGME Milestones for Neurosurgery. In this case, the CCC will not prescribe the course of action for remediation of a given deficiency. The CCC will work with the Program Director in assessing if the resident fulfilled the stipulations of remediation and make a recommendation regarding promotion in the program.

Grievances & Appeals:

A resident may appeal a milestone assessment or recommendation of the CCC only if it results in a reportable action (non-promotion, non-renewal or dismissal). This process is outlined in the Institutional GME Policy for Academic Improvement.

Approved by GMEC: 4/20/2020