The first priority of the Program Director (PD) is to ensure the quality of education for all residents at all participating sites. Quality of education includes both didactic and clinical components. At each participating site where residents rotate, the PD approves the local director as well as approves the selection of all new faculty members associated with the program. Continued participation of program faculty members is based on routine faculty evaluations completed by residents after each rotation.

To safeguard the learning environment, the PD must make sure that ACGME and institutional policies and procedures are implemented. This includes ensuring adequate supervision at each participating site, monitoring policy, adherence to duty hours, adjusting schedules to mitigate fatigue, and providing access to online educational resources [9].

The PD is also responsible for monitoring data for process improvement. This information comes by way of evaluations and surveys: evaluations of residents; the residents’ evaluations of faculty members, rotations, and program; and past graduates’ evaluations of the program. These will be detailed later in the chapter.

With the many varied responsibilities of the Program Director, a calendar is helpful. Our program developed this calendar to aid in staying on track (Table 11.2). The keystone meeting is the Residency Program Evaluation Committee (RPEC), which is convened on a semiannual basis; all evaluation data are reviewed and recommendations for program improvement are made. We also have other committees that enhance program administration. Twice a year, we hold a Resident Forum, where the PD and Associate Program Director (APD) meet with all the residents to discuss any suggestions and concerns. Then, between these meetings, the PD meets with the Resident Representation Committee (RRC)—comprised of one member elected from each class—on an as-needed basis to solicit comments and to handle problems. As required by the ACGME, we also convene the Clinical Competency Committee (CCC) ahead of each semiannual Residency Program Evaluation Committee. The CCC reviews data from each resident’s evaluations and pegs performance to the Milestones [22]. While we have not implemented this practice, resident self-assessment using the Milestones may provide personal insight, and one study found that residents were able to successfully self-assess, with improving proficiency over time [23].

A successful residency program requires a well-functioning team, and the key components of this team are the Associate Program Director (APD), Program Coordinator, and core faculty members.

The Associate Program Director (APD) , along with the Program Director (PD), carries authority and accountability in maintaining the residency program [24], particularly in programs with greater than 20 residents. The APD serves to assist, and, at times, stand in the stead of, the PD. The APD allows for continuous access for the residents to the staff and core faculty of the Residency Program. In addition to being the liaison between the residents and the program, the APD also serves to further aid in core faculty development within the residency. The APD collaborates with the PD to optimize scheduling and ensure adherence to ACGME policies, recommendations, and deadlines.

The role of the Program Coordinator is becoming increasingly important. From initially being more clerical, the increased requirements of the ACGME—from the Outcome Project to Milestones implementation—have driven the Coordinator’s role to be more managerial. One survey found a high level of day-to-day managerial oversight of all aspects of residency training, and often, there are additional responsibilities for faculty development and other business [25]. Because of the complexities of managing a residency, of assisting the Program Director in assuring compliance with current policies and maintaining accreditation, we recommend professional certification of the Program Coordinator. Training Administrators of Graduate Medical Education (TAGME) certification assures knowledge in key knowledge content areas, including milestones and competencies, evaluations, procedure logs, and other ACGME-related regulations. Engagement in the Association of Residency Coordinators in Orthopaedic Surgery (ARCOS) provides a forum for support and enables the coordinator to keep up to date with current recommendations and best practices.

The biggest recent change, and perhaps a challenge, in educating the program’s core faculty members came with the advent of competency-based education. To many faculty members who trained in the pre-competency era, much of the terminology remains nebulous. For instance, despite advances in defining systems-based practice competency, a recent study of orthopaedic educators and residents found that the teaching of this domain is highly inconsistent, and formal assessment rarely happens [26]. However, current guidelines mandate that training be mapped to core competencies, and with work-hour limits available for clinical training, rotations based on competency, rather than on time, may be the answer in maximizing the use of available hours [27].

While all faculty members have spent their lifetime in education, few are trained in education. One successful and highly recommended faculty development program is sponsored by the American Academy of Orthopaedic Surgeons (AAOS). We encourage each of our faculty members to attend this week-long AAOS Course for Orthopaedic Educators at least once. Upon returning, each faculty is given an opportunity to share points learned during a departmental meeting. These experiences enrich the faculty member, giving each one a better understanding of competency-based training, a sense of community with other orthopaedic educators, and tools for setting expectations, providing feedback to residents, and working with problem residents. Additionally, we invite speakers for Grand Rounds, and educational topics (such as recognizing resident fatigue) are covered several times a year. At the institutional level, our GME office holds a 1-day retreat for the Program Director, the Associate Program Director, and the Program Coordinator, where didactic sessions are mixed with case-based discussions on topics pertaining to resident education.

Ultimately, residency training produces graduates who are able to independently practice orthopaedic surgery without supervision. While this is difficult to fully assess, there are several measures of graduate performance. The American Board of Orthopaedic Surgery (ABOS) provides Part I and Part II scores to the programs, and the Part I scores are subdivided into domains. How a resident performs on the Orthopaedic In-Training Examination relates to ABOS Part I scores [5, 28–30], but certification is contingent on passing the both Parts I and II. One benchmark is to compare program pass rates to the national average, which is between 79 and 88% [31].