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RESIDENCY REVIEW COMMITTEES FOR INTERNAL MEDICINE, NEUROLOGY,

By Katie Andrews,2014-11-25 11:15
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RESIDENCY REVIEW COMMITTEES FOR INTERNAL MEDICINE, NEUROLOGY,

    RESIDENCY REVIEW COMMITTEES FOR INTERNAL MEDICINE

    515 N State, Ste 2000, Chicago, IL 60654 ; (312) 755-5000 ; www.acgme.org

    PROGRAM INFORMATION FORM - SLEEP MEDICINE

APPLICATIONS FOR A NEW PROGRAM: Each institution may sponsor only one sleep medicine program. All

    applications for new programs must be initiated by the sponsoring institution’s designated institutional official (DIO) using the Accreditation Data System (ADS), which can be accessed through the “Data Collection Systems” menu item on the ACGME home page (www.acgme.org). The DIO should log into ADS

    and select “Initiate New Program Application” from under the “Program & Resident Info” menu item and follow the steps provided. After the DIO has completed the initial application step, and once the program director has received the auto-generated email with the User ID and password, he/she can then log into ADS and complete the application following the steps provided.

All sections of the form applicable to the program must be completed to be accepted for review. The

    information provided should describe the proposed program. For items that do not apply, indicate “N/A” in the space provided. Where patient numbers are requested, estimate what you expect will occur. If any requested information is unavailable, an explanation should be provided in the appropriate, indicated space on the form.

    Once the data entry is complete, there are two ways to view and print your document: HTML and PDF. Note, if you view/print in HTML, you will need to manually insert page numbers (follow instructions on the PIF Preview Options screen); if you view/print in PDF, page numbers will be automatically generated. Select “View Printer Friendly Version” to print the final Program Information Form (PIF). You will need to use this

    final version to complete the Table of Contents on the PIF Preview Options screen.

    After obtaining the required signatures attesting to the completeness and accuracy of the information provided on the form, send three copies (with requested attachments, if applicable) to the Executive Director of the Residency Review Committee for Internal Medicine at the address above. All three copies

    must be identical and final. Draft copies are not acceptable. The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two- or three-ring binders, spiral bound notebooks, or any other form of binding. To finalize your application in ADS, select

    “Verify the accuracy of application information” from the application menu in the system.

REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the Program Information

    Form (PIF) is being completed for a currently accredited program, follow the provided instructions to create the correct form. ADS can be accessed through the “Data Collection Systems” menu item on the ACGME home page (www.acgme.org). Log in with your assigned User ID and password. In the “PIF Preparation” section in the left-hand menu, select the appropriate items in order to update the “Common PIF” for your program. Most of the data is kept current through annual updates, but some information is required to be submitted at the time of site visit only.

    Once the data entry is complete, there are two ways to view and print your document: HTML and PDF. Note, if you view/print in HTML, you will need to manually insert page numbers (follow instructions on the PIF Preview Options screen); if you view/print in PDF, page numbers will be automatically generated. Select “View Printer Friendly Version” to print the final Program Information Form (PIF). You will need to use this final version to complete the Table of Contents on the PIF Preview Options screen.

Proceed to the Residency Review Committee for Internal Medicine’s web page to retrieve the specialty-

    specific PIF. When you have filled out the specialty specific PIF, enter page numbers in the bottom center of each page, sequentially following the Common PIF, and complete the Table of Contents (found with the specialty specific PIF document). After obtaining the required signatures attesting to the completeness and accuracy of the information provided on the form, make four copies. All four copies must be identical and

    final. Draft copies are not acceptable. The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two- or three-ring binders, spiral bound notebooks,

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    or any other form of binding. Mail one set of the completed forms to the site visitor at least 14 days before the site visit. The remaining three sets should be provided to the site visitor on the day of the visit.

    GENERAL INSTRUCTIONS: The Program Requirements or the Institutional Requirements may be downloaded from your Residency Review Committee’s web page on the ACGME website (www.acgme.org).

    With questions regarding the completion of the form (content), contact your Review Committee’s Accreditation Administrator.

With questions regarding ADS, e-mail WebADS@acgme.org.

Click here for the ACGME’s Glossary of Terms

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    Attach the following documents to the application:

    References to Common Program and Institutional Requirements are in parenthesis

    1. Policy for supervision of residents (addresses residents’ responsibilities for patient care and

    progressive responsibility for patient management and faculty responsibilities for supervision) (CPR

    IV.A.4.; IR III.B.4.)

    2. Program policies and procedures for residents’ duty hours and work environment (CPR II.A.j.4.;

    CPR VI.C.; IR II.D.4.i.; IR III.B. 3.)

3. Moonlighting policy (CPR VI.F.1-2; CPR II.A.4.j.; IR II.D.4.j.)

4. Overall educational goals for the program (CPR IV.A.1.)

    5. A sample of competency-based goals and objectives for one assignment at each educational level

    (CPR IV. A. 2.)

6. All Program Letters of Agreement (PLAs) (CPR I.B.1.)

    7. A blank copy of the forms that will be used to evaluate residents at the completion of each

    assignment (CPR V.A.1.a.)

    8. Copies of tools the program will use to provide objective assessments of competence in patient care,

    medical knowledge, practice-based learning and improvement, interpersonal and communication

    skills, professionalism, and systems-based practice (CPR V.A.1.b.(1))

    9. A blank copy of the form that will be used to document the semiannual evaluation of the residents

    with feedback (CPR V.A.1.b.(2) & (4))

    10. A blank copy of the final (summative) evaluation of residents, documenting performance during the

    final period of education and verifying that the resident has demonstrated sufficient competence to

    enter practice without direct supervision (CPR V.A.2.)

    11. A blank copy of the form that residents will use to evaluate the faculty (CPR V.B. 3.)

    12. A blank copy of the form that residents will use to evaluate the program (CPR V.C.1.d.(1))

    13. For each site, a description of the lines of responsibility among fellows at various stages in education

    and faculty, on each type of teaching service.

14. Sample of log book for documenting fellow procedures.

    15. Documentation (one-page, print screen form ABIM website) of Program Director, Key Clinical

    Faculty (minimum required) current ABIM-certification

    Single Program Sponsors only:

    1. A copy of the resident contract with the pertinent items from the institutional requirements and

    Master Affiliation Agreements

    2. Institutional policy for recruitment, appointment, eligibility, and selection of residents (IR II.A.)

    3. Institutional policy for discipline and dismissal of residents, including due process (IR II.D.4.e.; IR

    III.B.7.)

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REVIEW OF AN ACCREDITED PROGRAM: Have the following documents available for the site visitor:

    References to Common Program and Institutional Requirements are in parenthesis

    1. Policy for supervision of residents (addressing resident responsibilities for patient care, progressive

    responsibilities for patient management, and faculty responsibility for supervision) (CPR IV.A.4) 2. Program policies and procedures for residents’ duty hours and work environment (CPR II.A.4.j)

    3. Moonlighting policy (CPR II.A.4.j; CPR VI.F)

    4. Documentation of internal review (date, participants’ titles, type of data collected, and date of review

    by the GMEC)

    5. Overall educational goals for the program (CPR IV.A.1)

    6. Competency-based goals and objectives for each assignment at each educational level (CPR IV.A.2) 7. Current Program Letters of Agreement (PLAs) (CPR I.B.1)

    8. Files of current residents who have transferred into the program, if applicable (including

    documentation of previous experiences and summative competency-based performance evaluations)

    (CPR III.C.1)

    9. Evaluations of residents at the completion of each assignment (CPR V.A.1.a)

    10. Evaluations showing use of multiple evaluators (faculty, peers, patients, self, and other professional

    staff) (CPR V.A.1.b.(2))

    11. Documentation of residents’ semiannual evaluations of performance with feedback (CPR II.A.4.g;

    V.A.1.b.(4))

    12. Final (summative) evaluation of residents, documenting performance during the final period of

    education and verifying that the resident has demonstrated sufficient competence to enter practice

    without direct supervision (CPR V.A.2)

    13. Completed annual written confidential evaluations of faculty by the residents (CPR V.B. 3) 14. Completed annual written confidential evaluations of the program by the residents (CPR V.C.1.d.(1)) 15. Completed annual written confidential evaluations of the program by the faculty (CPR V.C.1.d.(1)) 16. Documentation of program evaluation and written improvement plan (CPR V.C)

    17. Documentation of resident duty hours (CPR II.A.4.j; VI.D.1-3)

    18. Files of current residents and most recent program graduates

ADDED DOCUMENTS FOR SINGLE RRC SPONSORS ONLY:

    1. Copy of the resident contract with the pertinent items from the Institutional Requirements and Master

    Affiliation Agreements (IR II.D.4)

    2. Institutional policies and procedures for residents’ duty hours and work environment (CPR II.A.4.j;

    CPR VI.C; IR II.D.4.i; IR III.B.3)

    3. Institutional policy for recruitment, appointment, eligibility, and selection of residents (IR II.A) 4. Institutional policy for discipline and dismissal of residents, including due process (IR II.D.4.e; IR III.B.7)

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    RESIDENCY REVIEW COMMITTEE FOR INTERNAL MEDICINE

    515 N State, Ste 2000, Chicago, IL 60654 ; (312) 755-5000 ; www.acgme.org

10 Digit ACGME Program I.D. #:

    Program Name:

TABLE OF CONTENTS

    When you have completed the forms, number each page sequentially in the bottom center. Report this pagination in the Table of Contents and submit this cover page with the completed PIF.

    Electronic Application for New Program Page(s) Accreditation Information Participating Sites

    Single Program Sponsoring Institutions (if applicable) Faculty/Teaching Staff

    Program Director Information

    Physician Faculty Roster

    Physician Curriculum Vitae

    Non Physician Faculty Roster

    Non Physician Curriculum Vitae Program Resources Number of Positions

    Actively Enrolled Residents (if applicable)

    Physician Faculty to Resident Ratio

    Resident Appointments Evaluation (Fellows, Faculty, Program) Fellow Duty Hours Resident Scholarly Activities

    Common PIF for Continued Accreditation Page(s) Accreditation Information Respond to Previous Citation(s) (if applicable) Participating Sites

    Single Program Sponsoring Institutions (if applicable) Program Director Information Physician Faculty Roster Faculty Curriculum Vitae Non Physician Faculty Roster Program Resources Number of Positions

    Actively Enrolled Fellows (if applicable)

    Aggregated Data on Fellows Completing or Leaving the Program for the last 3 years (if applicable)

    Fellows Completed Program in the Last Three years (if applicable)

    Withdrawn and Dismissed Fellows (if applicable)

    Fellows Taking Leave of Absence from the Program Skills and Competencies Other Learners Grievance Procedures Medical Information Access Evaluation (Fellows, Faculty, Program)

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    Fellow Duty Hours

    Specialty Specific PIF Page(s) Facilities and Resources for Training Administration of the Sleep Medicine Fellowship Program Other Professional Faculty in the Sleep Medicine Fellowship Program Rotation/Assignment Description Curriculum Specific Program Content Clinical Experience Required Conferences Research and Scholarly Activity Evaluation and Counseling Narrative Documents Checklist

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    RESIDENCY REVIEW COMMITTEE FOR INTERNAL MEDICINE

    515 N State, Ste 2000, Chicago, IL 60654 ; (312) 755-5000 ; www.acgme.org

    PROGRAM INFORMATION FORM - SLEEP MEDICINE

    I. FACILITIES AND RESOURCES FOR TRAINING

    Use the site numbers as they appear in the Common PIF to complete this facilities checklist for all participating sites used for routine rotations.

    Checklist Site #1 Site #2 Site #3 Site #4 Site #5 AASM-accredited sleep center ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO # of fully-equipped sleep bedrooms Pediatric monitoring facilities and equipment ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Adequate laboratory support area ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Fellow office ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Outpatient clinic facilities ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Adequate clinic support staff ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Sleep center library ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO On-site medical library ( ) YES ( ) NO Electronic medical data base access ( ) YES ( ) NO Conference room ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Adequate educational support (AV/computers) ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Residency programs in: Internal Medicine ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Neurology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Otolaryngology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Pediatrics ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Psychiatry ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO

    Comment on any items on the checklist which are not available at one or more sites.

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    II. ADMINISTRATION OF THE SLEEP MEDICINE FELLOWSHIP PROGRAM

    1. There is a single program director responsible for the sleep medicine fellowship program?

     ........................................................................................................................... ( ) YES ( ) NO

2. The program director’s office is located at the primary training site? ................... ( ) YES ( ) NO

3. There is adequate institutional support for the program director’s administrative time spent in the

    program? ............................................................................................................ ( ) YES ( ) NO

    4. The administrative support for the program director includes adequate secretarial and administrative

    staff?................................................................................................................... ( ) YES ( ) NO

    5. The administrative support for the program director includes adequate technological support?

     ........................................................................................................................... ( ) YES ( ) NO

    6. The funds received from the sponsoring institution to support faculty & fellows and other aspects of

    the sleep medicine fellowship program are adequate? ....................................... ( ) YES ( ) NO

    7. There is adequate financial support from your institution for the research components of your

    program? ............................................................................................................ ( ) YES ( ) NO

    8. There are adequate inpatient facilities (e.g., conference rooms, on-call rooms) for the sleep medicine

    fellowship program? ........................................................................................... ( ) YES ( ) NO

    9. There are adequate facilities in the ambulatory settings (i.e. exam rooms, meeting/conf room, work

    area) for patient care and the educational components of the program? ............ ( ) YES ( ) NO

10. Does the program director have sufficient authority to:

    a) Select fellows for appointment ...................................................................... ( ) YES ( ) NO

    b) Determine fellow rotations-- including amount of fellow off-site time.............. ( ) YES ( ) NO

    c) Control fellow work load--including number of patients--on all rotations at principal teaching

    hospital ......................................................................................................... ( ) YES ( ) NO

    d) Control teaching space and other facilities relevant to the training program .. ( ) YES ( ) NO

    e) Make the teaching assignments (teaching attendings) ............................... ( ) YES ( ) NO

    f) Determine which physicians have admitting privileges to the teaching services

     ..................................................................................................................... ( ) YES ( ) NO

    g) Determine fellowship curriculum, including content of conferences fellows usually attend

     ..................................................................................................................... ( ) YES ( ) NO

If the answer to any of the above questions is no, please explain below.

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    III. OTHER PROFESSIONAL FACULTY IN SLEEP MEDICINE

    Provide the following information for all other physician faculty who participate in the sleep medicine program but devote less than 10 hours per week, on average, to the training program. Duplicate page if necessary.

    Year Year Year Name Specialty 1 Cert Specialty 2 Cert Specialty 3 Cert Hrs/Wk Wks/Yr

Role in Program:

    Year Year Year Name Specialty 1 Cert Specialty 2 Cert Specialty 3 Cert Hrs/Wk Wks/Yr

Role in Program:

    Year Year Year Name Specialty 1 Cert Specialty 2 Cert Specialty 3 Cert Hrs/Wk Wks/Yr

Role in Program:

    Year Year Year Name Specialty 1 Cert Specialty 2 Cert Specialty 3 Cert Hrs/Wk Wks/Yr

Role in Program:

    Year Year Year Name Specialty 1 Cert Specialty 2 Cert Specialty 3 Cert Hrs/Wk Wks/Yr

Role in Program:

    Year Year Year Name Specialty 1 Cert Specialty 2 Cert Specialty 3 Cert Hrs/Wk Wks/Yr

Role in Program:

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    IV. ROTATION/ASSIGNMENT SCHEDULE

Prepare the block diagram that describes the Rotations/Assignments (including inpatient, ambulatory, consulting, research, etc.) for a

    typical sleep medicine fellow. Do not include vacation blocks. Use distinct titles/abbreviations for each rotation/experience for example:

    SDC = Sleep Disorder Clinic IP = Inpatient PN = Pediatric Neurology AN = Adult Neurology EM = Emergency Room PSYC = Psychiatry ELEC = Elective OP = Outpatient

    If a rotation/assignment includes more than 1 experience, please list all that apply. For example: AN/SDC.

PLEASE PROVIDE A ROTATION SCHEDULE NARRATIVE THAT ACCURATELY DESCRIBES THIS COMPONENT OF YOUR

    PROGRAM. (APPENDIX 1)

    Month 1 2 3 4 5 6 7 8 9 10 11 12 Rotations Institution/Site Does the fellow

    attend continuity clinic during this

    rotation? (Y/N)

    Average Number of

    Hours on Duty per Week

    Number of Full Days

    off per week During this

    Rotation/Assignment

    Frequency of In

    House Night Call (Q3, Q4, etc.)

    Avg # hrs/week on

    phone calls and returning to hospital

    while on home call

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