THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY

THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR CONTINUED ACCREDITATIONGENERAL INSTRUCTIONSREVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the Program Information Form (PIF) isbeing completed for a currently accredited program, follow the provided instructions to create the correctform. Go to the Accreditation Data System found on the ACGME home page (www.acgme.org) under DataCollection Systems. Using your previously assigned User ID and password, proceed to the PIF Preparationsection on the left hand menu and update the Common PIF data. Most data are updated through annualupdates, but some information is required at the time of site visit only. Once the data entry is complete,select Generate PIF to review and print the Common PIF (PDF). Pages will be numbered consecutively inthe bottom center of each page.Once the Common PIF is complete, proceed to the appropriate Residency Review Committee webpage toretrieve the Specialty Specific PIF for CONTINUED ACCREDITATION. Once the forms are complete, enter pagenumbers for the Continued PIF in the bottom center for each page that consecutively follows the CommonPIF numbering, combine the Common PIF and the Continued Accreditation PIF and complete the Table ofContents (found with the Specialty Specific PIF instructions). After completing the PIF/documents, makefour copies. They must be identical and final. Draft copies are not acceptable. The forms should besubmitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as twoor three ring binders, spiral bound notebooks, or any other form of binding. Mail one set of the completedforms to the site visitor at least 14 days before the site visit. The remaining three sets should be provided tothe site visitor on the day of the visit.The program director is responsible for the accuracy of the information supplied in this form and must signit. It must also be signed by the designated institutional official of the sponsoring institution.Review the Program Requirements for Residency Education in Diagnostic Radiology. The ProgramRequirements and the Institutional Requirements may be downloaded from the ACGME website(www.acgme.org):For questions regarding: -the completion of the form (content), contact the Accreditation Administrator. -the Accreditation Data System, email WebADS@acgme.org.For a glossary of terms, use the following link –http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp Diagnostic Radiology Continued Accreditation PIF i

Please have the following documents available for the site visitor:References to Common Program and Institutional Requirements are in parentheses. 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 graduatesAdded documents for some programs: 1. Documentation of conference attendance 2. Single RRC Sponsors only: a) Copy of the resident contract with the pertinent items from the Institutional Requirements and Master Affiliation Agreements (IR II.D.4) b) 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) c) Institutional policy for recruitment, appointment, eligibility, and selection of residents (IR II.A) Diagnostic Radiology Continued Accreditation PIF ii

d) Institutional policy for discipline and dismissal of residents, including due process (IR II.D.4.e; IR III.B.7) THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org10 Digit ACGME Program I.D. #:Program Name:TABLE OF CONTENTSWhen you have the completed forms, number each page sequentially in the bottom center. Report thispagination in the Table of Contents and submit this cover page with the completed PIF. Common PIF1 Page(s)Accreditation InformationParticipating Sites Sponsoring Institution/Single or Limited Residency Institution (If applicable)Faculty/Teaching Staff Program Director Information Physician Faculty Roster Faculty Curriculum Vitae Non Physician Faculty RosterResident Appointments Number of Positions Actively Enrolled Residents (if applicable) Aggregated Data on Residents Completing or Leaving the Program for the last 3 years (if applicable) Residents Completing Program in the Last 3 years (if applicable) Transferred, Withdrawn, and Dismissed Residents (if applicable)EvaluationResident Duty Hours Specialty Specific PIF Page(s)Patient CareMedical Knowledge Summary of Training Rotation Schedule Didactic Components Narrative Description of Training ProgramPractice-Based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystems-Based PracticeImaging Examinations PerformedResident Information Resident/Faculty Ratio Prior Training/Clinical Year Training Other Residents Subspecialty Training Diagnostic Radiology Continued Accreditation PIF iii

Specialty Specific PIF Page(s)Facilities and Resources Space Allocation Equipment Radiology Information System Subspecialty ChiefsScholarly Activity Research Facilities Faculty Scholarly Activities Resident Publications Resident Research ProjectsAppendix A - Clinical DataAppendix B - Goals and Objectives Diagnostic Radiology Continued Accreditation PIF iv

RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org SPECIALTY SPECIFIC PROGRAM INFORMATION FORMI. PATIENT CARE 1. Is there a documented, supervised experience in interventional procedures as described in the diagnostic radiology program requirements? 2. Are the residents required to keep a log that documents their participation in interventional procedures? How often is the log reviewed by the Program Director or faculty/desingee? How does the Program Director use this information? 3. How do residents obtain: a) clinical training and experience (modalities) in cardiac imaging? b) didactic instruction in cardiac anatomy physiology and pathology? 4. Explain how residents will gain experience with OB ultrasound studies beyond the first trimester does each resident perform? 5. How does the program provide training in basic life support and/or advanced cardiac life-support? Diagnostic Radiology Continued Accreditation PIF v

II. MEDICAL KNOWLEDGEA. Summary of Training Complete the outline provided here to show the typical resident assignments for the four year program. Provide the information in weeks or months, but not both. Duration of Assignment or Rotation (Indicate Summary of Training Whether Weeks or Months) General Radiology Cardiothoracic Abdominal Imaging(GI/GU) Musculoskeletal Breast Imaging Nuclear radiology Neuroradiology Pediatric radiology Vascular/Interventional radiology Emergency Radiology (if separate), including night float Ultrasound Computed tomography Magnetic resonance imaging Pathology/AFIP Research Elective time (if not included above) Vacation Other (does not fit into above categories; identify and describe) Total (weeks/months)B. Rotation Schedule Insert a master list of resident rotations for each year of the program. All the information requested should be included for the normal schedule of rotations rather than the exception. A legible, easily understood block diagram may be provided on a separate sheet and inserted. Diagnostic Radiology Continued Accreditation PIF vi

C. Didactic Components 1. Conferences/Lectures: All radiology residents are expected to attend weekly core curriculum conferences/lectures on a regular basis. Participation by both residents and teaching staff must be documented. In the table below, list the intradepartmental conferences/lectures that occur in a typical month. Conferences, Individual(s)/and specialty Core or Subspecialty Frequency lectures, etc. responsible for organization of Teaching Conference / Time (Intradepartmental) sessions (specify) 2. Does the program provide the residents with the following educational experiences? Frequency Visiting Professors Program ..........YES ( ) NO ( ) Journal Club ..................................YES ( ) NO ( ) Radiology Grand Rounds ..............YES ( ) NO ( ) Other Educational Experiences (Specify) 3. What percentage of the conferences are prepared by By teaching staff? residents? 4. Are residents regularly relieved of clinical duties to attend conferences? .............( ) YES ( ) NO 5. Does the program provide adequate financial support for residents to present at national and local meetings?..............................................................................................................( ) YES ( ) NO 6. List of regional and national meetings that residents have attended in the last twelve months. Add more lines if needed. 1. 2. 3. Diagnostic Radiology Continued Accreditation PIF vii

7. Learning Resources a. Total number of cases in site accumulated file. b. Are all teaching files available to residents? ....................................................( ) YES ( ) NO c. How many ACR modules are available to residents? d. Are electronic teaching files available to the residents? ..................................( ) YES ( ) NOD. Narrative Description of Training Program The Residency Review Committee for Radiology must determine whether a truly educational experience is offered by your program as it is presented. The Committee recognizes that many variations exist among excellent programs and it does not intend to design or dictate curricula. In addition to the material already provided, information of significance relative to the following questions will be helpful in evaluating your program. Insert text in the boxes below. 1. Attach as Appendix B, a sample of the goals and objectives for one assignment 2. Describe the evaluation mechanism used to determine that the program goals and objectives are met. 3. Have the curriculum outline and statement of goals and objectives been distributed to teaching staff ..............................................................................................................................( ) YES ( ) NO 4. Explain how instruction in pathology is provided, i.e., whether through the AFIP course, in-house training, or through a combination of the two resources. 5. Do residents receive formal instruction in radiologic physics, radiobiology and radiation protection? Where, how much and by whom? 6. Do residents receive four months training and experience in nuclear radiology? ..( ) YES ( ) NO 7. Describe the nature of resident participation on rotations at the participating sites. 8. Describe the call schedule and specify whether residents take call on-site or from home. At what level of training do the residents begin to take independent, in-house call? How is faculty back-up arranged? When are the studies obtained on call reviewed by radiology faculty?III. PRACTICE-BASED LEARNING AND IMPROVEMENT Diagnostic Radiology Continued Accreditation PIF viii

Examples of Learning Activities: didactic lecture, assigned reading, seminar, self-directed learningmodule, conference, small group discussion, workshop, online module, journal club, project, casediscussion, one-on-one mentoring, or other examples of learning activities.1. Describe one learning activity in which residents engage to identify strengths, deficiencies, and limits in their knowledge and expertise (self-reflection and self-assessment); set learning and improvement goals; identify and perform appropriate learning activities to achieve self-identified goals (life-long learning). Limit your response to 400 words.2. Describe one example of a learning activity in which residents engage to develop the skills needed to use information technology to locate, appraise, and assimilate evidence from scientific studies and apply it to their patients’ health problems. The description should include: a) locating information b) using information technology c) appraising information d) assimilating evidence information (from scientific studies) e) applying information to patient care Limit your response to 400 words.3. Give one example and the outcome of a planned quality improvement activity or project in which at least one resident participated in the past year that required the resident to demonstrate an ability to analyze, improve and change practice or patient care. Describe planning, implementation, evaluation and provisions of faculty support and supervision that guided this process. Limit your response to 400 words.4. Describe how residents: a) develop teaching skills necessary to educate patients, families, students, and other residents; b) teach patients, families, and others; and c) receive and incorporate formative evaluation feedback into daily practice. (If a specific tool is used to evaluate these skills have it available for review by the site visitor.) Limit your response to 400 words. Diagnostic Radiology Continued Accreditation PIF ix

IV. INTERPERSONAL AND COMMUNICATION SKILLS 1. Describe one learning activity in which residents develop competence in communicating effectively with patients and families across a broad range of socioeconomic and cultural backgrounds, and with physicians, other health professionals, and health related agencies. Limit your response to 400 words. 2. Describe one learning activity in which residents develop their skills and habits to work effectively as a member or leader of a health care team or other professional group. In the example, identify the members of the team, responsibilities of the team members, and how team members communicate to accomplish responsibilities. Limit your response to 400 words. 3. Explain (a) how the completion of comprehensive, timely and legible medical records is monitored and evaluated, and (b) the mechanism for providing residents feedback on their ability to competently maintain medical records. Limit your response to 400 words. Diagnostic Radiology Continued Accreditation PIF x

V. PROFESSIONALISM 1. Describe at least one learning activity, other than lecture, by which residents develop a commitment to carrying out professional responsibilities and an adherence to ethical principles. Limit your response to 400 words. 2. How does the program promote professional behavior by the residents and faculty? Limit your response to 400 words. 3. How are lapses in these behaviors addressed? Limit your response to 400 words. Diagnostic Radiology Continued Accreditation PIF xi

VI. SYSTEMS-BASED PRACTICE 1. Describe the learning activity(ies) through which residents achieve competence in the elements of systems-based practice: work effectively in various health care delivery settings and systems, coordinate patient care within the health care system; incorporate considerations of cost- containment and risk-benefit analysis in patient care; advocate for quality patient care and optimal patient care systems; and work in interprofessional teams to enhance patient safety and care quality. Limit your response to 400 words. 2. Describe an activity that fulfills the requirement for experiential learning in identifying system errors. Limit your response to 400 words. Diagnostic Radiology Continued Accreditation PIF xii

VII. IMAGING EXAMINATIONS PERFORMED Site numbers are found in Common PIF. Number of Imaging Site # Examinations Performed 1 2 3 4 5 Diagnostic Radiology Continued Accreditation PIF xiii

VIII. RESIDENT INFORMATIONA. Resident/Faculty Ratio What is the full-time equivalent faculty to resident ratio at the sponsoring institution and integrated site(s)? (Do not include faculty at non-integrated sites)B. Prior Training/Clinical Year 1. Have all residents completed an ACGME accredited clinical year prior to entry into the program? ..............................................................................................................................( ) YES ( ) NO 2. If not, the Program Director should explain how and when the residents will complete the clinical year. If the program offers a non-accredited year, explain how the Program Director maintains oversight and assures the quality of the clinical year.C. Training Other Residents 1. Does the program provide training for radiology residents from other programs? .............................................................................................................................( ) YES ( ) NO 2. If yes, provide names of other programs, number of trainees, clinical area of rotation, whether the rotation is observational or full participation, and length of time spent in your department. Originating # of Trainees Per Clinical Area (Subspecialty) Length Of Program Year Full participation Observational Rotation Diagnostic Radiology Continued Accreditation PIF xiv

D. Subspecialty Training 1. List ACGME-accredited Diagnostic Radiology subspecialty programs offered by the sponsoring institution of the core program.* Number of trainees currently in each subspecialty Area of subspecialty training program 2. List any unaccredited subspecialty training offered beyond four years of Diagnostic Radiology Number of trainees currently in each subspecialty Area of subspecialty training program *The subspecialty areas of Diagnostic Radiology are listed below. The underlined subspecialties are ACGME-accredited one year fellowship programs. Abdominal Radiology Nuclear Radiology Chest Radiology Pediatric Radiology Musculoskeletal Radiology Vascular/Interventional Radiology Neuroradiology Diagnostic Radiology Continued Accreditation PIF xv

IX. FACILITIES AND RESOURCESA. Space Allocation Complete only for sites to which rotations total at least 3 months. Site numbers are found in the Common PIF Allocation Of Space: (Yes/No) Primary Site #1 Site #2 Site #3 Site #4 Site #5 Dedicated radiology conference room Dedicated radiology call room Dedicated resident offices/lounges (include size and capacity)B. Equipment Indicate the number of units available and year of most recent installation. Complete only for sites to which rotations total 3 months, 3 4-week rotations or more. Site numbers are found in the Common PIF. Primary Site #1 Site #2 Site #3 Site #4 Site #5 A. Diagnostic Radiographic Equipment 1. Radiographic units (include chest units) 2. Radiographic Fluoroscopic units 3. Mammography Units 4. CT Units B. Ultrasound Units (Sonographic Equipment) C. MRI Units 1. Units on-site in hospital complex 2. Units available off-site or mobile D. Nuclear Radiology Equipment Nuclear cameras (total) a) SPECT b) SPECT/CT c) PET d) PET/CT e) Planar E. Angiographic Units Single plane Bi-plane

C. Radiology Information System Radiology Information System Primary Site #1 Site #2 Site #3 Site #4 Site #5 Is there a radiology information system in the sponsoring institution? If yes, what type? Does it interface with the hospital information system? Include the year the system was installed. Is there PACS (Picture Archiving Communication System) in the sponsoring and integrated sites? If yes, describe the modalities that are incorporated in the PACS?

D. Subspecialty Chiefs Estimate % of time devoted to the Subspecialty Name of Subspecialty Chief subspecialty Abdominal Radiology (GI/GU) Breast Imaging Chest Musculoskeletal Nuclear Radiology Neuroradiology Pediatric Radiology Ultrasonography (including ob & vascular ultrasound) Vascular/Interventional Radiology Diagnostic Radiology Continued Accreditation PIF 18

X. SCHOLARLY ACTIVITYA. Research Facilities Describe the research space, equipment, and important special research facilities:B. Faculty Scholarly Activities List recently completed or on-going research projects (not more than ten) being conducted by members of the Department. Indicate by asterisk (*) if residents participated, list title of project, faculty mentor, and if it will be published or presented at regional and/or national meetings. Do not include past projects or those that are being planned. Do not submit copies of protocols, papers or grant applications.C Resident Publications List publications by the residents for the past three years. Include title of publication, date, resident name (underlined), faculty mentor, and if it was or will be presented at regional and/or national meetings. Do not submit copies of protocols, papers or grant applications. Do not include reprints.D Resident Research Projects List resident research projects for residents of the past two years which led or will lead to presentations at local or national meetings. Include title of project, resident name (underlined), and where and when the presentation was or will be presented. Diagnostic Radiology Continued Accreditation PIF 19

APPENDIX A - CLINICAL DATAAll information requested must be included for each participating site as identified in, with the exception ofthose sites where only a limited sub-specialty rotation is employed as a part of the educational experience.Example: For a cardiovascular rotation, include only the cardiovascular examination data and equipment.Please note, however, that total statistics are required for a pediatric rotation.Period covered by statistics (latest 12 From: To:month period available) Number of Primary Site #1 Site #2 Site #3 Site #4 Site #5 ExamsRadiographyMammography(Screening andDiagnostic)CTMRIUltrasoundNuclear MedicineStudiesVascular/Interventional StudiesTotal Exams Diagnostic Radiology Continued Accreditation PIF 20

APPENDIX B - GOALS AND OBJECTIVES Attach a sample of the goals and objectives for one assignment Diagnostic Radiology Continued Accreditation PIF 21

THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY

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THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY Document Transcript