Continued Accreditation


Published on

Published in: Health & Medicine, Technology
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Continued Accreditation

  1. 1. Procedural Dermatology i RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 515 N State, Ste 2000, Chicago, IL 60654  (312) 755-5000  FOR CONTINUED ACCREDITATION - PROCEDURAL DERMATOLOGY GENERAL INSTRUCTIONS 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. Go to the Accreditation Data System found on the ACGME home page ( under Data Collection Systems. Using your previously assigned User ID and password, proceed to the PIF Preparation section on the left hand menu and update the Common PIF data. Most data are updated through annual updates, 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 in the bottom center of each page. Once the Common PIF is complete, proceed to the appropriate Residency Review Committee webpage to retrieve the Specialty Specific PIF for CONTINUED ACCREDITATION. Once the forms are complete, enter page numbers for the Continued PIF in the bottom center for each page that consecutively follows the Common PIF numbering, combine the Common PIF and the Continued Accreditation PIF and complete the Table of Contents (found with the Specialty Specific PIF instructions). After completing the PIF/documents, make four copies. They 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. 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. The program director is responsible for the accuracy of the information supplied in this form and must sign it. It must also be signed by the designated institutional official of the sponsoring institution. Review the Program Requirements for Residency Education in Procedural Dermatology. The Program Requirements and the Institutional Requirements may be downloaded from the ACGME website ( For questions regarding: -the completion of the form (content), contact the Accreditation Administrator. -the Accreditation Data System, email For a glossary of terms, use the following link –
  2. 2. Procedural Dermatology ii Have the following documents available for the site visitor References to Common Program and Institutional Requirements are in parentheses The Designated Institutional Official should provide the following: 1. Policy for supervision of fellows (addressing fellow responsibilities for patient care, progressive responsibilities for patient management, and faculty responsibility for supervision) (CPR VI.B) 2. Program policies and procedures for fellows’ duty hours and work environment, including grievance and due process (CPR VI; IR II.D.4.e.; IR II.D.4.i.; IR III.B. 3.) 3. Moonlighting policy (CPR VI.E) 4. Documentation of monitoring of fellow duty hours to determine compliance with the requirements (CPR VI.C.1-3) 5. Documentation of internal review (date, participants’ titles, type of data collected, and date of review by the GMEC) (IR IV.) 6. Current Program Letters of Agreement (PLAs) (CPR I.B.1) The Program Director should provide the following: 1. Document delineating the eligibility criteria to enter the program (CPR III.A) 2. Document delineating the skills and competencies the fellow will be able to demonstrate at the conclusion of the program (CPR IV.A.1) 3. Evaluations: a) Objective assessments for the six competencies (Patient Care, Medical Knowledge, Practice- based learning & improvement, Interpersonal & Communication Skills, Professionalism, Systems- based Practice) showing input from multiple evaluators (faculty, peers, patients, self, and other professional staff) (CPR V.A.1.b.(1) and (2)) b) Documentation of fellows’ semiannual evaluations of performance with feedback (CPR V.A.1.b.(3)) c) Final (summative) evaluation of fellows, documenting performance during the final period of education and verifying that the fellow has demonstrated sufficient competence to enter practice without direct supervision (CPR V.A.2) d) Documentation of program evaluation and written improvement plan (CPR V.C) 4. Files of current fellows and most recent program graduates 5. Agenda and/or minutes of faculty meetings devoted to evaluation of program goals, objectives and effectiveness Single Program Sponsors only, have the following additional documents available for review by the site visitor: 1. Copy of the institutional statement that commits the necessary financial, educational, and human resources to support the GME program(s) and provide documentation that the statement has been approved by the governing body, the administration and the teaching staff. (IR I.B.2) 2. Copy of the fellow contract with the pertinent items required by the Institutional Requirements highlighted and numbered according to the Institutional Requirements (IR II.C-D). 3. Institutional policy for recruitment, appointment, eligibility, and selection of fellows (IR II.A) 4. Institutional policy for discipline and dismissal of fellows (IR III.B.7)
  3. 3. Procedural Dermatology iii RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 515 N State, Ste 2000, Chicago, IL 60654  (312) 755-5000  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. Common PIF Page(s) Accreditation Information Participating Sites Single Program Sponsoring Institutions (if applicable) Faculty/Resources Program Director Information Physician Faculty Roster Faculty Curriculum Vitae Non Physician Faculty Roster Program Resources Fellow Appointments 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 Grievance Procedures Medical Information Access Evaluation (Fellows, Faculty, Program) Fellow Duty Hours Specialty Specific PIF Page(s) Operative Procedures Outline of Fellow Assignments Narrative Description of the Program Institutional Support Responsibilities of the Program Director Other Specialties and Program Personnel The Educational Program Scholarly Activity Fellow Duty Hours & Working Environment Evaluation Supplement I - Goals and Objectives
  4. 4. Procedural Dermatology 1 RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 515 N State, Ste 2000, Chicago, IL 60654  (312) 755-5000  FOR CONTINUED ACCREDITATION - PROCEDURAL DERMATOLOGY I. OPERATIVE PROCEDURES Provide number of dermatologic procedures performed in a recent 12 month period in each site identified in the Common PIF. If more than four sites are involved in the program, duplicate the form as needed. 12-Month Period Covered by Statistics From: To: #1 #2 #3 #4 Total Excision - Benign Lesion Excision - Malignant Lesion Nail procedures Repair (closure) simple / intermediate / complex Grafts (split or full) Flaps Ambulatory phlebectomy / vein surgery Dermabrasion Chemical Peel: superficial-epi Chemical Peel: deep dermal Tumescent liposuction Hair removal laser Vascular lesion laser Pigmented lesion laser Laser (ablation, resurfacing) Non-ablative rejuvenation Intense pulsed light Mohs micrographic surgery Mohs micrographic surgery (complex / large) Sclerotherapy Hair transplantation Soft Tissue Augmentation / Skin Fillers Rhinophyma correction Lip excision / wedge / vermilionectomy Scar revision (acne scar or procedure not otherwise listed) Botulinum toxin chemodeinnervation Other
  5. 5. Procedural Dermatology 2 II. OUTLINE OF FELLOW ASSIGNMENTS Provide a typical weekly schedule for a program fellow using the chart below. Monday Tuesday Wednesday Thursday Friday Saturday Sunday AM PM
  6. 6. Procedural Dermatology 3 III. NARRATIVE DESCRIPTION OF THE PROGRAM The questions which follow provide programs with an opportunity to systematically describe the manner in which they comply with accreditation requirements. Responses should be concise and focused. During the site visit, residents, faculty, and others will be asked for comment on the information provided. As a result, those who will be interviewed should read the PIF prior to their meeting with the site visitor. A. Institutional Support 1. Program Sponsorship and Affiliation a) If the program is sponsored by an institution that also sponsors a Dermatology residency, how do the two program directors monitor the interaction of residents and fellow to ensure appropriate educational experiences for both? b) If the program is not affiliated with an accredited Dermatology residency, explain why. Note: Programs that are not sponsored by institutions that also sponsor other programs must document compliance with the ACGME's institutional requirements. 2. Describe the space dedicated to the performance of dermatologic surgery, including Mohs micrographic frozen section laboratories and patient examination areas. Are program's laboratory facilities accredited? If so, identify the accreditation agency(ies). 3. Summarize fellow access to (a) a major medical library, (b) electronic retrieval of information and medical databases, and (c) on-site collection of texts and journals at each site. B. Responsibilities of the Program Director 4. How does the program director select, supervise, and evaluate the teaching staff and other program personnel at each site participating in the program? Has a local site director been identified in each site? How does the director monitor resident supervision at each site? 5. Has the program implemented procedures regarding fellow grievances during the last five years? If yes, provide a concise summary. 6. How does the program monitor fellow stress, including mental or emotional conditions inhibiting performance or learning? What arrangements does the program have for the provision of counseling and psychological support services for fellow?
  7. 7. Procedural Dermatology 4 C. Other Specialties and Program Personnel 7. Concisely describe the opportunities fellows have to work with personnel from other specialties. 8. Concisely summarize the technical, clerical, and other non-physician personnel who provide support for the administrative and educational conduct of the program. Is the support of the program in this area satisfactory at all sites? D. The Educational Program 9. Describe the didactic component of the program. Include a list of the conferences that were held during the last year, including those that were devoted to each of the three components of the body of knowledge which serve as the basis for procedural dermatology: cutaneous oncologic surgery, cutaneous reconstructive surgery, and cutaneous cosmetic surgery. Provide the date, location, audience and specific topic of each session. 10. Concisely describe fellow education in related disciplines such as surgical anatomy, sterilization of equipment, aseptic technique, anesthesia, closure materials, instrumentation, cardiopulmonary resuscitation, and wound healing. PR V.B.2. 11. How does the program ensure that fellows have opportunity to develop competence in pre-operative evaluation of patients? Include comment on the manner in which fellows gain experience in the identification of a) patients whose conditions should be treated by dermatologic surgical techniques and b) those who should be referred to other specialists. 12. How does the program ensure that fellows have opportunity to gain experience in the post-operative follow up care of patients? 13. Describe the manner in which faculty instruct and supervise fellows during the performance of dermatologic surgical procedures. How are fellows given the opportunity to assume increasing responsibility as they gain experience and develop more advanced skills. 14. Summarize fellow education and experience in laboratory management and slide review. 15. Summarize fellow education and experience in the area of quality improvement activities.
  8. 8. Procedural Dermatology 5 E. Scholarly Activity 16. Summarize program research activity, including comment on each of the following: a) List the staff who provide stimulation and supervision of clinical or laboratory research activity by residents and identify their particular area(s) of expertise. b) List the publications in refereed journals (during the last 3 years) by program residents. Provide titles, co-authors, dates with resident name in bold font. c) List the research presentations (during the last three years) that resulted from resident research activity during the program. 17. Describe the time free of clinical duties that is provided for resident participation in clinical or laboratory research. F. Fellow Duty Hours & Working Environment 18. Describe the manner in which the program ensures the fellows' call schedule is in compliance with V.F.3. of the program requirements. G. Evaluation 19. Describe the manner in which the program director and other members of the teaching staff participate in a quality improvement review of the frozen section slides. 20. Describe the manner in which program personnel (including at least one fellow) review, at least once each year, program effectiveness. How are evaluations of fellow performance utilized in this process?
  9. 9. Procedural Dermatology 6 SUPPLEMENT I - GOALS AND OBJECTIVES Attach a copy of the educational goals and objectives for each required rotation or major assignment.