• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content

Loading…

Flash Player 9 (or above) is needed to view presentations.
We have detected that you do not have it on your computer. To install it, go here.

Like this document? Why not share!

New Application Only

on

  • 335 views

 

Statistics

Views

Total Views
335
Views on SlideShare
335
Embed Views
0

Actions

Likes
0
Downloads
0
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft Word

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    New Application Only New Application Only Document Transcript

    • RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - PROCEDURAL DERMATOLOGY GENERAL INSTRUCTIONS APPLICATIONS FOR A NEW PROGRAM: This Program Information Form (PIF) is for programs applying for INITIAL ACCREDITATION ONLY (for Continued Accreditation or re-accreditation, use the CONTINUED ACCREDITATION PIF in conjunction with the Web Accreditation Data System). All sections of the form applicable to the program must be completed in order 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 not available, an explanation should be given and it should be so indicated in the appropriate place on the form. Once the forms are complete, number the pages sequentially in the bottom center. Send three complete copies to the executive director of the Residency Review Committee for Dermatology at the address above. 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. 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 or 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 Procedural Dermatology i
    • 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)) 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.) Procedural Dermatology ii
    • RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 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. Common PIF1 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) Skills and Competencies Grievance Procedures Medical Information Access Evaluation (Fellows, Faculty, Program) Fellow Duty Hours Specialty Specific PIF Page(s) Program Personnel and Resources Faculty Program Director Qualifications and Responsibilities Resources Educational Program Patient Care Medical Knowledge Curriculum Fellow Scholarly Activity Summative Evaluation Procedural Dermatology iii
    • RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - PROCEDURAL DERMATOLOGY Date: Title of Program: Core Program Information Title of Core Program: Core Program Director: 10 Digit ACGME Program ID#: Accreditation Effective Date: Status: Next Review Last Review Date: Cycle Length: Date: The signatures of the director of the program and the Designated Institutional Official attest to the completeness and accuracy of the information provided on these forms: Signature of Program Director (and Date): Signature of Core Program Director (and Date): Signature of Designated Institutional Official (DIO) (and Date): 1. Respond to previous citation(s) Provide a concise update on each previous citation and indicate how each has been addressed (if applicable). 2. Describe changes not mentioned above Provide a concise update explaining any major changes, not described in your response to question # 1, to the fellowship program since the last site visit (for example, changes in program format, fellow complement, program leadership, or participating sites). 3. Planned start date for the first class of fellows (answer only if this is a new application) Procedural Dermatology 1
    • B. PARTICIPATING SITES SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.) Name of Sponsor: Address: Single Program Sponsor? ( ) YES ( ) NO City, State, Zip code: Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School) Name of Designated Institutional Official: Mailing Address: Phone Number: Email: Name of Chief Executive Officer: PRIMARY SITE (Site #1) Name: Address: City, State, Zip Code: Clinical Site? ( ) YES ( ) NO Type of Rotation (select one) Elective ( ) Required ( ) Both ( ) Length of Fellow Rotations (in months) CEO/Director/Pfellow’s Name: Joint Commission Accredited? ( ) YES ( ) NO If no, explain: The Program Director must submit any participating sites routinely providing an educational experience, required for all fellows. Duplicate as necessary. PARTICIPATING SITE (Site #2) Name: Address: City, State, Zip Code: Integrated: ( ) YES ( ) NO Does this site also sponsor its own program in this subspecialty? ( ) YES ( ) NO Does it participate in any other ACGME-accredited programs in this ( ) YES ( ) NO subspecialty? Distance between #2 & Miles: Minutes: #1: Type of Rotation ( ) Elective ( ) Required ( ) Both (select one) Length of Fellow Rotations (in months) CEO/Director/Pfellow’s Name: Brief Educational Rationale: Procedural Dermatology 2
    • 1. Single Program Sponsoring Institutions (Institutions that sponsor a single core or subspecialty program, or a single core program and its subspecialties). For those institutions which are either a single-program sponsoring institution (e.g., medical genetics only), or an institution with multiple residencies accredited by the same Residency Review Committee (RRC), the institutional review will be conducted in conjunction with the review of the program. Only programs in these two categories are to complete the following institutional questions. a) Provide an 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) b) Describe the formal method by which a periodic evaluation of the program’s educational quality and compliance with the program requirements occurs. Explain how fellows and faculty in the program are involved in the evaluation process. (CPR V.C; IR IV) c) Describe how the institution complies with the Institutional Requirements regarding “Fellow Eligibility and Selection” and the development of appropriate criteria for the selection, evaluation, promotion and dismissal of fellows in accordance with the Program and Institutional Requirements. (IR II.A-B) d) Summarize how the institution complies with the ACGME Institutional Requirements regarding fellow support, benefits and conditions of employment to include the details of the fellow contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the fellow contract/agreement to the PIF but state when it is given to the fellows and applicants. Have a copy available for verification by the site visitor on the day of the survey with the various items required by the ACGME numbered according to the Institutional Requirements.) (IR II.C-D) e) Describe in detail the grievance (due process) procedure(s) that is available to fellows, including the composition of the grievance committee, and mechanisms for handling complaints and grievances related to actions which could result in dismissal, non-renewal of a fellow’s contract, or other actions that could significantly threaten a fellow’s intended career development. (IR II.D.4.c-d) Procedural Dermatology 3
    • C. FACULTY / RESOURCES 1. Program Director Information Name: Title: Address: City, State, Zip code: Telephone: FAX: Email: Date First Appointed as Program Director: Principal Activity Devoted to Fellow Education? Yes: No: Term of Program Director Appointment: Date first appointed as faculty member in the program: Number of hours per week Director spends in: Clinical Administration: Research: Didactics/Teaching: Supervision: Primary Specialty Board Certification: Most Recent Year: Subspecialty Board Certification: Most Recent Year: Number of years spent teaching in this subspecialty: a) Is the program director familiar with and does he/she oversee compliance with ACGME/RRC policies and procedures as outlined in the ACGME Manual of Policies and Procedures (found at http://www.acgme.org/acWebsite/about/ab_ACGMEPoliciesProcedures.pdf)? .....................................................................................................................( ) YES ( ) NO b) Using the form provided in section C.3. provide a one page CV for the program director. 2. Physician Faculty Roster List physicians and other staff who supervise Procedural Dermatology fellows and contribute to their instruction. Include faculty from: dermatology; dermatopathology; general surgery; medical oncology; ophthalmology; orthopaedic surgery; otolaryngology; pathology and radiation therapy; plastic surgery and prosthetics. List the salaried positions first then volunteer. Provide a one page CV for each faculty member. Primary and Secondary Specialties / Average Field Hours Per Based Years as Week Mainly Board Faculty Devoted at Site Specialty / Certification Recertification in to Fellow Name (Position) Degree # Field (Y/N)† Date Specialty Education (PD) † Certification for the primary specialty refers to ABMS Board Certification. Certification for the subspecialty refers to ABMS sub-board certification. Procedural Dermatology 4
    • 3. Faculty Curriculum Vitae First Name: MI: Last Name: Present Position: Graduate Medical Education Program Name(s); include all residencies and fellowships: Certification and Re- Certification Information Current Licensure Data Certification Re-Certification Date of Expiration Specialty Year Year State (mm/yyyy) Academic Appointments - List the past ten years, beginning with your current position. Start Date (mm/ End Date yyyy) (mm/yyyy) Description of Position(s) Present Concise Summary of Role in Program: Current Professional Activities / Committees: Selected Bibliography - Most representative Peer Reviewed Publications / Journal Articles from the last 5 years (limit of 10): Selected Review Articles, Chapters and/or Textbooks (Limit of 10 in the last 5 years): Participation in Local, Regional, and National Activities / Presentations - Abstracts (Limit of 10 in the last 5 years): If not ABMS board certified, explain equivalent qualifications for Review Committee consideration: 4. Non Physician Faculty Roster List alphabetically the non-physician faculty who provide required instruction or supervision of fellows in the program. # of Years Based Teaching as Primarily at Subspecialty / Role In Faculty in Name (Position) Degree Site # Field Program Subspecialty Procedural Dermatology 5
    • 5. Program Resources a) How will the program ensure that faculty (physician and nonphysician) have sufficient time to supervise and teach fellows? Include time spent in activities such as conferences, rounds, journal clubs, research, mentoring, teaching technical skills etc. if relevant. b) Briefly describe the educational and clinical resources available for fellow education. [The answer must include how specialty specific reference materials are accessible. It should also include resources provided by the program and the institution.] D. FELLOW APPOINTMENTS 1. Number of Positions (for the current academic year) Number of Requested Positions Number of Filled Positions* *Not applicable to new programs with no fellows on duty. Count part-time fellows as 0.5 FTE. If the number of filled positions exceeds the number of positions approved by the Review Committee, provide an explanation of this variance. 2. Actively Enrolled Fellows (if applicable) a) List alphabetically all fellows actively enrolled in this program as of August 31 of current academic year. Has completed an ACGME- accredited specialty Program Expected Specialty of program Start Completion Year in Years of Most Recent (Y/N) If no, Name Date Date Program Prior GME Prior GME explain b) Did you obtain documentation that each fellow has met the eligibility criteria? ( ) YES ( ) NO Procedural Dermatology 6
    • E. SKILLS AND COMPETENCIES Describe how fellows are informed about their assignments and duties during the fellowship. [The answer must confirm that there are skills and competencies that the fellow will be able to demonstrate at the conclusion of the program, and that these are distributed (hard copy, electronically, listserv, etc.) to all fellows.] F. GRIEVANCE PROCEDURES Describe how the program handles complaints or concerns the fellows raise. (The answer must describe the mechanism by which individual fellows can address concerns in a confidential and protected manner as well as steps taken to minimize fear of intimidation or retaliation.) G. MEDICAL INFORMATION ACCESS 1. Do fellows have access to specialty-specific and other appropriate reference material in print or electronic format? .............................................................................................( ) YES ( ) NO 2. Are electronic medical literature databases with search capabilities available to fellows? .........................................................................................................................( ) YES ( ) NO H. EVALUATION (FELLOWS, FACULTY, PROGRAM) 1. Are fellows provided with a description of the skills and competencies that they should be able to demonstrate by the conclusion of the program? ...............................................( ) YES ( ) NO 2. Does the faculty provide formative feedback in a timely manner?.....................( ) YES ( ) NO 3. Describe how evaluators are educated to use assessment methods for the six competencies so that fellows are evaluated fairly and consistently. Limit your response to 400 words. 4. Describe how fellows are informed of the performance criteria on which they will be evaluated. Limit your response to 400 words. 5. Describe how the fellows develop skills to locate, appraise, and assimilate evidence from scientific studies related to their patients’ health. Limit your response to 400 words. 6. Describe at least one change implemented during the last year due to fellow participation in quality improvement activities. Limit your response to 400 words. Procedural Dermatology 7
    • 7. Describe the mechanism used to provide the semiannual evaluations of fellows (e.g., who meets with the fellows and how the results are documented in fellow files). Limit your response to 400 words. 8. Describe the system for evaluating faculty performance as it relates to the educational program. Limit your response to 400 words. 9. Describe the mechanisms used for program evaluation, including how the program uses aggregated results of the fellows’ performance and/or other program evaluation results to improve the program. (Have the written plan of action available for review by the site visitor.) Limit your response to 600 words. I. FELLOW DUTY HOURS 1. Concisely describe how faculty members supervise fellows in patient care activities. 2. How will the program ensure that fellows comply with the ACGME duty hour standards? Be specific as regards the duty hour weekly limit, time spent on-call, days free each week, length of duty shifts, periods of rest between duty shifts, and moonlighting policies, as applicable. 3. How are fellow duty hours monitored? 4. How are identified fellow duty hour violations addressed? Procedural Dermatology 8
    • RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - PROCEDURAL DERMATOLOGY PROGRAM PERSONNEL AND RESOURCES Program Director Qualifications and Responsibilities 1. Does the program director have at least five years of patient care experience as a dermatologist and dermatologic surgeon? (PR II.A.2.e))...................................................................( ) YES ( ) NO 2. Does the program director have at least five years of experience as a teacher in graduate medical education in dermatology and dermatologic surgery? (PR II.A.2.f)).....................( ) YES ( ) NO 3. Does the program director have an ongoing clinical practice in dermatologic surgery? (PR II.A.2.g)) .......................................................................................................( ) YES ( ) NO 4. Does the program director review and confirm the operative records of all fellows? (PR II.A.3.f)).........................................................................................................( ) YES ( ) NO Faculty During any short-term periods of absence of the program director, has there been a member of the faculty designated to assume responsibility for the direction of the program? (PR II.B.7.) ......................................................................................................................( ) YES ( ) NO ( ) NA Resources (PR II.D.1-6) Is the frozen section Are program laboratories laboratory adjacent to the in compliance with all operating suite or rooms federal, state and local Mohs Micrographic in which dermatologic regulations regarding a Frozen Section Accreditation surgery is performed? work environment? Laboratory (PR II.D.1) Agency(ies) (Yes/No) (Yes/No) 1. Describe examination areas for surgical patients. (PR II.D.1) 2. Identify the peer-review organization that reviews and approves the frozen section slides for Mohs micrographic surgery. (PR II.D.2.) 3. Describe the space available for fellows to read, study and complete their paperwork. (PR II.D.3.) Procedural Dermatology 9
    • 4. Operative Procedures (PR II.D.4.) For new applications provide the number of dermatologic procedures performed in a recent 12 month period at each site identified in the Common PIF. If more than four sites are involved in the program, duplicate the form as needed. Identify recent 12-Month period used: From: To: #1 #2 #3 #4 Total Ambulatory phlebectomy / vein surgery Botulinum toxin chemodenervation Chemical Peel: deep dermal Chemical Peel: superficial-epi Dermabrasion Excision - Benign Lesion Excision - Malignant Lesion Flaps Grafts (split or full) Hair removal laser Hair transplantation Intense pulsed light Laser (ablation, resurfacing) Lip excision / wedge / vermilionectomy Mohs micrographic surgery Mohs micrographic surgery (complex / large) Nail procedures Repair (closure) simple / intermediate / complex Tumescent liposuction Vascular lesion laser Pigmented lesion laser Non-ablative rejuvenation Rhinophyma correction Scar revision (acne scar or procedure not otherwise listed) Sclerotherapy Soft Tissue Augmentation / Skin Fillers Other Procedural Dermatology 10
    • EDUCATIONAL PROGRAM 1. List all clinical rotations, both required and elective, in which the fellow participates. (PR IV A.1.a)) 1 2 3 4 5 6 7 8 9 10 11 12 Rotation R or E* Site # * Required or Elective 2. Provide an average weekly schedule for a program fellow. (PR IV A.1.a)) Monday Tuesday Wednesday Thursday Friday Saturday Sunday AM PM 3. Patient Care a) Describe how the fellows demonstrate proficiency in decisions regarding patient treatment, including instances in which the patient should be referred to a different specialty or individual. (PR IV.A.2.a).(1)) b) Describe how fellows demonstrate competence in the performance of skin neoplasm destruction techniques, excision, and Mohs micrographic surgery. (PR IV.A.2.a).(1).(a)) Procedural Dermatology 11
    • c) Describe how the fellows demonstrate competence in cutaneous reconstructive surgery including random pattern and axial flap repair, grafting techniques, and staged reconstructive techniques. (PR IV.A.2.a).(1).(b)) d) Describe how fellows demonstrate advanced evaluation and management skills for all cutaneous surgical patients regardless of diagnosis, including preoperative, perioperative, and postoperative evaluation. (PR IV.A.2.a).(3)) e) Describe how the fellows demonstrate proficiency in the early identification of benign premalignant and malignant skin lesions through unaided and aided visual morphologic recognition. (PR IV.A.2.a).(4)) 4. Medical Knowledge a) Describe how the fellows demonstrate knowledge of related disciplines including surgical anatomy, sterilization of equipment, aseptic technique, anesthesia, closure materials, and instrumentation. (PR IV.A.2.b).(1)) b) Describe how the fellows demonstrate in-depth knowledge of clinical diagnosis, biology, and pathology of skin tumors as well as laboratory interpretation related to diagnosis and surgical treatment. (PR IV.A.2.b).(2)) 5. Describe how the program is structured so that fellows are involved in procedural dermatology throughout the year. (PR IV.A.3) 6. List regularly scheduled and held lectures, tutorials, seminars, conferences with clinical services and conferences to consider complications and outcomes and utilization review that are a part of the subspecialty program and indicate the frequency of each (e.g., weekly, monthly, etc). (PR IV.A.4) Didactic Session Type Frequency Procedural Dermatology 12
    • 7. Indicate whether fellows receive didactic instruction or clinical experience in the following aspects of procedural dermatology: (PR IV.A.5.a)-d)) Didactic Instruction Clinical Experience Basic science Anatomy Anesthesia Ethics Pre- and post- operative management Surgical technique Wound healing Laboratory technique Interpretation of pathologic specimens related to Mohs micrographic surgery Cutaneous reconstruction of surgical defects Chemical Peel Hair transplantation Dermabrasion Rhinophyma correction Cutaneous oncology Laser surgery Epidemiology Medicolegal and regulatory issues Quality assurance Electrosurgery for benign and malignant lesions Cryosurgery Curettage and electrosurgery Scalpel surgery Mohs micrographic surgery Reconstruction of defects Staged reconstructive techniques Chemical destructive techniques Nail surgery Grafts Local flaps Sclerotherapy Wedge excision Complex cutaneous closures Cutaneous soft tissue augmentation with injectable filler material Chemo denervation Tumescent liposuction and fat transplantation Hair replacement surgery Skin resurfacing and tightening techniques Cosmetic laser procedures Use of specialized wound dressings appropriate to the clinical problems 8. Describe the fellows’ experience in setting up and operating a frozen section laboratory capable of Procedural Dermatology 13
    • processing sections for Mohs micrographic surgery as well as supervision and training laboratory personnel. (PR IV.A.6) 9. Other Personnel and Disciplines (PR IV.A.7) a) Do the fellows have the opportunity to work with the following health care personnel? Dermatology...................................................................................................( ) YES ( ) NO Dermatopathology..........................................................................................( ) YES ( ) NO Medical Oncology..........................................................................................( ) YES ( ) NO b) Does fellow experience include interaction with the following disciplines? General Surgery.............................................................................................( ) YES ( ) NO Ophthalmology...............................................................................................( ) YES ( ) NO Otolaryngology...............................................................................................( ) YES ( ) NO Plastic Surgery...............................................................................................( ) YES ( ) NO Radiation Therapy..........................................................................................( ) YES ( ) NO If no, explain or describe the interactions. 10. Describe how fellows actively engaged in teaching. (PR IV.A.8) 11. Scholarly Activity - List the scholarly activity for each graduate of the program during the last three years. Include manuscripts submitted for publication in a peer-reviewed publication and presentations at local, regional, or national professional society meetings. (PR IV.B) SUMMATIVE EVALUATION Is the summative evaluation completed using the evaluation form available on the American Board of Dermatology website? (PR V.A.2.c)) ........................................................................( ) YES ( ) NO Procedural Dermatology 14