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New Application Only

  1. 1. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • FOR NEW APPLICATIONS ONLY - NUCLEAR RADIOLOGY 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 Diagnostic Radiology 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 Nuclear Radiology. The Program Requirements or 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 – Nuclear Radiology i
  2. 2. Attach the following documents to the application: 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 Single Program Sponsors only, attach the following additional documents to the application: 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) Nuclear Radiology ii
  3. 3. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 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 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) Institutional Data Medical Data Narrative Description Space and Equipment Teaching File Educational Program Nuclear Radiology iii
  4. 4. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • FOR NEW APPLICATIONS ONLY - NUCLEAR RADIOLOGY A. ACCREDITATION INFORMATION Date: Title of Program: Core Program Information Title of Core Program: Core Program Director: 10 Digit ACGME Program ID#: Accreditation Status: Effective Date: Next Review Date: Last Review Date: Cycle Length: 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) Nuclear Radiology 1
  5. 5. 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/President’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 subspecialty? ( ) YES ( ) NO Distance between #2 & #1: Miles: Minutes: Type of Rotation (select one) ( ) Elective ( ) Required ( ) Both Length of Fellow Rotations (in months) CEO/Director/President’s Name: Brief Educational Rationale: Nuclear Radiology 2
  6. 6. 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 “Resident 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) Nuclear Radiology 3
  7. 7. 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 Supervision: Administration: Research: Didactics/Teaching: 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 .....................................................................................................................( ) YES ( ) NO b) Using the form provided in section C.3. provide a one page CV for the program director. 2. Physician Faculty Roster Calculate the number of faculty required for your program, based on the requirement for one full time equivalent faculty member at the parent institution and integrated sites for each resident in the program. List alphabetically and by site the faculty counted by the program to meet this requirement. Using the form provided below, supply a one page CV for each faculty listed. Name (Position) Degree Based Mainly at Site # Primary and Secondary Specialties / Field Years as Faculty in Specialty Average Hours Per Week Devoted to Fellow Education Specialty / Field Board Certification (Y/N)† Recertification Date (PD) † Certification for the primary specialty refers to ABMS Board Certification. Certification for the subspecialty refers to ABMS sub-board certification. Nuclear Radiology 4
  8. 8. 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 Specialty Certification Year Re-Certification Year State Date of Expiration (mm/yyyy) Academic Appointments - List the past ten years, beginning with your current position. Start Date (mm/yyyy) End Date (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. Name (Position) Degree Based Primarily at Site # Subspecialty / Field Role In Program # of Years Teaching as Faculty in Subspecialty Nuclear Radiology 5
  9. 9. 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.] Nuclear Radiology 6
  10. 10. 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. Name Program Start Date Expected Completion Date Year in Program Years of Prior GME Specialty of Most Recent Prior GME Has completed an ACGME- accredited specialty program (Y/N) If no, explain b) Did you obtain documentation that each fellow has met the eligibility criteria? ( ) YES ( ) NO Nuclear Radiology 7
  11. 11. 11RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • FOR NEW APPLICATIONS ONLY - NUCLEAR RADIOLOGY I. INSTITUTIONAL DATA All information requested must be included for each site listed in the Common PIF. Reporting Period (Recent 12- month period): From: To: Site #1 Site #2 Site #3 Total beds in facility Adult Admissions Pediatric Admissions # cutoff age for pediatrics Newborn nursery admissions Neonatal intensive care unit admissions Total Admissions (enter on this line) Adult Outpatient visits Pediatric Outpatient (include neonates) Total Outpatients Visits *Note: The cutoff age used by each participating s for pediatric patients should be indicated. Nuclear Radiology 8
  12. 12. II. MEDICAL DATA Site # 1 Site #2 Site #3 Thyroid Brain Lung: perfusion Ventilation Cardiac: Myocardial perfusion Infarct avid study Wall motion study Total number of imaging studies(continued) Liver: morphology Biliary tract study Bone Kidney: morphology Excretion Tumor/abscess localization Other* Total number of non-imaging in vivo studies Thyroid uptake Renogram Blood volume (including PV, RSM) Ferrokinetics RBC survival and sequestration Schilling text Fibrogen uptake study Other* Total number of in vitro studies: Check those performed in Radiology Dept. T³ and T4 Radioimmunoassay (specify type) Other* Total number of therapeutic procedures (by radionuclide): *Please list “Other” studies for 5% of the category workload: Nuclear Radiology 9
  13. 13. III. NARRATIVE DESCRIPTION 1. What are the principal objectives of the program? 2. Describe the organization of the teaching. 3. Explain the provision for graduated resident responsibility. 4. Explain the availability of attending coverage and provision for fellow supervision. 5. How does each of the participating sites contribute to the educational program? a) Describe the nature of fellow participation on rotations at the participating sites. 6. How does the program provide for graduated study, experience and responsibility in the following areas: a) nuclear radiologic diagnosis b) medical nuclear and diagnostic radiological physics c) radiobiology d) health physics and protection e) nuclear medicine instrumentation f) radiopharmaceutical chemistry and instrumentation Nuclear Radiology 10
  14. 14. g) clinical applications of nuclear radiology h) pathology 7. Describe how the fellows participate in the teaching conferences. a) How much responsibility do they have for their preparation and presentation? b) Is attendance/participation of fellows and faculty documented? ( ) YES ( ) NO 8. Describe briefly the research space and important special research facilities. a) List intramural research programs (not more than 5) being conducted by members of the Department, indicating those in which (if any) fellows participate. DO NOT SUBMIT COPIES OF PROTOCOLS, PAPERS OR GRANT APPLICATIONS. Nuclear Radiology 11
  15. 15. IV. SPACE AND EQUIPMENT 1. Complete only for sites to which rotations total a minimum of 3 months Site #1 Site #2 Site #3 Nuclear Radiology (square feet)) Physics Radiological Research Other (specify) Allocation of Space: Number of examining rooms controlled by Nuclear Radiology (including any rooms used to perform patient examinations) Number of nuclear examining rooms not controlled by Radiology, but located in Nuclear Radiology space Number of Nuclear Radiology staff offices Number of conference rooms available to Nuclear Radiology for regular use Number of Nuclear Radiology resident offices/lounges 2. List number of units available to residents in each site. Include units in other departments, e.g., cardiology, GI and GU. Append copy of current equipment list. Nuclear Radiology Equipment Site #1 Site #2 Site #3 In Vivo Imaging/Counting Single or Multi Probe Counting Systems Tomographic Imaging Systems (specify) Cameras Stationary, standard or large field Mobile In Vitro Laboratory Other Nuclear Imaging Equipment (specify) 3. Are residents required to learn to operate, utilize or program any phase of computer utilization specifically part of nuclear units?.........................................................................( ) YES ( ) NO If yes, describe briefly: Nuclear Radiology 12
  16. 16. V. TEACHING FILE 1. Total number of cases in institutionally accumulated nuclear radiology file: ( ) 2. Does the department have a teaching file gathered from outside the site? ( ) YES ( ) NO 3. ACR file (list sections available and date of acquisition) Sections Available Date of Acquisition Nuclear Radiology 13
  17. 17. VI. EDUCATIONAL PROGRAM 1. Please submit an outline of typical assignments and the time spent in each assignment during the 12 months of the fellowship program. Assignment: Time Spent Location Months Weeks Site #1,2,3 2. List regular conferences, lectures, and seminars in nuclear medicine, physics, radiobiology, nuclear radiology, etc. (Conferences must include those in which there is resident participation.) Also list clinicopathological conferences, journal club, etc. Extradepartmental conferences in which the department and nuclear radiology residents participate or attend may be listed separately. Attach the lecture/conference schedule for the past year, to include topics, dates and presenters. Conferences, lectures, etc. (Intradepartmental) Frequency Individual (s) (and specialty) responsible for organization of sessions Nuclear Radiology 14