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  • THE RESIDENCY REVIEW COMMITTEE FOR THORACIC SURGERY 515 North State Street, Suite 2000 Chicago, Illinois 60654 Phone: (312) 755-7471 PROGRAM INFORMATION FORM – CONGENITAL CARDIAC SURGERY FOR NEW APPLICATIONS ONLYGENERAL INSTRUCTIONSAPPLICATION FOR A NEW PROGRAM: This form is for use by programs making Initial Application Only (forre-accreditation, use the Continued Accreditation PIF and the Web Accreditation Data System). All sections ofthe form applicable to the program must be completed in order to be accepted for review. The informationprovided should describe the proposed program. For items that do not apply indicate N/A in the space provided. Ifany requested information is not available, an explanation should be given and it should be so indicated in theappropriate place on the form. Note that the process takes approximately one year from the time theapplication is received until it is evaluated by the Residency Review Committee. A site visit will be scheduledduring that year.Once the forms are complete, number the pages sequentially in the upper right hand corner, starting with Part 1,Section 1. Send four complete copies to the Executive Director of the RRC for Thoracic Surgery at the addressabove.Review the Program Requirements for Residency Education in Thoracic Surgery. The Program Requirements orthe Institutional Requirements may be downloaded from the ACGME Website (www.acgme.org):For questions regarding the site visit, contact the writer of the letter announcing the site visit. For questions regarding the completion of the form (content), contact the Accreditation Administrator (Phone: 312-755-5498). For word processing questions/problems, contact the ACGME Help Desk (Phone: 312-755-7464). For Web Accreditation Data System questions, contact 312-755-7123 to be directed to an ADS representative or email WebADS@acgme.org.For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.aspTo facilitate review of the program, the information submitted should be clear, concise, and consistent. Do notattach any unnecessary materials, as extraneous materials will delay program accreditation.The program director is responsible for the accuracy of the information supplied in this form and must sign it. Itmust also be signed by the Department Chair/Chief of Service and the DIO of the sponsoring institution.health-services-research3791.doc
  • THE RESIDENCY REVIEW COMMITTEE FOR THORACIC SURGERY 515 North State Street, Suite 2000 Chicago, Illinois 60654 Phone: (312) 755-7471 PROGRAM INFORMATION FORM – CONGENITAL CARDIAC SURGERY10 Digit ACGME Program I.D. #:Program Name:TABLE OF CONTENTSWhen you have the completed forms, number each page sequentially in the upper right hand corner. Starton Part 1, Section 1 of the PIF. Report this pagination in the Table of Contents and submit this cover page withthe completed PIF. 1Part 1 Section Page(s)General Program Information 1 Accreditation Information 1.A Program Director Information 1.BParticipating Institutions 2Resident Complement 3 Number of Positions 3.A Actively Enrolled Residents 3.B Aggregate Data on Residents Completing or Leaving the Program for the Last Three (3) Years 3.C Residents Who Completed the Program 3.D Withdrawn / Dismissed Residents 3.E Scholarly Activity 3.F Duty Hours 3.GFaculty 4 Faculty Roster 4.A Part 2 Section Page(s)Background Information 5 Previous Citations or Concerns 5.A Changes 5.BInstitutional Facilities 6Program Goals and Objectives 7Other Residents and Fellows 8Conferences 9Resident Evaluation 10Educational Program – Surgical Volume 11Appendix A. Curriculum VitaAppendix B. Institutional Operative ExperienceAppendix C. For Continued Accreditation Programs Only: Operative Log For Each Congenital Cardiac Surgery ResidentAppendix D. Duty Hour PolicyAppendix E. Supervision Policyhealth-services-research3791.doc
  • THE RESIDENCY REVIEW COMMITTEE FOR THORACIC SURGERY 515 North State Street, Suite 2000 Chicago, Illinois 60654 Phone: (312) 755-7471 PROGRAM INFORMATION FORM – CONGENITAL CARDIAC SURGERY (Part 1) FOR NEW APPLICATIONS ONLYSECTION 1. GENERAL PROGRAM INFORMATIONA. Accreditation InformationDate:Title of Program:10 Digit ACGME Program ID# (for accredited programs):B. Program Director InformationName:Title:Address:City, State, Zip code:Telephone: FAX: Email:Date First Appointed as Program Director:Principal Activity Devoted to Resident Education?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 Date:Secondary Specialty Board Certification: Most Recent Date:Number of years spent teaching in GME in this specialty:Director based at primary teaching institution? ( ) YES ( ) NOIs Program Director also Department Chair? ( ) YES ( ) NOIf No, Chair Name:The signatures of the director of the program, the chief of the department and the designated institutional officialattest to the completeness and accuracy of the information provided on these forms.Signature of Program Director (and date):Signature of Chief/Department Chair if different from Program Director (and date):Signature of Designated Institutional Official (DIO) (and date):health-services-research3791.doc
  • SECTION 2. PARTICIPATING INSTITUTIONSSPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.)Name of Sponsor:Address: Single Program Sponsor? ( ) YES ( ) NOCity, 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:Does SPONSOR have an affiliation with a medical school (could be the sponsoring institution)? ( ) YES ( ) NOIf yes, name the medical school below and have an affiliation agreement that describes the effect of these arrangements onthis program available.Name of Medical School #1:Name of Medical School #2:PRIMARY INSTITUTION (Institution #1)Name:Address:City, State, Zip Code:Type of Relationship with Program: Sponsor ( ) Major ( ) Clinical ( ) Other ( )Type of Rotation Elective ( ) Required ( ) Both ( ) (select one)Length of Fellows Rotation (in months) Year 1: Year 2:CEO/Director/President’s Name: JCAHO Approved? ( ) YES ( ) NO ( ) NAType of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)Ownership Type: (e.g., State, Corporation, Church)Brief Educational Rationale:PARTICIPATING INSTITUTION (Institution #2) Select one (if applicable)Name: INTEGRATED ( )Address: PARTICIPATING ( )City, State, Zip Code:Type of Relationship with Program: Sponsor ( ) Major ( ) Clinical ( ) Other ( )Does this institution also sponsor its own program in this specialty?Does it participate in any other ACGME accredited programs in this specialty?Distance between 2 & 1: Miles: Minutes:Type of Rotation Elective ( ) Required ( ) Both ( ) (select one)Length of Fellows Rotation (in months) Year 1: Year 2:CEO/Director/President’s Name: JCAHO Approved? ( ) YES ( ) NO ( ) NAType of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)Ownership Type: (e.g., State, Corporation, Church)Brief Educational Rationale:PARTICIPATING INSTITUTION (Institution #3) Select one (if applicable)Name: INTEGRATED ( )Address: PARTICIPATING ( )health-services-research3791.doc
  • City, State, Zip Code:Type of Relationship with Program: Sponsor ( ) Major ( ) Clinical ( ) Other ( )Does this institution also sponsor its own program in this specialty?Does it participate in any other ACGME accredited programs in this specialty?Distance between 3 & 1: Miles: Minutes:Type of Rotation Elective ( ) Required ( ) Both ( ) (select one)Length of Fellows Rotation (in months) Year 1: Year 2:CEO/Director/President’s Name: JCAHO Approved? ( ) YES ( ) NO ( ) NAType of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)Ownership Type: (e.g., State, Corporation, Church)Brief Educational Rationale:health-services-research3791.doc
  • SECTION 3. RESIDENTSA. Number of Positions (for the current academic year) Positions Total Number of Requested Positions Number of Filled Positions* * Not applicable to new programs with no residents on duty.B. Actively Enrolled Residents (if applicable) List all residents actively enrolled in this program as of August 31 of current academic year (see Section 3.A). List names alphabetically within Year in Program. Place an (*) asterisk next to the name of each resident accepted as a transfer. Documentation of previous experience for transfer students should be available for review by the site visitor. Program Expected Years of Year of Med Year in Type of Specialty of Most Name Start Completion Prior Medical School School Program Position Recent Prior GME Date Date GME GraduationC. Aggregate Data on Residents Completing or Leaving the Program for the Last Three (3) Years (if applicable) June 30, __ June 30, __ June 30, __ Based in academic year ending: (indicate year) (indicate year) (indicate year) Number of Graduates Who Started in Program Year 1 and Finished this Program* Number of Graduates Regardless of Whether They Began in this Program* Number of Residents That Completed Preliminary Year(s) Number of Residents Who Withdrew from the Program Number of Residents Who Transferred Out of the Programhealth-services-research3791.doc
  • Number of Residents on Leave of Absence from the Program Number of Residents Dismissed from the Program *Excludes residents preliminary complement year(s).D. Residents Completing Program in the Last Three Years (if applicable) List of residents who completed all training for this specialty based on the last academic year ending June 30, ____. Date Took First Stage of Date First Took Second Actual Date of Board Exam - Passed on Stage of Board Exam - Name Start Date Completion First Attempt Passed on First Attempt (Y/N/Unknown) (Y/N/Unknown) List of residents who completed all training for this specialty based on the last academic year ending June 30, ____. Date Took First Stage of Date First Took Second Actual Date of Board Exam - Passed on Stage of Board Exam - Name Start Date Completion First Attempt Passed on First Attempt (Y/N/Unknown) (Y/N/Unknown) List of residents who completed all training for this specialty based on the last academic year ending June 30, ____. Date Took First Stage of Date First Took Second Actual Date of Board Exam - Passed on Stage of Board Exam - Name Start Date Completion First Attempt Passed on First Attempt (Y/N/Unknown) (Y/N/Unknown)health-services-research3791.doc
  • E. Withdrawn Residents (if applicable) List residents who withdrew or were dismissed from the program for the last three years and provide the reason. Withdrawn or Name Start Date End Date Reason DismissedF. Scholarly Activity (if applicable) Based on Academic Year Ending June 30, ____. June 30, ____. June 30, ____. Number of Nationally Peer-Reviewed Published Articles Authored or Co-Authored by Residents in the Past Year. Number of Resident Presentations at Regional or National Meetings in the Past Year.G. Duty Hours For the previous four week period: Yr 1 Excluding call from home, what was the average number of hours on duty per resident per week? Excluding call from home, what was the maximum number of continuous hours worked by any resident? On average, how many days per week of in-house call were residents assigned? How many times (in the last 4 weeks) have residents worked more than 30 continuous hours? (This continuous time includes in-house call that directly follows a regular duty shift. Add together the number of times for all residents.) On average, how many days (for the entire last 4 week period) did each resident have completely free from all educational and clinical responsibilities? On average, how many hours off duty did each resident have between duty shifts? (Duty shifts include in-house call.)health-services-research3791.doc
  • SECTION 4. FACULTY (PR IV A, C)A. Faculty RosterList all major faculty who participate directly and regularly in congenital cardiac surgery resident education. Primary and Secondary Specialties / Field Average Hours Per Week Spent On Based Most Board Years as Primarily at Recent Clinical DidacticName (Position) Degree Specialty / Field Certification Faculty in Admin Research Institution Certification Supervision Teaching (Y/N)† Specialty #* Date(PD)*as listed in Part 1, Section 2.† Certification for the primary specialty refers to ABMS Board Certification. Certification for the secondary specialty refers to sub-Board certification in a subspecialty oranother specialty area.
  • THE RESIDENCY REVIEW COMMITTEE FOR THORACIC SURGERY 515 North State Street, Suite 2000 Chicago, Illinois 60654 Phone: (312) 755-7471 PROGRAM INFORMATION FORM – CONGENITAL CARDIAC SURGERY (Part 2) FOR NEW APPLICATIONS ONLYSECTION 5. BACKGROUND INFORMATIONA. Previous Citations or Concerns (if applicable) List the citations from last RRC accreditation if applicable and describe briefly the steps that have been taken to address the citations or suggestions made by the RRC. If documentation is required, provide a specific reference to the information provided in the PIF or append additional support materials. If no citations were listed, indicate this in the response.B. Changes (if applicable) Briefly describe major changes, other than those included in the response to previous citations and/or concerns (above) that have been implemented since the last survey and review. Include changes in sponsoring organization, participating hospitals, required rotations, resident complement, and facility or facilities.health-services-research3791.doc
  • SECTION 6. INSTITUTIONAL FACILITIES (PR II)Time period covered (an academic 1 year time frame): From: To: Sponsoring Institution #1 Institution #21. Name Chief of Congenital Cardiac Surgery2. Patient Facilities - Total number of: a. hospital beds b. congenital cardiac surgery surgical beds c. operating rooms d. operating rooms dedicated to congenital cardiac surgery e. dedicated congenital cardiac surgery intensive care unit beds3. Laboratory Facilities - (Y/N) Does institution offer: a. cardiac catheterization b. cardiothoracic surgical researchhealth-services-research3791.doc
  • SECTION 7. PROGRAM GOALS AND OBJECTIVES1. Insert the goals and objectives for the Program:2. Congenital Cardiac Surgery residents are provided with skills in the following areas: a. Perfusion........................................................................................................................... YES ( ) NO ( ) b. Ultrasound......................................................................................................................... YES ( ) NO ( ) c. Echo cardiology................................................................................................................. YES ( ) NO ( ) d. Other imaging techniques: YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) e. Cardiac catheterization...................................................................................................... YES ( ) NO ( ) f. Critical Care....................................................................................................................... YES ( ) NO ( ) Explain all “no” responses above: If noninvasive imaging assignments occur, please describe:3. Describe the daily role of the Congenital Cardiac Surgery resident in preoperative and post operative care, including the critical care followup for their patients.4. Describe the provisions for the Congenital Cardiac Surgery resident longitudinal responsibility for patient care.5. Describe the educational relationships between the Thoracic Surgery program and the Congenital Cardiac Surgery program.6. Describe in detail the educational and clinical relationships between the Thoracic Surgery residents and the Congenital Cardiac Surgery residents.health-services-research3791.doc
  • SECTION 8. OTHER RESIDENTS AND FELLOWS (PR III. D)Indicate the following information for any additional personnel assigned to the Congenital Cardiac Surgery serviceat any one time.Additional Physician Personnel Number Duration of Rotations on CCS ServiceGeneral Surgery ResidentsThoracic Surgery ResidentsThoracic Surgery Residents from other ProgramsOther fellowsForeign fellowshealth-services-research3791.doc
  • SECTION 9. CONFERENCES (PR V. E. 1)List teaching rounds, conferences, seminars, journal club, etc., in which there is participation by the resident. Name of Conference Individual(s) or Department Frequency(weekly, Mandatory or(teaching round, seminar, Responsible for Organization monthly, etc.) Elective journal club, etc.) of Sessionshealth-services-research3791.doc
  • SECTION 10. RESIDENT EVALUATION (PR VI. A)1. At least semiannually evaluate the knowledge, skills, and professional growth of the residents, using appropriate criteria for procedures?............................................................................................( ) YES ( ) NO2. Communicate each evaluation to the resident in a timely manner?............................................( ) YES ( ) NO3. Advance resident to positions of higher responsibility only on the basis of evidence of their satisfactory progressive scholarship and professional growth?.....................................................................( ) YES ( ) NO4. Maintain a permanent record of evaluation for each resident and have it accessible to the resident and other authorized personnel?.................................................................................................................( ) YES ( ) NO5. If no (to any of the above questions), please explain.health-services-research3791.doc
  • SECTION 11. EDUCATIONAL PROGRAM - SURGICAL VOLUME (PR V. E. 2.d)1. Does each resident have an average annual caseload of 75 major operations?......................YES ( ) NO ( ) If no, please explain.2. Did each resident document the required minimum number of cases per category?................YES ( ) NO ( )3. Do cases reflect adequate distribution of categories and complexity of procedures such that each resident is ensured a balanced and equivalent operative experience?......................................................YES ( ) NO ( ) If no, please explain.4. Does the resident participate in the diagnosis, preoperative planning, and selection of the operation for each patient?.....................................................................................................................................YES ( ) NO ( ) If no, please explain.5. Does the resident perform those technical manipulations that constitute the essential parts of the patients operation?.................................................................................................................................YES ( ) NO ( ) If no, please explain.6. Is the resident substantially involved in postoperative care?.....................................................YES ( ) NO ( ) If no, please explain.7. Are there other residents and fellows in the program that have an impact on case distribution?. YES ( ) NO ( ) If yes, please describe impact and submit a log of these fellows’ cases.health-services-research3791.doc
  • APPENDIX A. CURRICULUM VITA (PR V. C)Provide DOCUMENTATION OF SCHOLARLY ACTIVITY (a limited curriculum vita) for all congenital cardiacsurgery faculty.When listing publications, do not include manuscripts that are in preparation or have been submitted but not yetaccepted. Articles that have been accepted but not yet published should be listed as In Press and should includethe name of the journal. It is not necessary to enclose a copy of the letter of acceptance with the application butthis letter should be available for inspection by the site visitor.Name:Address:Principal hospital base:Current professional and academic appointments (Include starting date):Undergraduate medical education (including dates and degrees):Postgraduate medical education (including dates of internships, residencies, fellowships, etc.):Licensure(s):Education activities and recognition:Resident contact - Teach thoracic surgery resident(s) basic Bedside teachinghours/week science - hours/year rounds - hours/weekTeach ATLS? ( ) YES ( ) NO ACLS? ( ) YES ( ) NO Hours of lecture CME course/year (lectures given):Documented participation in the undergraduate curriculum? ( ) YES ( ) NOResearch ActivitiesBasic ResearchProjects: Funding Source:Clinical ResearchRetrospective reviews: Funding Source:Pharmaceutical trials: Funding Source:Therapeutic interventions: Funding Source:Health Services ResearchProjects: Funding Source:Evidenced based Practice guidelines:Prospective randomized trials:System analysis:Ethics:Outcomes:health-services-research3791.doc
  • APPENDIX B. INSTITUTIONAL OPERATIVE EXPERIENCEMAJOR CARDIOVASCULAR PROCEDURES INSTITUTION 1 INSTITUTION 21. Closed Operations for Congenital Heart Disease a. Patent Ductus Arteriosus b. Coarctation of Aorta c. Shunting Procedure d. Vascular Ring or Arch Anomalies e. Valvotomy f. Pulmonary Artery Banding g. Atrial Septectomy h. Others (Specify) TOTAL2. Open Operations for Congenital Heart Disease a. Tetralogy of Fallot b. Transposition c. Truncus Arteriosus d. A-V Septal Defect e. Anomalous Pulmonary Venous Drainage f. Ventricular Septal Defect g. Atrial Septal Defect h. Interrupted Arch/Hypoplastic Left Heart i. Fontan Procedure j. Others (Specify) TOTAL3. Valvular Heart Disease a. Mitral Commissurotomy b. Mitral/Aortic Valve Repair c. Valve Replacement d. Combined Valve/Coronary e. Aortic Root Replacement f. Others (Specify) TOTAL4. Resection of Cardiac Tumor TOTAL5. Pericardium a. Pericardial Window b. Pericardiectomy c. Others (Specify) TOTAL6. Other Cardiac Procedures a. Arrhythmia Surgery b. Insertion/Removal Cardiac Assist Device c. Removal of Intra-Cardiac Foreign Body d. Repair Cardiac Trauma e. Re-exploration for Bleeding f. Others (Specify) TOTAL7. Thoracic Vascular a. Traumatic Injury b. Repair of Aneurysm c. Repair of Aortic Dissection d. Pulmonary Embolectomy/Endarterectomy e. Others (Specify) TOTALhealth-services-research3791.doc
  • MAJOR CARDIOVASCULAR PROCEDURES INSTITUTION 1 INSTITUTION 28. Transplantation a. Single Lung b. Double Lung c. Heart d. Procurement of Lung e. Procurement of Heart f. Others (Specify) TOTALhealth-services-research3791.doc
  • APPENDIX C. FOR CONTINUED ACCREDITATION PROGRAMS ONLY: OPERATIVE LOG FOREACH CONGENITAL CARDIAC SURGERY RESIDENTResidents NameLog Covering Period (dates)MAJOR CARDIOVASCULAR PROCEDURES SURGEON ASSISTANT1. Closed Operations for Congenital Heart Disease a. Patent Ductus Arteriosus b. Coarctation of Aorta c. Shunting Procedure d. Vascular Ring or Arch Anomalies e. Valvotomy f. Pulmonary Artery Banding g. Atrial Septectomy h. Others (Specify) TOTAL2. Open Operations for Congenital Heart Disease a. Tetralogy of Fallot b. Transposition c. Truncus Arteriosus d. A-V Septal Defect e. Anomalous Pulmonary Venous Drainage f. Ventricular Septal Defect g. Atrial Septal Defect h. Interrupted Arch/Hypoplastic Left Heart i. Fontan Procedure j. Others (Specify) TOTAL3. Valvular Heart Disease a. Mitral Commissurotomy b. Mitral/Aortic Valve Repair c. Valve Replacement d. Combined Valve/Coronary e. Aortic Root Replacement f. Others (Specify) TOTAL4. Resection of Cardiac Tumor TOTAL5. Pericardium a. Pericardial Window b. Pericardiectomy c. Others (Specify) TOTAL6. Other Cardiac Procedures a. Arrhythmia Surgery b. Insertion/Removal Cardiac Assist Device c. Removal of Intra-Cardiac Foreign Body d. Repair Cardiac Trauma e. Re-exploration for Bleeding f. Others (Specify) TOTAL7. Thoracic Vascular a. Traumatic Injury b. Repair of Aneurysmhealth-services-research3791.doc
  • MAJOR CARDIOVASCULAR PROCEDURES SURGEON ASSISTANT c. Repair of Aortic Dissection d. Pulmonary Embolectomy/Endarterectomy e. Others (Specify) TOTAL8. Transplantation a. Single Lung b. Double Lung c. Heart d. Procurement of Lung e. Procurement of Heart f. Others (Specify) TOTALhealth-services-research3791.doc
  • APPENDIX D. DUTY HOUR POLICYInsert the Congenital Cardiac Surgery specific policy.health-services-research3791.doc
  • APPENDIX E. SUPERVISION POLICYInsert the Congenital Cardiac Surgery specific supervision policy.health-services-research3791.doc