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  • 1. RESIDENCY REVIEW COMMITTEE FOR ANESTHESIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - CRITICAL-CARE MEDICINE 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 Anesthesiology 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 Critical Care Medicine. 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 Critical-Care Medicine i
  • 2. 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.) Critical-Care Medicine ii
  • 3. RESIDENCY REVIEW COMMITTEE FOR ANESTHESIOLOGY 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) Clinical and Education Resources Critical Care Unit Data (For Each Unit) Patient Population Data Educational Program Quality Assurance Critical-Care Medicine iii
  • 4. RESIDENCY REVIEW COMMITTEE FOR ANESTHESIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - CRITICAL-CARE MEDICINE 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) Critical-Care Medicine 4
  • 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: Critical-Care Medicine 5
  • 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) Critical-Care Medicine 6
  • 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 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 alphabetically and by site all physician faculty who devote at least 10 hours a week to resident education. 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. Critical-Care Medicine 7
  • 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 Critical-Care Medicine 8
  • 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.] Critical-Care Medicine 9
  • 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 Critical-Care Medicine 10
  • 11. 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. Critical-Care Medicine 11
  • 12. 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? Critical-Care Medicine 12
  • 13. RESIDENCY REVIEW COMMITTEE FOR ANESTHESIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - CRITICAL-CARE MEDICINE I. CLINICAL AND EDUCATION RESOURCES 1. Describe the resources provided by the anesthesia that are designed specifically for the care of critically ill patients. 2. Indicate where the following tests are performed. If these tests are not available, check the last column. In ICU In Hospital Outside Lab N/A Biochemistry tests Arterial blood gas analysis Culture and sensitivity Toxicology Plasma drug concentrations 3. Indicate whether the following procedures are available in the site. a) Chest X-Ray..................................................................................................( ) YES ( ) NO b) Fluoroscopy..................................................................................................( ) YES ( ) NO c) CAT Scanning (head & body) .......................................................................( ) YES ( ) NO d) Echocardiography.........................................................................................( ) YES ( ) NO e) Ultrasonography............................................................................................( ) YES ( ) NO f) PET scanning................................................................................................( ) YES ( ) NO g) Hemodialysis.................................................................................................( ) YES ( ) NO h) MRI...............................................................................................................( ) YES ( ) NO 4. Describe the following facilities: a) Conference facilities b) Research space and facilities Critical-Care Medicine 13
  • 14. 5. List types of equipment and number of pieces of each type. Type Site #1 Site #2 Site #3 6. Are these staff specialists available for instruction and consultation? a) Clinical (biomedical) engineers.....................................................................( ) YES ( ) NO b) Respiratory therapists...................................................................................( ) YES ( ) NO c) Dietitians.......................................................................................................( ) YES ( ) NO d) Physical and/or occupational therapists........................................................( ) YES ( ) NO Critical-Care Medicine 14
  • 15. II. CRITICAL CARE UNIT DATA (FOR EACH UNIT) Duplicate this page as needed. Provide for each unit: Name, location, proximity to OR. The Critical Care Unit Data should be provided for each unit that is used in the anesthesiology critical care training program. It is not necessary to list or provide data for any of the other units in the hospital if they are not used for training as part of the critical care program. Name of Unit: Site # Physical Relationship to OR(s): Medical Director (if not the CCM program Director): Name: Primary Specialty Board Certification: Specialty: Date: Critical Care Certification: ( ) YES ( ) NO Date: Certifying Board: Name of Unit: Site # Physical Relationship to OR(s): Medical Director (if not the CCM program Director): Name: Primary Specialty Board Certification: Specialty: Date: Critical Care Certification: ( ) YES ( ) NO Date: Certifying Board: Name of Unit: Site # Physical Relationship to OR(s): Medical Director (if not the CCM program Director): Name: Primary Specialty Board Certification: Specialty: Date: Critical Care Certification: ( ) YES ( ) NO Date: Certifying Board: Critical-Care Medicine 15
  • 16. III. PATIENT POPULATION DATA All of the data on this page pertain to the critical care units: admissions, percent of admissions requiring interventions and percent of admissions to the various critical care units (as listed above) Reporting for one year period From: To: Admissions for Reporting Period: Average Daily Census: A. Indicate the percent of patients requiring the following: Percentages Mechanical ventilation Hemodialysis Pulmonary artery catheters B. Indicate the percent of admissions for: Percentages Burns Cardiac surgery Cardiology General medicine General surgery Neonatology Neurology or neurosurgery Obstetrics Pediatrics Pulmonary Transplant surgery Trauma Vascular surgery Other Critical-Care Medicine 16
  • 17. IV. EDUCATIONAL PROGRAM 1. Describe the selection process for Critical Care Fellows. 2. Provide a line drawing of the chain of administrative command for faculty positions and fellowship positions in the program. 3. Provide a detailed description of clinical experience (including rotations of the Critical Care Fellow). Include an explanation of how supervision occurs in each unit. 4. Describe the role of the Critical Care Fellow in teaching other fellows, respiratory therapists, dietitians, and physical and occupational therapists. 5. Describe the experience of the Critical Care Fellow in critical care unit administration and organization. 6. Describe the role of the Critical Care Fellow as a consultant to other specialties. 7. Provide a list of didactic exercises actually conducted during the past year. Didactic Exercises Date Title Instructor/Presenter Anesthesia Faculty Fellow Guest Lecturer Subspecialty Conferences Morbidity and Mortality Conferences Journal Club Research Seminars Critical-Care Medicine 17
  • 18. Designate which conferences are multidisciplinary and describe the role of the Critical Care Fellow in each category. 8. Indicate which of the following areas of study are included in the didactic or clinical curriculum. a) Respiratory Physiology, pathology, pathophysiology and therapy.................( ) YES ( ) NO b) Renal physiology, pathology, pathophysiology and therapy..........................( ) YES ( ) NO c) Central nervous system physiology, pathology, pathophysiology and therapy ......................................................................................................................( ) YES ( ) NO d) Metabolic and endocrine effects of critical illness..........................................( ) YES ( ) NO e) Infectious disease physiology, pathology, pathophysiology and therapy.......( ) YES ( ) NO f) Hematologic disorders secondary to critical illness.......................................( ) YES ( ) NO g) Gastrointestinal, genitourinary, and obstetrics-gynecologic acute disorders. ( ) YES ( ) NO h) Trauma, including burns................................................................................( ) YES ( ) NO i) Monitoring, bioengineering, biostatistics........................................................( ) YES ( ) NO j) Life-threatening pediatric conditions..............................................................( ) YES ( ) NO k) Administrative and management principles and techniques..........................( ) YES ( ) NO l) Transport of critically ill patients....................................................................( ) YES ( ) NO m) Pharmacokinetics and dynamics; drum metabolism and excretion in critical illness .....................................................................................................................( ) YES ( ) NO n) Ethical and legal aspects..............................................................................( ) YES ( ) NO 9. Does the Critical Care Fellow gain clinical experience in the following? a) Airway maintenance......................................................................................( ) YES ( ) NO b) Mechanical ventilation of the lungs...............................................................( ) YES ( ) NO c) Emergency and therapeutic treatment of pneumothorax requiring placement of chest tubes ......................................................................................................................( ) YES ( ) NO d) Emergency and therapeutic treatment requiring fiberoptic laryngotracheobronchoscopy ......................................................................................................................( ) YES ( ) NO e) Pulmonary function tests...............................................................................( ) YES ( ) NO f) Cardiopulmonary resuscitation......................................................................( ) YES ( ) NO g) Emergency and therapeutic placement of artificial transvenous cardiac pacemakers Critical-Care Medicine 18
  • 19. ......................................................................................................................( ) YES ( ) NO h) Monitoring central nervous system function and management of intracranial hypertension ......................................................................................................................( ) YES ( ) NO i) Recognition and treatment of hepatic and renal dysfunction.........................( ) YES ( ) NO j) Diagnosis and treatment of sepsis................................................................( ) YES ( ) NO k) Management of massive fluid and/or blood loss...........................................( ) YES ( ) NO l) Total parenteral nutrition...............................................................................( ) YES ( ) NO m) Bioengineering and monitoring......................................................................( ) YES ( ) NO n) Interpretation of laboratory results.................................................................( ) YES ( ) NO 10. Describe research opportunities for Critical Care Fellows. Include a list of research projects progress. (Please do not furnish copies of reprints) Critical-Care Medicine 19
  • 20. V. QUALITY ASSURANCE Describe the Quality Assurance program for critical care medicine during the past 12 months. Do Critical Care Fellows participate in quality assurance? Critical-Care Medicine 20

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