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RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY

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    RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY Document Transcript

    • RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5046 • www.acgme.org PROGRAM INFORMATION FORM (PIF) - CLINICAL NEUROPHYSIOLOGY FOR NEW APPLICATIONS ONLY GENERAL INSTRUCTIONS APPLICATION FOR A NEW PROGRAM: This form is for use by programs making initial application only. 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 NA 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. Number the pages sequentially in the upper right hand corner. Three copies should be mailed to the Committee. The Clinical Neurophysiology Program Director is personally responsible for the content of the completed form and the information will not be considered complete without the Program Director’s signature. All sections of the form applicable to the program must be completed in order to be accepted for review. 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. Many items require a composed response to a specific question. Please respond briefly and concisely. Please do not attach any unnecessary materials such as reprints, brochures, annual reports, schedules, minutes of meetings and conferences, etc. The Residency Review Committee considers only the information requested on the form. Any material not requested will be discarded. Do not submit any material larger than 8-1/2”X11”. 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: 312-755-5030). For word processing questions/problems, contact the ACGME Help Desk (Phone: 312-755-7464) For Web Accreditation Data System questions email WebADS@acgme.org. The form also includes requests for the following additional data, which should be attached as appendices at the end of the form. Appendices should be indexed and referenced as follows: Appendix A: Explanation, in the event the neurology department is not autonomous, or the institution does not hold JCAHO accreditation. Appendix B: Letters of agreement which have been prepared specifically for this review, from each of the institutions participating in the program. The letters should summarize the institution's participation in the program and be signed by the person responsible for the on-site direction of the program. Do not submit the full affiliation agreement. Appendix C: One-page curriculum vitae for program faculty. Please use the form provided. Appendix D1: List of lectures, conferences, courses in basic neuroscience. Appendix D2: Basic science curriculum. Appendix D3: List of clinical neurophysiology conferences at each institution. Appendix D4: List of clinical courses, conferences and/or lectures given in the subspecialties of neuromuscular diseases, autonomic disorders, sleep and vestibular disorders at each institution. Appendix E: List of other lectures. Appendix F: Written statement of supervisory lines of responsibility. Appendix G: List of neurophysiology meetings attended by clinical neurophysiology residents. residency-review-committee-for-neurology1406.doc i
    • Appendix H: List of resident research projects. Appendix I: List of resident publications. Appendix J: Written goals and objectives by rotation. REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the program information form is being completed for a currently accredited program this is not the correct form. Use the Continued Accreditation PIF in conjunction with the Web Accreditation Data System (Web ADS). Follow the provided instructions to create the correct PIF. Go to the Web Accreditation Data System (Web ADS) found on the ACGME home page (www.acgme.org), using your previously assigned username and password, update your program and resident data, retrieve Part 1 of the PIF under the Site Visit Information section, complete the shaded items (as appropriate), print all sections of Part 1 of the PIF and sign the form. If you find items displayed incorrectly change your data using ADS update sections; in some instances you may need to contact your DIO for the entry of updated information. Next proceed to the section under the RRC for Clinical Neurophysiology to retrieve Part 2 of the PIF for continued accreditation in either Word or WordPerfect. Complete Part 2 of the PIF using your preferred word processor (only after Part 1 has been completed). Combine Part 1 and Part 2, number the pages consecutively on the upper right corner, beginning with Part 1 Section 1 and complete the Table of Contents (found with the Part 2 instructions). Send one copy of the entire packet to the site visitor identified in your letter and hold three copies for the site visitor's arrival. residency-review-committee-for-neurology1406.doc ii
    • AREAS OF SPECIAL IMPORTANCE IN THE SURVEY OF CLINICAL NEUROPHYSIOLOGY PROGRAMS PERSONNEL A separate conference or meeting room is required for the various interviews that take place during the survey. In addition to the program director, it will be necessary for the site visitor to interview key members of the clinical neurophysiology faculty, and a member of the administration, in addition to personnel involved in support services. The resident interview is very important to a successful survey. The site visitor may wish to randomly select one or more clinical neurophysiology residents to be interviewed. The surveyor will also need to review any written agreements between the program and the clinical neurophysiology residents, the methodology of resident selection, and the teaching role of the staff involved in the program. FACILITIES The site visitor should have the opportunity to see inpatient and outpatient facilities, including support elements in electroencephalography, electromyography, polysomnography, and other areas of clinical neurophysiology including the evoked potential labs and the autonomic labs. Institutional and laboratory library facilities, including collections of clinical neurophysiology and neurologic textbooks and access to the National Library of Medicine (Pub Med) should also be available for inspection. DATA The role of the site visitor is that of fact gatherer. The site visitor will, therefore, need to confirm that complete statistical information is available, particularly with regard to the volume and variety of patient cases, and the procedures performed. Institutional (and resident) logs need to be available for this purpose. Copies of education committee minutes, resident evaluation forms, and other similar data required in the program essentials must also be available to the site visitor. CURRICULUM The site visitor will need to review the rotation schedule for clinical neurophysiology residents, the written goals and objectives of the program, the criteria used in assessing whether these goals and objectives are met, and the written lines of supervisory responsibility. The site visitor will need to review the role of clinical neurophysiology residents in the teaching of neurologic residents rotating on the respective clinical neurophysiology services including EEG, EMG, and polysomnography. The site visitor will need to review all aspects of the curriculum, with special attention to the resident’s experience in the three major neurophysiology subspecialties (i.e. EEG, EMG, and polysomnography), basic neuroscience lectures, and the treatment of patients, particularly those having seizures, neuromuscular disorders, and sleep dysfunction. OTHER The site visitor will need to gain information concerning the administrative support for the program and the type and extent of involvement in the program by clinical and academic affiliations. In this regard, the dean, and/or the hospital director, and/or the head of the faculty practice group should be available. ACCREDITATION PROCEDURE Residencies in clinical neurophysiology are evaluated by the Residency Review Committee for Neurology, composed of representatives of the American Academy of Neurology, the American Board of Psychiatry and Neurology and the Council on Medical Education of the American Medical Association, at one of the Committee’s two meetings during the year. The Committee has a cut-off date for preparation of its agenda ten weeks prior to its semi-annual meetings. There will be a delay of over six months following a survey if the surveyor report or the PIF are received after the cut-off date for the next meeting. The number of clinical neurophysiology residents appointed to the program must be commensurate with the educational resources available, and is subject to the approval of the RRC. Any increase or decrease in the resident complement (since the time of the last survey) must be carefully documented and justified. The Committee will consider the number of clinical neurophysiology residents with respect to all aspects of the program. Documentation must be provided to show that an residency-review-committee-for-neurology1406.doc iii
    • increased number of appointees has not diluted the educational experience available, or that a reduced number of appointees has not accentuated unduly the service aspects of the program and created an inadequate educational environment. The documentation should include all major clinical neurophysiology teaching rotations of the program, i.e., all aspects of electroencephalography, including video-EEG monitoring, electromyography, polysomnography, and other clinical neuro- physiologic techniques when applicable to the specific program. These may include evoked potential analysis, single-fiber EMG, autonomic nervous system testing, botulinum toxin therapies, tremor analysis, intraoperative monitoring, central EMG, and magnetoencephalography. In addition reference must be made to the specific seizure and/or neuromuscular outpatient, and inpatient adult clinical neurophysiology experiences; child clinical neurophysiology experiences, primarily EEG and EMG; and any other pertinent rotations. residency-review-committee-for-neurology1406.doc iv
    • GLOSSARY OF TERMS A. Terms used in Program Requirements (PR) Desirable: “Desirable” or “highly desirable” are phrases used for aspects of a training program which are not absolutely essential but are considered to be very significant. Essential: Equates with indispensable and definitely identifies an absolute requirement. Must: Indicates that something is required and connotes an absolute requirement. Should: Is used for those dimensions of a training program which are so important that their absence must be justified. If the program has an alternative way to accomplish the intent of the requirement, this should be fully described. A program is at risk if it is not in compliance with a “should”. Substantial Compliance: The determination of substantial compliance results from a judgment based on all available information as to the degree that the entity being evaluated meets accreditation standards. Suggested: A term, along with its companion “strongly suggested,” used to indicate that something is distinctly urged rather than required. An institution or a program will not be cited for failing to do something that is suggested or strongly suggested. B. Terms used in the Program Information Forms (PIF) Elective: Indicates a rotation/experience that may be chosen at the resident’s discretion in consultation with the faculty. Required: Designates those experiences required by the program of all residents although they may choose which month or year they are to be taken. C. Other terms used in Graduate Medical Education (GME) Applicant: Persons invited to come for an interview for a GME program. Categorical Position (see also “Graduate Year 1" and “Preliminary Positions”): Positions for residents who begin and remain in a given program or specialty until completion of the year(s) required for admission to specialty board examination. Consortium: Two or more organizations or institutions that have come together to pursue common objectives (e.g. GME). A consortium may serve as a “sponsoring institution” for GME programs if it is formally established as an ongoing institutional entity with a documented commitment to GME. Designated Institutional Official (DIO): The person in a sponsoring institution of GME who assumes the authority and responsibility for the GME programs and oversees the implementation of the Institutional Requirements. The DIO is responsible for completing the Annual Update for the Web Accreditation Data System and seeing that all sponsored programs complete their updates on schedule. Fellow: A term used by some sponsoring institutions and in some specialties to designate participants in subspecialty GME programs. Such physicians may also be termed "resident" as well. Other uses of the term "fellow" require modifiers for precision and clarity, e.g. "research fellow." Institution: An organization having the primary purpose of providing educational and/or health care services (e.g. a university, a medical school, a hospital, a school of public health, a health department, a public health agency, an organized health care delivery system, a medical examiner’s office, a consortium, an educational foundation). Major Participating Institution: An institution to which residents rotate for a required experience and/or those that require explicit approval by the appropriate RRC prior to utilization. Major participating institutions are listed as part of an accredited program in the Graduate Medical Education Directory. Other Participating Institution: An institution that provides specific learning experiences within a multi-institutional program of GME. Subsections of institutions, such as department, clinic, or unit of a hospital do not qualify as participating institutions. Sponsoring Institution: The institution that assumes the ultimate responsibility for a program of GME. residency-review-committee-for-neurology1406.doc v
    • Institutional Review: The process undertaken by the ACGME to judge whether a sponsoring institution offering GME programs is in substantial compliance with the Institutional Requirements. Institution Type: (these designations do not apply to all specialties) Integrated Institution: One that must formally acknowledge the authority of the core Program Director over the educational program in that hospital, including the appointments of all faculty and all residents. Integrated institutions should be in close geographic proximity to the parent institution to allow all residents to attend joint conferences. If an institution is not in geographic proximity and joint conferences cannot be held, an equivalent educational program in the integrated institution must be fully established and documented. Affiliated Institution: One that is related to the core program for the purpose of providing limited rotations that com- clement the experience available in the parent institution. Assignments at affiliated institutions must be made for educational purposes and not to fulfill service needs. Intern: Historically, “intern” was used to designate individuals in the first year of GME; less commonly it designates individuals in the first year of any residency program. Since 1975, the Graduate Medical Education Directory and the ACGME have not used the term, instead referring to individuals in their first year of GME as residents. Internal Review: The formal process undertaken by a sponsoring institution of its individual ACGME accredited programs in conformity with Section I.B.3.c of the Institutional Requirements to evaluate the sponsored programs. International Medical Graduate (IMG): A graduate from a medical school outside the United States and Canada (and not accredited by the Liaison Committee on Medical Education (LCME)). IMGs may be citizens of the United States who chose to be educated elsewhere or non-citizens who were admitted to the United States by US Immigration authorities. All IMGs should undertake residency training in the United States before they can obtain a license to practice medicine in the United States even if they were fully trained, licensed, and practicing in another country. Medical School Affiliation: Institutions that sponsor an accredited program may have a formal relationship with a medical school. Indicate that a medical school affiliation exists for an institution (or program) if the institution (or program) is an important part of the teaching program for the medical school. Do not include only brief, occasional, and/or unique rotations of students or residents. Months of Rotation: Refers to the total number of months a typical resident spends at an institution. If the total number of months that each resident spends at a location is different for different residents, use the average (a decimal number may be reported). Ownership Type of Institution: Refers to the governance, control, or type of ownership of the institution. Program: The unit of specialty education, comprising a series of graduated learning experiences in GME, designed to conform to the program requirements of a particular specialty. Preliminary Positions (see also “Graduate Year 1"): Positions for residents who are obtaining training required to enter another program or specialty. Some residents in preliminary positions may move into permanent positions in the second year. Preliminary positions are usually 1 year in length and usually offered for Graduate Year 1. Internal medicine, surgery, and transitional year programs commonly offer preliminary positions. Preliminary Designated Positions: Residents matched by/for other specialties. The resident is designated as having a permanent position after completing the preliminary year(s). Specialties that do not designate preliminary positions will use this option to indicate preliminary positions. Preliminary Non-Designated: Residents accepted into the program for 1 or 2 years of training; these residents do not have designated permanent positions in the current program or another program at time of acceptance. Primary Teaching Hospital: If the sponsoring institution is a hospital, it is by definition the principal or primary teaching hospital for the residency program. If the sponsoring institution is a medical school, university, or consortium of hospitals, the hospital that is used most heavily in the residency program is the principal teaching hospital. Program Director: The official responsible for maintaining the quality of a GME program so that it meets ACGME accreditation standards. Other duties of the Program Director preparing a written statement outlining the program’s educational goals; providing an accurate statistical and narrative description of the program as requested by the Residency Review Committee (RRC); and providing for the selection, supervision, and evaluation of residents for appointment to and completion of the program. Program Merge/Split/Absorption: In a merger, two programs combine to create one new program; the new program becomes the accredited unit and accreditation is voluntarily withdrawn from both former programs. In a split, one program residency-review-committee-for-neurology1406.doc vi
    • divides into two separate programs and each program receives accreditation. In absorption, one program takes over the other program; the absorbed program is granted voluntary withdrawal status, while the other program remains accredited. Program Letters of Agreement: The sponsoring institution must ensure that for each accredited program appropriate letters of agreement exist between the sponsoring institution and the participating institutions used by a program that provides specific learning experiences. Program Year (see also “Graduate Year”): Refers to the current year of training within a specific program; this may or may not correspond to the graduate year. For example, a resident in pediatric cardiology could be in the first program year of the pediatric cardiology program but in his/her fourth graduate year of GME (including 3 prior years of pediatrics). The Web Accreditation Data System tracks residents according to his/her current year in the program, regardless of prior training. Resident: A physician at any level of GME in a program accredited by the ACGME. Participants in accredited subspecialty programs are included. Other uses of the term “resident” require modifiers. Scholarly Activity: Educational experiences that include active participation of the teaching staff in clinical discussions, rounds, and conferences in a manner that promotes a spirit of inquiry and scholarship; active participation in journal clubs, research conferences, regional or national professional and scientific societies, particularly through presentations at the organizations’ meetings and publications in their journals; participation in research, particularly in projects that are funded following peer review and/or result in publications or presentations at regional and national scientific meetings; offering of guidance and technical support (e.g., research design, statistical analysis) for residents involved in research; and provision of support for resident participation as appropriate in scholarly activities. May be defined in more detail in specific Program Requirements. Sponsoring Institution (See also “Institution”): The institution that assumes the ultimate responsibility for a program of GME. Teaching Staff: Any individual who has received a formal assignment to teach resident physicians. In some institutions appointment to the medical staff of the hospital constitutes appointment to the teaching staff. residency-review-committee-for-neurology1406.doc vii
    • RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5046 • www.acgme.org PROGRAM INFORMATION FORM (PIF) - CLINICAL NEUROPHYSIOLOGY TABLE OF CONTENTS When you have the completed forms, number each page sequentially in the upper right hand corner. Start on Part 1, Section 1 of the PIF. Report this pagination in the Table of Contents and submit this cover page with the completed PIF. 1Part 1 Section Page(s) General Program Information 1 Accreditation Information 1.A Program Director Information 1.B Participating Institutions 2 Resident 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.G Part 2 Section Page(s) Background 4 Previous Citations Or Concerns (If Applicable) 4.A Changes (If Applicable) 4.B Participating Institutions 5 JCAHO 5.A Participating Institution Program Coordinators 5.B Personnel 6 Clinical Neurophysiology Program Director (PR III.A.) 6.A Program Teaching Staff- Clinical Neurophysiology (PR III.B.) 6.B Other Neurology Staff (P4.III.B.2-6) 6.C Other Non-Neurology Clinical Faculty (PR III.B.3-6.) 6.D Residents 7 Clinical Neurophysiology Residents 7.A Other Clinical Neurophysiology Trainees 7.B Other Residents In Training 7.C Clinical And Educational Facilities And Resources 8 Facilities 8.A Library Facilities (PR IV.C.) 8.B Supporting Facilities 8.C Educational Program 9 Curriculum (PR V.A.) 9.A Seminars And Conferences (PR V.G.2.) 9.B Clinical And Basic Science 9.C Clinical Teaching – Outpatient 9.D residency-review-committee-for-neurology1406.doc
    • Part 2 Section Page(s) Clinical Neurophysiology EEG/EMG/Sleep Outpatient Diagnostic Categories 9.E Outpatient Specialty Clinics 9.F Educational Program 9.G Educational Policies 9.H Research And Scholarly Activity (PR IV.C.10.) 10 Resident Meeting Attendance 10.A Resident Research Projects 10.B Resident Publications 10.C Evaluation 11 Resident Evaluation 11.A Resident Feedback And Records 11.B Impaired Residents 11.C Resident Stress 11.D Moonlighting Policies 11.E Outpatient Specialty Clinics 11.F Final Evaluation 11.G Faculty Evaluation 11.H Director’s Comments On Plans For Program Development 12 Appendix A: Explanation, in the event the neurology department is not autonomous, or the institution does not hold JCAHO accreditation. Appendix B: Letters of agreement which have been prepared specifically for this review, from each of the institutions participating in the program. The letters should summarize the institution's participation in the program and be signed by the person responsible for the on-site direction of the program. Do not submit the full affiliation agreement. Appendix C: One-page curriculum vitae for program faculty. Please use the form provided. Appendix D1: List of lectures, conferences, courses in basic neuroscience. Appendix D2: Basic science curriculum. Appendix D3: List of clinical neurophysiology conferences at each institution. Appendix D4: List of clinical courses, conferences and/or lectures given in the subspecialties of neuromuscular diseases, autonomic disorders, sleep and vestibular disorders at each institution. Appendix E: List of other lectures. Appendix F: Written statement of supervisory lines of responsibility. Appendix G: List of neurophysiology meetings attended by clinical neurophysiology residents. Appendix H: List of resident research projects. Appendix I: List of resident publications. Appendix J: Written goals and objectives by rotation. residency-review-committee-for-neurology1406.doc
    • RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5046 • www.acgme.org PROGRAM INFORMATION FORM (PIF) - CLINICAL NEUROPHYSIOLOGY- (Part 1) FOR NEW APPLICATIONS ONLY SECTION 1. GENERAL PROGRAM INFORMATION A. Accreditation Information Date: Title of Program: 10 Digit ACGME Program ID# (for accredited programs): B. Program Director Information Name: Title: Address: City, State, Zip code: Telephone: FAX: Email: Date First Appointed: Principal Activity Devoted to Resident Education: Term of PD Appointment: 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 ( ) NO Number of hours per week Director Spends in: Clinical Supervision: Administration: Research: Didactics/Teaching: Is Program Director also Department Chair? ( ) YES ( ) NO If No, Chair Name: The signatures of the director of the program, the chief of the department 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 Chief/Department Chair if different from Program Director (and date): Signature of Designated Institutional Official (DIO) (and date): residency-review-committee-for-neurology1406.doc
    • SECTION 2. PARTICIPATING INSTITUTIONS 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: Does SPONSOR have an affiliation with a medical school (could be the sponsoring institution)? ( ) YES ( ) NO If yes, name the medical school below and have an affiliation agreement that describes the effect of these arrangements on this 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 Residents Rotation (in months) Year 1: CEO/Director/President’s Name: JCAHO Approved? ( ) YES ( ) NO ( ) NA Type 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: AFFILIATED ( ) 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 Residents Rotation (in months) Year 1: CEO/Director/President’s Name: JCAHO Approved? ( ) YES ( ) NO ( ) NA Type 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: AFFILIATED ( ) residency-review-committee-for-neurology1406.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 Residents Rotation (in months) Year 1: CEO/Director/President’s Name: JCAHO Approved? ( ) YES ( ) NO ( ) NA Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School) Ownership Type: (e.g., State, Corporation, Church) Brief Educational Rationale: PARTICIPATING INSTITUTION (Institution #4) Select one (if applicable) Name: INTEGRATED ( ) Address: AFFILIATED ( ) 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 4 & 1: Miles: Minutes: Type of Rotation Elective ( ) Required ( ) Both ( ) (select one) Length of Residents Rotation (in months) Year 1: CEO/Director/President’s Name: JCAHO Approved? ( ) YES ( ) NO ( ) NA Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School) Ownership Type: (e.g., State, Corporation, Church) Brief Educational Rationale: PARTICIPATING INSTITUTION (Institution #5) Select one (if applicable) Name: INTEGRATED ( ) Address: AFFILIATED ( ) 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 5 & 1: Miles: Minutes: Type of Rotation Elective ( ) Required ( ) Both ( ) (select one) Length of Residents Rotation (in months) Year 1: CEO/Director/President’s Name: JCAHO Approved? ( ) YES ( ) NO ( ) NA Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School) Ownership Type: (e.g., State, Corporation, Church) Brief Educational Rationale: residency-review-committee-for-neurology1406.doc
    • SECTION 3. RESIDENTS A. Number of Positions (For the current academic year). Positions Year 1 Total Number of Requested Positions Number of Filled Positions* Date Last Resident Completed this Program (if total filled positions = 0)*: * 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 should be available for review by the site visitor. Expected Program Year in Years of Specialty of Most Recent Year of Med School Name Completion Medical School Start Date Program Prior GME Prior GME Graduation Date residency-review-committee-for-neurology1406.doc
    • C. 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 Program 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) E. Withdrawn / Dismissed 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 Dismissed residency-review-committee-for-neurology1406.doc
    • F. 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 (if applicable) For the previous four week period: Yr 1 Yr 2 Yr 3 Yr 4 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.) residency-review-committee-for-neurology1406.doc
    • RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5046 • www.acgme.org PROGRAM INFORMATION FORM (PIF) - CLINICAL NEUROPHYSIOLOGY- (Part 2) FOR NEW APPLICATIONS ONLY SECTION 4. BACKGROUND A. Previous Citations or Concerns (if applicable) List each of the citations and/or concerns, if any, from the notification letter that was sent following the last survey and review of the program. Briefly and concisely describe the steps that have been taken to correct the problem. If such correction is documented in the program information form you prepare for this review, provide page references. 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, faculty or facilities. residency-review-committee-for-neurology1406.doc
    • SECTION 5. PARTICIPATING INSTITUTIONS A. JCAHO If any of the participating institutions listed in Part 1, Section 2 are not accredited by the Joint Commission on Accreditation of Healthcare Organizations, attach an explanation as Appendix A and label appropriately. B. Letters of Agreement Attach as Appendix B letters of agreement which have been prepared specifically for this review, from each of the institutions participating in the program. The letters should summarize the institution's participation in the program and be signed by the person responsible for the on-site direction of the program. Do not submit the full affiliation agreement. C. Participating Institution Program Coordinators List the person responsible for supervising the resident education activities of your program at each institution. The institution numbers are listed in Section 1, Part 2. Add more lines as needed. Institution # and Name Program Coordinator 1. 2. 3. 4. residency-review-committee-for-neurology1406.doc
    • SECTION 6. PERSONNEL A. Clinical Neurophysiology Program Director (PR III.A.) 1. Is the Program Director ABPN certified with special qualifications in Clinical Neurophysiology? ( ) YES ( ) NO If no, explain. 2. Is the Program Director full-time? ( ) YES ( ) NO 3. What percentage of time does the Program Director give to the leadership, direction and monitoring of the program? % hours per week 4. Give a brief description of the clinical neurophysiology program director’s responsibilities and activities. Attach a one page (Appendix C) curriculum vitae for the program director (use the form in Appendix C). 5. Please attach as Appendix C a one page curriculum vitae (using copies of Appendix C) for: a. the head of neurology, if different from the clinical neurophysiology program director, b. the head of child neurology, c. the head of each specialty component that participates in the program, and (PR II.B.6) d. the head of the clinical neurophysiology teaching program at each participating institution. B. Program Teaching Staff- Clinical Neurophysiology (PR III.B.) List all members of the neurology department responsible for clinical training on the clinical neurophysiology services. For those with dual appointments, identify primary appointment (Neurology or other department) in parentheses. Attach a one- page curriculum vitae (Appendix C) for each of the faculty listed above. Please use the form provided (as Appendix C). If additional rows are needed to list more than 10 faculty, insert additional rows in the table. See Part 1, Section 2 for institution numbers. If part-time state Certification* (by Location by ABPN-Clinical neuro., Name, Degree, Title and Position Full-Time Institution # Mos/yr Hrs/wk and/or ABPN-Neuro, a/o AB Peds) *If not certified in Clinical Neurophysiology, note other certification or give statement of education. Attach a one page curriculum vitae (Appendix Item C) for each of the faculty listed above. Please use the form provided (make copies of page CV). If additional rows are needed to list more than 10 faculty insert additional rows in the table. residency-review-committee-for-neurology1406.doc
    • C. Other Neurology Staff (PR III.B.2-6) List all other neurology faculty involved in teaching the resident(s), including consultants and basic science teachers. Identify those actually responsible for clinical training with an asterisk. See Part 1, Section 2 for institution numbers. If part-time state Certification* (by Name, Degree, Title and Position or Role in Location by Full-time ABPN, a/o AB Curriculum Institution # Mos/Yr Hrs/wk Peds) *If not certified in Clinical Neurophysiology, note other certification or give statement of education. D. Other Non-Neurology Clinical Faculty (PR III.B.3-6.) List non-neurology staff members regularly involved in teaching clinical neurophysiology residents, including consultants and basic science faculty. Note their department, title and certifying credentials, and supervisory responsibilities to the program. See Part 1, Section 2 for institution numbers. Number who interact Name of primary person who Name and with clinical interacts with clinical year of Institution Discipline/service neurophysiology neurophysiology residents or board # patients division chief or chairman certification Medicine Critical care medicine Pulmonary Neuropathology Neuroradiology Neurorehabilitation Physical medicine and rehabilitation residency-review-committee-for-neurology1406.doc
    • SECTION 7. RESIDENTS (PR I) A. Clinical Neurophysiology residents 1. What mechanism is there to ensure that the Program Requirement I.B.1 concerning prerequisite training is met? 2. Describe procedures for evaluation and selection of applicants to the program: residency-review-committee-for-neurology1406.doc
    • B. Other Clinical Neurophysiology Trainees 1. List those clinical neurophysiology trainees who do not meet the ABPN’s preliminary training requirements before beginning the program. Type of Years of Year of medical Expected Year in Specialty of Program Status in Name positio prior Medical school school completion program prior training start date program n GME graduation date residency-review-committee-for-neurology1406.doc
    • C. Other Residents in training 1. List the graduate medical education (GME) residents (fellows) from other specialties who rotated through clinical neurophysiology during the last academic year. Clinical Months each resident Specialty & years of GME Number of these residents neurophysiology spent in clinical (e.g. PGY-2 child) in the last year assignment (EEG, neurophysiology EMG, sleep, other) Adult neurology PGY- Child neurology PGY- Neurosurgery PGY- Physical medicine & rehabilitation PGY- Psychiatry PGY- Other PGY- residency-review-committee-for-neurology1406.doc
    • SECTION 8. CLINICAL AND EDUCATIONAL FACILITIES AND RESOURCES (PR III) A. Facilities 1. Describe the physical facilities at each institution for the clinical neurophysiology outpatient and inpatient evaluation and care of patients with seizure, neuromuscular, and sleep disorders. 2. Describe the availability of the office space at each institution for faculty, clinical neurophysiology residents, and sup- port staff. 3. Indicate if the following office spaces and resources available. See Part 1, Section 2 for institution numbers. Duplicate this section if more than 4 institutions are used. Institution 1 2 3 4 a. Faculty office and facilities Are there offices for clinical ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO neurophysiology faculty? Is there secretarial office space for ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO clinical neurophysiology? Is there a departmental library? ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO b. Clinical neurophysiology resident offices and resources Does each clinical neurophysiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO resident have his/her own office? Are there offices for groups of ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO clinical neurophysiology residents? Do the offices have computers and computer internet search ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO capabilities? Do the clinical neurophysiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO residents have secretarial support? Do the clinical neurophysiology residents have access to other office equipment such as copiers, ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO slide projectors, equipment or services to make slides, illustrations services? Do the clinical neurophysiology residents have access to major ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO texts in the office? 3. Describe the clinical neurophysiology laboratory facilities at each institution, including mechanisms for reporting of test results. 4. Describe clinical neurophysiology conference facilities at each institution. 5. Describe the space provided for clinical neurophysiology faculty and clinical neurophysiology resident research at each institution. residency-review-committee-for-neurology1406.doc
    • 6. Describe for each institution how the charts or medical records are made available for inpatients, outpatients, and consultation use. B. Library Facilities (PR IV.C.) Use the table below to describe the institutional and departmental library holdings and other reference resources at each institution. See Part 1, Section 2 for institution numbers. Duplicate the section as needed. Institution 1 2 3 4 1. Journals Number of Journals Number of clinical neurophysiology journals Reference databases ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO 2. Computer databases available Access in hospital ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Access in library ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO 24 hour access ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Computer internet search capabilities ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO 3. Library on site Library with major texts in all areas of ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO medicine on site or near by Number of reference books ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO 4. Textbook Major clinical neurophysiology, adult neurology and child neurology texts ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO in the clinical neurophysiology laboratories C. Supporting Facilities Indicate whether the facilities and resources listed below are AVAILABLE for all participating institutions listed in Part I on the web at ACGME.ORG. If more than four institutions participate, duplicate the section and include after this page. See Part 1, Section 2 for institution numbers. Institution 1 2 3 4 Diagnostic Resources 1. Electroencephalography EEG ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Ambulatory EEGs ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Video-EEG monitoring ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Intraoperative monitoring ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO 2. Electromyography: EMG/NCV ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Neuromuscular transmission testing ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO including single fiber studies Cranial nerve testing including blink ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO reflexes and facial nerve evaluation 3. Sleep Lab: Polysomnography ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Multiple sleep latency ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO 4. Other clinical neurophysiology modalities: residency-review-committee-for-neurology1406.doc
    • Institution 1 2 3 4 Evoked potentials ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Visual ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Auditory ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Somatosensory ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Autonomic testing ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Movement disorder assessment with ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO botulinum toxin therapy Central EMG ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Magnetoencephalography ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Electroretinograms (ERGs) ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO 5. Diagnostic neuroimaging services ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO MRI and MRA ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO CT ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO SPECT ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO PET ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO 6. Related diagnostic and therapeutic services: a. Cytogenetics and genetic testing ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO b. Genetic counseling service ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO c. Occupational therapy ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO d. Pain management ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO e. Adult rehabilitation medicine ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO f. Pediatric rehabilitation medicine ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO g. Physical therapy ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO residency-review-committee-for-neurology1406.doc
    • SECTION 9. EDUCATIONAL PROGRAM A. Curriculum (PR V.A.) Describe in block and longitudinal templates the typical curriculum for clinical neurophysiology residents. Curricular components may be offered in blocks or longitudinally. Those components offered in block assignments during this subspecialty year should be recorded in the block template by months, not weeks, including the institution (#1,2,3,4) and the experience on each rotation. Clearly identify elective time. Exclude mention of vacation time. Obvious examples include EEG, EMG, Sleep, Seizure clinic, Neuromuscular clinic, etc. An example of longitudinal curriculum is a regularly scheduled clinical neurophysiology activity or clinic attended over a period of time while assigned to other rotations. Both longitudinal and block components can be applied toward FTE minimums described in the program requirements. For example, one half-day per week for ten months of a longitudinal clinic would count for one month FTE. SAMPLE BLOCK ROTATIONS - PG-2 July August September October November December January February March April May June Intro to Intro to EEG Inst 1 EEG Inst 1 EEG Inst 1 EEG Inst 3 Sleep Inst 2 Sleep Inst 2 EMG Inst 1 EMG Inst 1 EMG Inst 1 EMG Inst 1 CNP Inst 1 CNP Inst 1 SAMPLE LONGITUDINAL EXPERIENCES - PG-2 Type Of Experience* Weekly Structured Amount Of Time (FTE) EEG including adult and child 1/2 day each week 52 weeks EMG including adult and child 1/2 day each week 52 weeks Other Clinical neurophysiology One half day per week for……… 2 months Sleep One half day per week for……. 6 months Evoked Potentials One half day per week for….. 12 months Seizure Clinics BLOCK ROTATIONS – PG-1 YEAR IF THE PROGRAM IS A 4-YEAR PROGRAM July August September October November December January February March April May June LONGITUDINAL EXPERIENCES - PG-1 Type Of Experience* Weekly Structured Number Of Weeks Amount Of Time (FTE) residency-review-committee-for-neurology1406.doc
    • B. Seminars And Conferences (PR V.G.2.) 1. Attach as Appendix D1 the clinical neurophysiology lecture schedule. Name the faculty member assigned to the conference. 2. Attach as Appendix D2 the lecture schedule for the basic sciences underlying clinical neurophysiology. C. Clinical and Basic Science 1. See Part 1, Section 2 for institution numbers. Institution 1 2 3 4 1. EEG Name of director(s) Number of studies per year EEG: adult/child Other Months residents assigned Residents’ responsibilities 2. EMG Name of director(s) Number of studies per year EMG: adult/child Other Months residents assigned Residents’ responsibilities 3. Sleep Name of director(s) Number of studies per year EMG: adult/child Other Months residents assigned Residents’ responsibilities 4. Neuropathology Name of director(s) CNS surgical specimens per year Muscle biopsies Nerve biopsies Months residents assigned Residents’ responsibilities 5. Autonomic Name of director(s) Number of studies per year EMG: adult/child Other Months residents assigned Residents’ responsibilities residency-review-committee-for-neurology1406.doc
    • D. Clinical Teaching – Outpatient 1. Clinical neurophysiology resident outpatient experience can include block time and longitudinal time in the outpatient clinics described under curriculum (V.A. above). For non-continuity and clinical neurophysiology related clinics, list the following as averages per resident per clinic half-day: # New patients seen # Follow-up patients seen Staff/ resident ratio 2. For the continuity seizure and/or neuromuscular longitudinal clinics, list the following as averages per resident per clinic half-day. # New patients seen # Follow-up patients seen Staff/ resident ratio 3. What is the role of the clinical neurophysiology resident in the performance of and interpretation of clinical neurophysiology studies of adult patients? E. Clinical Neurophysiology EEG/EMG/SLEEP Diagnostic Categories Provide the number of patients in each of the following diagnostic categories that were available in the program for the past year. Each patient should be listed only once in the most appropriate category. Use institution numbers in Part 1, Section 2. Institution #1 #2 #3 #4 Epilepsy (adult/child) Generalized Tonic-clonic Absence Myoclonic Localization-related Simple partial Complex partial Secondarily generalized Syncope Vasovagal Indeterminate spells Other alterations of consciousness Coma Motor unit disorders (adult/child) Motor neuron disorders Nerve root disorders Plexopathies Polyneuropathies Mononeuropathies residency-review-committee-for-neurology1406.doc
    • Institution #1 #2 #3 #4 Cranial nerve disorder Neuromuscular junction disorder Muscle disorder Dystrophies Congenital myopathies Channelopathies Inflammatory Sleep Disorders Dysomnias Obstructive sleep apnea Central sleep apnea Narcolepsy Periodic limb movements Parasomnias Autonomic Disorders (adult/child) Stroke related disorders Neoplastic disease Movement disorder Cognitive disorder Multiple Sclerosis Metabolic disorder Trauma Drugs and other toxic disorders Psychiatric disorders TOTAL residency-review-committee-for-neurology1406.doc
    • F. Outpatient Specialty Clinics Institution #1 #2 #3 #4 Specialty Clinics Clinic Name: Seizure Number of clinics per month Average number of visits per clinic Percent visits seen by clinical neurophysiology residents Clinic Name: Neuromuscular Number of clinics per month Average number of visits per clinic Percent visits seen by clinical neurophysiology residents Clinic Name: Sleep Number of clinics per month Average number of visits per clinic Percent visits seen by clinical neurophysiology residents * If more specialty clinics need to be listed, attach as supplemental pages. G. Educational Program Educational Program 1. What teaching responsibilities do clinical neurophysiology residents have? (PR IV.C.II) 2. Outline resident responsibility and frequency on night call at each institution. 3. What provision is there to assure increasing patient responsibility and professional maturation of clinical neurophysiology residents? (PR IV.) 4. Additional Curricular Areas (PR IV.) Medical Ethics Quality Assurance Health Care Organization, Practice Management residency-review-committee-for-neurology1406.doc
    • Financing of Health Care Management Information Systems H. Educational Policies 1. Clinical neurophysiology residents’ time off Describe provisions for clinical neurophysiology residents to spend 1 day out of 7 away from the hospital and for the clinical neurophysiology residents to be on call no more than every 3rd night. (PR IV.C12) 2. How does the program ensure compliance with the ACGME duty hour guidelines? 3. Supervisory lines of resident responsibility Attach as an Appendix (Appendix F) the written statement of the supervisory lines of responsibility for clinical neurophysiology residents involved in patient care. residency-review-committee-for-neurology1406.doc
    • SECTION 10. RESEARCH AND SCHOLARLY ACTIVITY (PR IV.C.10.) A. Resident meeting attendance Provide a list of local, regional, and national neurological meetings that clinical neurophysiology residents have attended over the past three years, showing the clinical neurophysiology residents by name, as Appendix G. B. Resident research projects Describe the research projects, supervisors and their specialties, and the nature of the clinical neurophysiology residents’ involvement in clinical neurophysiology research during the past five years. List by name those clinical neurophysiology residents who participated in such research, the duration of their assignment, and whether full-time or part-time as Appendix H. C. Resident publications List the publications of clinical neurophysiology residents from the clinical neurophysiology section/division during the past 36 months as Appendix I. (Do not include manuscripts submitted or in preparation) residency-review-committee-for-neurology1406.doc
    • SECTION 11. EVALUATION A. Resident Evaluation (PR III.A.2.g) 1. Describe the system of formative evaluation of clinical neurophysiology residents. How often does it occur? 2. Does the faculty review a representative sample of the clinical neurophysiology resident’s written patient records and reports? ( ) YES ( ) NO 3. Does the program provide feedback to clinical neurophysiology residents on audits of their written patient records? ( ) YES ( ) NO 4. Does the program perform a formal, observed clinical evaluation exercise (CEX) on clinical neurophysiology residents at least once? ( ) YES ( ) NO 5. Describe the standardized methods for resident evaluation used in the program (e.g., an in-service training exam). 6. Over the past 5 years what proportion of clinical neurophysiology residents has taken these examinations? B. Resident feedback and records Describe how and by whom feedback to clinical neurophysiology residents is provided and what remedial actions are taken in cases of deficiency. What kind of records of resident evaluations does the program maintain? C. Impaired residents How does the program deal with impaired clinical neurophysiology residents? D. Resident stress How does the does the program monitor clinical neurophysiology resident stress, provide counseling and support services? E. Moonlighting policies Describe the policies on clinical neurophysiology resident moonlighting; explain whether the policies are written and distributed to all residents; and describe how the program director monitors the effects of outside activities, including moonlighting, on the training program. Be prepared to provide documentation to the site visitor. F. Final evaluation Does the program have a final evaluation of the clinical neurophysiology residents? ( ) YES ( ) NO If so, please describe how this evaluation is done and what the evaluation covers. G. Faculty evaluation residency-review-committee-for-neurology1406.doc
    • 1. Describe the system by which the faculty is evaluated. 2. Are written evaluations by clinical neurophysiology residents used in this process? ( ) YES ( ) NO If not, please explain. residency-review-committee-for-neurology1406.doc
    • SECTION 12. DIRECTOR’S COMMENTS ON PLANS FOR PROGRAM DEVELOPMENT Information Furnished By: Name: Position: Date: If information is furnished by someone other than the Program Director, the latter must verify the accuracy of the above statements by signature: Verified By: Clinical Neurophysiology Program Director (Signature) (Date) Neurology Program Director (Signature) (Date) residency-review-committee-for-neurology1406.doc
    • APPENDIX A: EXPLANATION OF NON-ACCREDITATION BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS. residency-review-committee-for-neurology1406.doc
    • APPENDIX B : LETTERS OF AGREEMENT Letters of agreement which have been prepared specifically for this review, from each of the institutions participating in the program. The letters should summarize the institution's participation in the program and be signed by the person responsible for the on-site direction of the program. Do not submit the full affiliation agreement. residency-review-committee-for-neurology1406.doc
    • APPENDIX C: CURRICULUM VITAE (CV) Use the CV template that follows for all of the major program faculty. This must include the program director, all of the clinical neurophysiology faculty, the child neurology faculty and any other faculty members who have major teaching responsibilities in the clinical neurophysiology training program or who serve as division or departmental heads. Curriculum Vitae Name Degree(s) Year of Birth Medical School Date of Graduation Certification(s) ABPN-Clinical Neurophysiology ( ) YES ( ) NO Date AB Peds ( ) YES ( ) NO Date ABPN Neuro ( ) YES ( ) NO Date ABPN-Other (specify) ( ) YES ( ) NO Date Other (name below) ( ) YES ( ) NO Date List any equivalent training here: Date Active State Licensure(s): Date(s) Current Academic Positions: Date Assumed this Position Current Hospital Appointments: Date of Appointments Fellowship/post-graduate training (type & location): Date of Completion In the space below list the most recent publications in refereed journals (maximum 10 articles). Do not include presentations, abstracts, and those ‘in preparation’ or ‘submitted.’ (PR III.B1.) residency-review-committee-for-neurology1406.doc
    • APPENDIX D: BASIC AND CLINICAL NEUROPHYSIOLOGY SCIENCES INSTRUCTION AND LECTURES 1. Basic science clinical neurophysiology curriculum 2. List of lectures, conferences, courses in applied clinical neurophysiology 3. List of neurology clinical conferences which the clinical neurophysiology resident is expected to attend or participate in. 4. List of clinical courses, conferences and/or lectures given in the subspecialties of epilepsy, neuromuscular diseases, autonomic disorders, sleep, and vestibular disorders at each institution. residency-review-committee-for-neurology1406.doc
    • APPENDIX F: SUPERVISORY LINES OF RESPONSIBILITY FOR CLINICAL NEUROPHYSIOLOGY RESIDENTS (PR II.F.) residency-review-committee-for-neurology1406.doc
    • APPENDIX G: LIST OF NEUROLOGICAL MEETINGS ATTENDED BY CLINICAL NEUROPHYSIOLOGY RESIDENTS residency-review-committee-for-neurology1406.doc
    • APPENDIX E: LIST OF OTHER LECTURES residency-review-committee-for-neurology1406.doc
    • APPENDIX H: LIST OF CLINICAL NEUROPHYSIOLOGY RESIDENT RESEARCH PROJECTS residency-review-committee-for-neurology1406.doc
    • APPENDIX I: LIST OF CLINICAL NEUROPHYSIOLOGY RESIDENT PUBLICATIONS residency-review-committee-for-neurology1406.doc
    • APPENDIX J: GOALS AND OBJECTIVES FOR THIS CLINICAL NEUROPHYSIOLOGY RESIDENCY PROGRAM. (PR II.A2) residency-review-committee-for-neurology1406.doc