Continued Accreditation


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Continued Accreditation

  1. 1. THE RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • FOR CONTINUED ACCREDITATION – PEDIATRIC GASTROENTEROLOGYGENERAL INSTRUCTIONSREVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the Program Information Form (PIF) isbeing completed for a currently accredited program, follow the provided instructions to create the correctform. Go to the Accreditation Data System found on the ACGME home page ( under DataCollection Systems. Using your previously assigned User ID and password, proceed to the PIF Preparationsection on the left hand menu and update the Common PIF data. Most data are updated through annualupdates, but some information is required at the time of site visit only. Once the data entry is complete,select Generate PIF to review and print the Common PIF (PDF). Pages will be numbered consecutively inthe bottom center of each page.Once the Common PIF is complete, proceed to the appropriate Residency Review Committee webpage toretrieve the Specialty Specific PIF for CONTINUED ACCREDITATION. Once the forms are complete, enter pagenumbers for the Continued PIF in the bottom center for each page that consecutively follows the CommonPIF numbering, combine the Common PIF and the Continued Accreditation PIF and complete the Table ofContents (found with the Specialty Specific PIF instructions). After completing the PIF/documents, makefour copies. They must be identical and final. Draft copies are not acceptable. The forms should besubmitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as twoor three ring binders, spiral bound notebooks, or any other form of binding. Mail one set of the completedforms to the site visitor at least 14 days before the site visit. The remaining three sets should be provided tothe site visitor on the day of the visit.The program director is responsible for the accuracy of the information supplied in this form and must signit. It must also be signed by the designated institutional official of the sponsoring institution.Review the Program Requirements for Residency Education in Pediatric Gastroenterology. The ProgramRequirements and the Institutional Requirements may be downloaded from the ACGME website( questions regarding: -the completion of the form (content), contact the Accreditation Administrator. -the Accreditation Data System, email a glossary of terms, use the following link – continued-accreditation1573.doc i
  2. 2. Have the following documents available for the site visitor:References to Common Program and Institutional Requirements are in parentheses. 1. Policy for supervision of residents (addressing resident responsibilities for patient care, progressive responsibilities for patient management, and faculty responsibility for supervision) (CPR IV.A.4) 2. Program policies and procedures for residents’ duty hours and work environment (CPR II.A.4.j; CPR VI.C; IR II.D.4.i; IR III.B.3) 3. Moonlighting policy (CPR II.A.4.j; CPR VI.F) 4. Documentation of internal review (date, participants’ titles, type of data collected, and date of review by the GMEC) 5. Overall educational goals for the program (CPR IV.A.1) 6. Competency-based goals and objectives for each assignment at each educational level (CPR IV.A.2) 7. Current Program Letters of Agreement (PLAs) (CPR I.B.1) 8. Files of current residents who have transferred into the program, if applicable (including documentation of previous experiences and summative competency-based performance evaluations) (CPR III.C.1) 9. Evaluations of residents at the completion of each assignment (CPR V.A.1.a) 10. Evaluations showing use of multiple evaluators (faculty, peers, patients, self, and other professional staff) (CPR V.A.1.b.(2)) 11. Documentation of residents’ semiannual evaluations of performance with feedback (CPR II.A.4.g; V.A.1.b.(4)) 12. 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) 13. Completed annual written confidential evaluations of faculty by the residents (CPR V.B. 3) 14. Completed annual written confidential evaluations of the program by the residents (CPR V.C.1.d. (1)) 15. Completed annual written confidential evaluations of the program by the faculty (CPR V.C.1.d.(1)) 16. Documentation of program evaluation and written improvement plan (CPR V.C) 17. Documentation of resident duty hours (CPR II.A.4.j; VI.D.1-3) 18. Files of current residents and most recent program graduatesSingle Program Sponsors only: 1. Copy of the resident contract with the pertinent items from the Institutional Requirements and Master Affiliation Agreements (IR II.D.4) 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) continued-accreditation1573.doc ii
  3. 3. THE RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org10 Digit ACGME Program I.D. #:Program Name: TABLE OF CONTENTSWhen you have the completed forms, number each page sequentially in the bottom center. Report thispagination in the Table of Contents and submit this cover page with the completed PIF. Common PIF1 Page(s)Accreditation InformationParticipating Sites Sponsoring Institution/Single or Limited Residency Institution (If applicable)Faculty/Teaching Staff Program Director Information Physician Faculty Roster Faculty Curriculum Vitae Non Physician Faculty RosterResident Appointments Number of Positions Actively Enrolled Residents (if applicable) Aggregated Data on Residents Completing or Leaving the Program for the last 3 years (if applicable) Residents Completing Program in the Last 3 years (if applicable) Transferred, Withdrawn, and Dismissed Residents (if applicable)EvaluationResident Duty Hours Pediatric Subspecialty PIF Page(s)Faculty ResearchResearch ResourcesProgram Curriculum Block Diagram Goals and Objectives Collaboration Between Programs General Subspecialty Curriculum Conferences Scholarship Oversight Committee Fellow Research Activities continued-accreditation1573.doc iii
  4. 4. Specialty Specific PIF Page(s)Personnel, Facilities and Resources 1 Support Services Outpatient and InpatientPatient Care Patient Data Ambulatory Pediatric Gastroenterology Experience for All Years of Training 12-Month Summary: Outpatient Clinics/Inpatient Services List of Diagnoses Skill ObjectivesMedical Knowledge Core Curriculum Inpatient Experiences Outpatient ExperiencesPractice-based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystems-based PracticeAppendix A – Goals and Objectives continued-accreditation1573.doc iv
  5. 5. RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • COMMON SUBSPECIALTY PROGRAM INFORMATION FORMFACULTY RESEARCH 1. Complete the table below regarding the involvement of faculty in research. Add rows as necessary. # of current # of current research projects # presentations IRB Total # of with peer review at national # publications approved current funded funding (subset of scientific in peer review research research total # in previous meetings in the journals in the projects projects column) last 5 years last 5 years Program Director: Key Faculty: Mentors Who Are Not Key Faculty: 2. List active research projects in the subspecialty. Put an “X for funding awarded by Years of Faculty investigator and role peer review funding in grant (i.e. PI, Co-PI, Co- Project title Funding source process (dates) investigator) continued-accreditation1573.doc 1
  6. 6. 3. To enable the Committee to assess the scholarly environment of the program, provide a list of scholarly publications and presentations at regional, national and international meetings by faculty and fellows within the program for the last five years only. Do not duplicate citations. Underline the names of subspecialty fellows. List journal articles and presentations (abstracts, workshops, invited talks) separately under those headings.RESEARCH RESOURCES 1. Does the program provide research laboratory space and equipment? (if appropriate) ..............................................................................................................................( ) YES ( ) NO 2. Does the program provide financial support for research?....................................( ) YES ( ) NO 3. Does the program provide computer and statistical consultation services?...........( ) YES ( ) NO continued-accreditation1573.doc 2
  7. 7. PROGRAM CURRICULUM 1. Block Diagram The purpose of a block diagram is to give the Residency Review Committee an overview of what takes place during each year of training. EXPERIENCES OF ROTATIONS • In each one month or 4 week block indicate the following: (1) the learning activity (i.e., Trauma) or vacation, (2) percentage of clinical (C) and research (R) time (i.e., 50% C; 50% R) (3) the site in which the activity occurs (i.e., HOSP1, HOSP 2 or OTHER – clinical site or office) as designated in Common PIF. • Provide a key/legend for the abbreviations used (i.e., ED = Emergency Department), DUTY HOURS • In the row requesting duty hours, report (1) the usual number of hours/week worked and (2) the longest consecutive hours during that week. • Indicate whether call is call from home (H) or in-house call (IH). • Asterisk the rotations that are call free.ExampleMonth/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13 ED ED Trauma ELEC ELEC ELEC Research ED Anes Research ResearchExperience or 100% 100% 100% 100% 100% 100% 20% (C) 100% (C) 100% (C) 100% (R) 100% (R) VAC N/Arotations (C) (C) (C) (C) (C) (C) 80% (R) HOSP1 HOSP1 HOSP2 HOSP1 HOSP1 HOSP1 HOSP2 HOSP1 HOSP1 HOSP2 HOSP1 70/20 70/10 70/10 80/24 85/30 70/30 70/30 80/30Duty Hours 60/20 * 60 * 60 * IH IH IH IH IH IH IH H continued-accreditation1573.doc 3
  8. 8. FIRST YEAR BLOCK DIAGRAMMonth/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13Experienceor rotationsDuty HoursSECOND YEAR BLOCK DIAGRAMMonth/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13Experienceor rotationsDuty HoursTHIRD YEAR BLOCK DIAGRAMMonth/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13Experienceor rotationsDuty HoursTotal number of clinical months _____________Total number of research months ____________If there are any exceptions to the fellowship program as outlined above for any of the current fellows, describe these exceptions below (Inserttext in box.):Limit response to 50 words continued-accreditation1573.doc 4
  9. 9. 2. Goals and Objectives A complete set of goals and objectives must be available for the site visitor. Choose as a sample the goals and objectives for one clinical rotation and attach it to the PIF as Appendix A (do not append all of the goals and objectives). For new applications, submit the complete set of goals and objectives.Place an ‘X” in the box before the applicable response.Are there goals and objectives for all training ( ) YES ( ) NOexperiences?Are they rotation and level specific? ( ) YES ( ) NOHow are they distributed? ( ) Hard Copy ( ) Electronic or web-basedIf not web-based, when are they distributed to ( ) Prior to Each Rotation ( ) Annuallyfellows? ( ) Once in Handbook ( ) Other ( ) Prior to Each RotationIf not web-based, when are they distributed to ( ) Annuallyfaculty? ( ) OtherIf web-based, do you send out reminders to access ( ) YES ( ) NOthem?If yes, when do you send them?3. Collaboration between ProgramsAre there meetings among the core Program ( ) YES ( ) NODirector and subspecialty Program Directors? If yes, have minutes available for site visitor confirmationHow often do these meetings occur?Who is typically involved in these meetings? ( ) Core program director(check all that apply) ( ) Subspecialty program director for this specialty ( ) Program directors from other subspecialties continued-accreditation1573.doc 5
  10. 10. 4. General Subspecialty Curriculum Participants (place and X in the appropriate Where Taught in Number of column) Curriculum? Structured Fellows in All Residents & (Name should Teaching Hours this Subspecialty Subspecialty match name in Dedicated to Topic Discipline Fellows FellowsTopic conference list) Area? Attend Attend Attende.g., Biostatistics Research Course 14 XBasic science as relatedto the application inclinical subspecialtypracticeClinical subspecialtycontentFor the topics below, if the topic is not appropriate for your discipline (i.e., lab research for fellows indevelopmental and behavioral pediatrics), enter N/A into column 1.BiostatisticsLab researchmethodology (ifappropriate)Clinical researchmethodologyStudy designGrant preparationPreparation of protocolsfor institutional reviewboardPrinciples of evidence-based medicine/ Criticalliterature reviewQuality ImprovementTeaching skillsProfessionalism/EthicsCultural DiversitySystems-based practice(economics ofhealthcare, practicemanagement, clinicaloutcomes, etc.) continued-accreditation1573.doc 6
  11. 11. 5. Conferences Have Conference Schedule Available For Review By Site Visitor. Do Not Append Conference Schedule. a) List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the subspecialty training program. Identify the "SITE" by using the corresponding number as appears on the Common PIF. Indicate the frequency, e.g., weekly, monthly, etc., and whether conference attendance is required (R) or optional (0). List the role of the fellow in this activity. (e.g., conducts conference, presents case and participates in discussion, case presentation only, participation limited to Q&A component, etc.) Conference Site # Frequency R/O Role of the Fellow b) Describe the mechanism that is used to assure fellow attendance at required conferences. State the degree to which faculty attendance is expected, and how this is monitored. Limit response to 50 words6. Scholarship Oversight Committee a) Is there a scholarship oversight committee for every fellow?........................( ) YES ( ) NO If yes, have names of committee members for each fellow available for site visitor confirmation. b) How often does the committee meet with the fellow?...............................# ( ) times per year c) Are there written guidelines outlining the responsibility of the oversight committee? If yes, have the guidelines available for site visitor confirmation...................( ) YES ( ) NO 7. Fellow Research Activities a) Describe how the program ensures a meaningful supervised research experience for the fellows, beginning in their first year and extending throughout their training. b) If faculty outside the division are actively involved in mentoring the fellows, list and provide details. continued-accreditation1573.doc 7
  12. 12. RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • PROGRAM INFORMATION FORM - PEDIATRIC GASTROENTEROLOGYPERSONNEL, FACILITIES AND RESOURCESA. Support Services List the clinical training settings/experiences and for each indicate with a check mark the personnel who interact regularly with fellows. Related Disciplines Physical Occupational Feeding Setting Therapy* Therapy* Social Work* Nutrition* Therapy* * appear as “must” in the requirements. For categories of personnel that are unavailable, describe how that function is addressed in the program. continued-accreditation1573.doc 8
  13. 13. B. Outpatient and Inpatient Indicate the availability of the following: Facility/Service Site 1 Site 2 Site 3 Space in an ambulatory setting for optimal evaluation and care of patients (yes/no) PICU (indicate total number of beds) NICU (indicate total number of beds) An inpatient area with pediatric and related services staffed by pediatric residents and faculty (yes/no) Support services including: • radiology (yes/no) • nuclear medicine (yes/no) • pathology(yes/no) Endoscopy facilities (yes/no) Procedure facility for measuring gastrointestinal motility (yes/no) 1. For every facility/service that is not available at any of the sites, provide an explanation below. Explain how the service is provided for patients. 2. In a bulleted format explain how fellows, in caring for patients, have access to a laboratory that can either perform or assess measures of intestinal absorptive and pancreatic function; nutritional parameters; and specialized serological, parasitological, immunological, metabolic, and toxicological studies applicable to gastrointestinal and hepatobiliary disorders. • continued-accreditation1573.doc 9
  14. 14. I. PATIENT CAREA. Patient Data Provide the following information for the most recent 12-month academic or calendar year. Note the same timeframe should be used throughout the forms. Inclusive Dates: FROM: (mm/dd/yy) TO: (mm/dd/yy) Site 1 Site 2 Site 3 Total number of admissions to the Pediatric Gastroenterology service Number of new patients admitted each year (“new” refers to those who are seen by members of the Gastroenterology service for the first time.) Average length of stay of patients on the pediatric Gastroenterology service Total number of consultations by pediatric Gastroenterologists on other inpatients Number of consultations provided to the NICU Number of consultations provided to the PICU Average daily census of patients on the Pediatric Gastroenterology service, including consultations Number of patients requiring follow-up care by Gastroenterology service as outpatients during 12-month period reported If the ADC on the pediatric gastroenterology service is less than six, explain how fellows have an adequate exposure to inpatients. If applicable, provide the following information for the most recent 12-month academic or calendar year for each hospital used to provide a specific required experience, such as transplant, cardiology, intensive care, etc. Note the same timeframe should be used throughout the forms. Duplicate this table as necessary. Inclusive Dates: FROM: (mm/dd/yy) TO: (mm/dd/yy) Site 1 Site 2 Site 3 Name of service: Total number of fellows and residents on the service Total number of admissions to the service Number of new patients admitted each year (“new” refers to those who are seen by members of the service for the first time.) Average length of stay of patients on the service Average daily census of patients on the service, including consultations continued-accreditation1573.doc 10
  15. 15. B. 1Ambulatory Pediatric Gastroenterology Experience for All Years of Training For New Applications: Indicate projected numbers for fellows: Average Number of Number of New Number of Number Duration of Sessions Per Patients Per Return Patients Teaching Name of Experience Experience Week Per Fellow Per Per Fellow Per Attendings Per Hospital/Other Setting Identifier (in wks/yr) Fellow Session Session Session If the experience is in a private office, provide full details, including name and credentials of supervisor, numbers and types of patients, degree of fellow responsibility for their care, frequency of attendance at office, how director monitors the experience and fellow performance. continued-accreditation1573.doc 11
  16. 16. C. 12-Month Summary: Outpatient Clinics/Inpatient Services During the same 12-month period as used in previous sections, how many pediatric patients with the following gastroenterology problems were: a) seen in the ambulatory settings; b) were admitted to and/ or consulted on by the pediatric gastroenterologists at the primary hospital? New applications should complete only the columns marked by an asterisk (*). Inclusive dates: FROM (mm/dd/yy): TO (mm/dd/yy): Outpatients Inpatients Total # of patients: # seen by fellows: # seen in # on # seen in Gastroenterology Diagnosis/ Total # of # seen by # on gastro consultati gastro consultati Disorder patients* fellows service* on service* on Growth failure and malnutrition Malabsorption/maldigestion • celiac disease • cystic fibrosis • pancreatic insufficiency Gastrointestinal allergy Peptic ulcer disease Hepatobiliary Disease: • biliary atresia • diseases of the gallbladder • fatty liver • intrahepatic cholestasis • autoimmune liver disease • viral hepatitis • metabolic liver diseases Liver failure (including evaluation and follow-up care of patient requiring liver transplantation) Congenital Digestive tract anomalies (including Hirshsprung’s disease) Inflammatory bowel disease Functional bowel disorders • Vomiting (including gastroesophageal reflux) • Acute and chronic abdominal pain • Acute and chronic diarrhea • Constipation • Gastrointestinal bleeding • Motility disorders Pancreatitis (acute & chronic) continued-accreditation1573.doc 12
  17. 17. Gastrointestinal problems in the immune-compromised host Transplantation • Liver • Small BowelD. List of Diagnoses List 150 CONSECUTIVE admissions and/or consultations to the gastroenterology service. Identify the time period during which these admissions/consultations occurred. The date range should occur within the same 12-month period used in previous sections. The dates must begin on the date the first patient on the list was admitted and end with the date the 150th patient was admitted, e.g., July 1, 2007 through October 20, 2007. Submit a separate list for each hospital that provides required rotations. Use additional pages as necessary. Hospital: Give inclusive dates during which these From (mm/dd/yy): To (mm/dd/yy): admissions/consultations occurred: Patient ID Number of days in Gastroenterologic diagnosis Number Age hospital (may include secondary diagnosis if relevant) continued-accreditation1573.doc 13
  18. 18. E. Skill Objectives Indicate whether or not the program provides experience in each of the following procedures. Use the same 12-month period as indicated on the previous sections. For procedures not performed at any of the participating sites, provide an explanation. New applications complete only the column marked "number performed on service(s)" for each hospital. Hospital: Give inclusive dates during which these admissions/ From (mm/dd/yy): To (mm/dd/yy): consultations occurred: Site 1 Site 2 Site 3 # performed Total # # performed Total # Total # # performed on performed on performed performed on service(s) service(s) by fellows service(s) by fellows by fellows Diagnostic & Therapeutic Colonoscopy (including biopsy) Diagnostic upper endoscopy (including biopsy) Provide a description of the method by which fellows acquire skills and how their competence is assured for the required procedures listed above continued-accreditation1573.doc 14
  19. 19. II. MEDICAL KNOWLEDGEA. Core Curriculum Identify the learning activities (clinical experience, conference series, journal club, etc.) and training sites (hospital #) used to address the required core knowledge area. List in Bulleted Format the Learning List the Corresponding Setting in Activities Used to Address the Core Which These Learning Activities Year(s) of Core Knowledge Area Knowledge/Skills Area Take Place Training gastrointestinal manometry • • • rectal suction biopsy • • • paracentesis • • • esophageal impedance/pH testing • • • pancreatic function testing • • • breath hydrogen analysis • • • endoscopic placement of feeding • • • tubes (including percutaneous endoscopic gastrostomy placement) videocapsule endoscopy • • • endoscopic retrograde • • • cholangiopancreatography (ERCP) management of gastrointestinal • • • foreign bodies hemostatic techniques for variceal • • • and nonvariceal gastrointestinal bleeding percutaneous liver biopsy • • • training in the evaluation of the • • • psychosocial aspects of chronic gastrointestinal disease as they affect the child competence in counseling chronically • • • ill patients and their families including preventive measures for digestive disease continued-accreditation1573.doc 15
  20. 20. B. Inpatient Experiences What responsibilities do the fellows have for inpatients and how and by whom are they supervised when assigned to inpatient services?C. Outpatient Experiences 1. Describe the responsibilities that fellows have for outpatients and how and by whom fellows are supervised. 2. Describe the continuity of care experience fellows receive during their period of assignment to the outpatient clinic. To what extent do fellows have the opportunity to provide outpatient care for patients whom they treated on the inpatient service? continued-accreditation1573.doc 16
  21. 21. Examples of Learning Activities: didactic lecture, assigned reading, seminar, self-directed learningmodule, conference, small group discussion, workshop, online module, journal club, project, casediscussion, one-on-one mentoring, or other examples of learning activities.III. PRACTICE-BASED LEARNING AND IMPROVEMENT 1. Describe one learning activity in which fellows engage to identify strengths, deficiencies, and limits in their knowledge and expertise (self-reflection and self-assessment); set learning and improvement goals; identify and perform appropriate learning activities to achieve self-identified goals (life-long learning). Limit your response to 400 words. 2. Describe one example of a learning activity in which fellows engage to develop the skills needed to use information technology to locate, appraise, and assimilate evidence from scientific studies and apply it to their patients’ health problems. The description should include: a) locating information b) using information technology c) appraising information d) assimilating evidence information (from scientific studies) e) applying information to patient care Limit your response to 400 words. 3. Give one example and the outcome of a planned quality improvement activity or project in which at least one fellow participated in the past year that required the fellow to demonstrate an ability to analyze, improve and change practice or patient care. Describe planning, implementation, evaluation and provisions of faculty support and supervision that guided this process. Limit your response to 400 words. 4. Describe how fellows: a) develop teaching skills necessary to educate patients, families, students, and other residents; b) teach patients, families, and others; and c) receive and incorporate formative evaluation feedback into daily practice. (If a specific tool is used to evaluate these skills have it available for review by the site visitor.) Limit your response to 400 words. 5. Describe the process for mentoring the fellows. Address the following items for each type of mentor if more than one is assigned to each fellow (i.e., if there is a separate research mentor). Describe (1) how mentors are selected, (2) how often the mentor meets with the mentee and (3) the guidelines that are provided for topics to be addressed during meetings between mentors and mentees. Limit response to 150 words (1) continued-accreditation1573.doc 17
  22. 22. (2) (3)6. Outline the faculty development activities that are provided for acquainting the faculty with mentoring skills. Limit response to 50 words7. Learning Plans Is each fellow required to have an individualized learning plan? (If yes, have learning plans ( ) YES ( ) NO available for site visitor verification.) ( ) No guidance, resident driven Who provides guidance to the fellow in ( ) Fellow’s mentor completing this plan (check all that apply)? ( ) Program Director ( ) Other (describe) ( ) Annually How often are these plans developed or updated? ( ) Semi- Annually ( ) Other (describe)8. List the clinical quality improvement activities in which fellows actively participate and identify who guides them in this process. Limit response to 150 words9. Using the bulleted list below (add bullets as needed) identify specific ways in which the program fosters reflection, self-assessment, and practice improvement for fellows. Limit response to 150 words • • continued-accreditation1573.doc 18
  23. 23. IV. INTERPERSONAL AND COMMUNICATION SKILLS 1. Describe one learning activity in which fellows develop competence in communicating effectively with patients and families across a broad range of socioeconomic and cultural backgrounds, and with physicians, other health professionals, and health related agencies. Limit your response to 400 words. 2. Describe one learning activity in which fellows develop their skills and habits to work effectively as a member or leader of a health care team or other professional group. In the example, identify the members of the team, responsibilities of the team members, and how team members communicate to accomplish responsibilities. Limit your response to 400 words. 3. Explain (a) how the completion of comprehensive, timely and legible medical records is monitored and evaluated, and (b) the mechanism for providing fellows feedback on their ability to competently maintain medical records. Limit your response to 400 words. 4. How do fellows learn to achieve competence in conducting a family meeting to deliver critical/complex information about patient diagnosis, prognosis and /or treatment. Answer by using a specific example to illustrate. Limit response to 150 words 5. Describe (1) how the fellow’s written communication (including but not limited to progress notes, consults, and letters to referring physicians) is reviewed and (2) how feedback is given regarding its quality. Limit response to 150 words (1) (2) 6. Using the bulleted list below (add bullets as needed) identify the specific methods the program uses to ensure that fellows achieve competence in effective communication (verbal & written) in a consultative role with other physicians, health care workers and outside agencies. Limit response to 150 words • • continued-accreditation1573.doc 19
  24. 24. V. PROFESSIONALISM 1. Describe at least one learning activity, other than lecture, by which fellows develop a commitment to carrying out professional responsibilities and an adherence to ethical principles. Limit your response to 400 words. 2. How does the program promote professional behavior by the fellows and faculty? Limit your response to 400 words. 3. How are lapses in these behaviors addressed? Limit your response to 400 words. 4. Explain how the following contribute to the evaluation of professionalism: (1) patients/families, and (2) members of the health care team. Limit response to 150 words (1) (2) 5. Using the bulleted list below (add bullets as needed) identify specific methods the program uses to teach and evaluate the elements of professional competence. Limit response to 100 words • • continued-accreditation1573.doc 20
  25. 25. VI. SYSTEMS-BASED PRACTICE 1. Describe the learning activity(ies) through which fellows achieve competence in the elements of systems-based practice: work effectively in various health care delivery settings and systems, coordinate patient care within the health care system; incorporate considerations of cost- containment and risk-benefit analysis in patient care; advocate for quality patient care and optimal patient care systems; and work in interprofessional teams to enhance patient safety and care quality. Limit your response to 400 words. 2. Describe an activity that fulfills the requirement for experiential learning in identifying system errors. Limit your response to 400 words. a. Identify who guides/supervises fellows in this activity. Limit response to 75 words 3. Address how the elements of this competency are taught and how they are evaluated. System errors need not be addressed here. Limit response to 200 words 4. How does your program meet the requirement for exposure to administrative experience in the context of your subspecialty? Limit response to 200 words 5. Give an example of how fellows are expected to navigate the “system”, that is identify/access resources, make referrals, and coordinate services for patients within your subspecialty practice. continued-accreditation1573.doc 21
  26. 26. APPENDIX A - GOALS AND OBJECTIVES Append a sample of the goals and objectives for one rotation. continued-accreditation1573.doc 22