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  • RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60610 • www.acgme.org PROGRAM INFORMATION FORM - PEDIATRIC HEMATOLOGY-ONCOLOGY MEDICINE FOR INITIAL APPLICATION ONLY GENERAL INSTRUCTIONS APPLICATION FOR A NEW PROGRAM: This form is for use by programs making Initial Application Only (for re-accreditation, use the Continued Accreditation PIF and the Accreditation Data System). All sections of the form applicable to the program must be completed in order to be accepted for review. The information provided should describe the proposed program. For items that do not apply indicate N/A in the space provided. Where patient numbers are requested, estimate what you expect will occur. If any requested information is not available, an explanation should be given and it should be so indicated in the appropriate place on the form. Combine Part 1, Part 2, and Part 3, number the pages consecutively on the lower center of each page, beginning with Part 1 Section 1, complete the Table of Contents (found with the Part 3 instructions) and obtain all required signatures. Once the forms are complete, send four complete copies to the Executive Director of the RRC for Pediatrics at the address above. Before work is begun on this form, the following three (3) sets of requirements should be thoroughly reviewed: 1. ACGME Institutional Requirements (IR) 2. Program Requirements for the Subspecialties of Pediatrics (GPR) 3. The subspecialty specific Program Requirements (PR) Copies of these requirements may be obtained from our website (www.acgme.org). For questions regarding the site visit, contact the writer of the letter announcing the site visit. For questions regarding the completion of the form (content), contact the Accreditation Administrator (Phone: 312-755-7478). For word processing questions/problems, contact the ACGME Help Desk (Phone: 312-755-7464). For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp The program director is responsible for the composition and accuracy of the information supplied in this form and must sign it. It must also be signed by the Designated Institutional Official of the sponsoring institution. 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. Program Directors must justify (in narrative form) any deliberate variations from the required core curriculum and must provide an educational rationale. Parenthetical references at the beginning of various sections refer to the Program Requirements. The pagination in the RRC’s form must be maintained in the lower center of the page. The completed copies of the form may be secured with a rubber band or enclosed in a folder. Do not staple any sections of the form or any or any of the attachments. Many questions in the PIF have word limits (e.g., limited to 150 words) for responses. Programs are encouraged to use lists or bullets for these responses. SPECIFIC INSTRUCTIONS A pediatric subspecialty program must function in conjunction with an accredited program in pediatrics that is in good standing. The title of the program should correspond to the title of the affiliated pediatrics program. All 8g4907.doc
  • program titles are subject to editing to conform to ACGME policies. Identify as the SPONSORING INSTITUTION that entity that assumes ultimate responsibility for the program, as evidenced by the fact that it monitors the quality of the education and coordinates accreditation activity. There may only be one sponsor and it must be the same sponsor as the sponsor for the core residency program. Refer to the ACGME Institutional Requirements. If the SPONSORING INSTITUTION and the PRIMARY HOSPITAL are one and the same, the hospital’s name should be entered in the section requesting NAME AND ADDRESS OF SPONSORING INSTITUTION and in the section requesting PRIMARY HOSPITAL. All hospitals offering required rotations or experiences should be listed. One hospital should be designated as the PRIMARY HOSPITAL and identified as Institution #1. Faculty Instructions FACULTY DATA: In Part 1, Section 4.A, identify the essential faculty members who are direct contributors to the program. In Section 4.B, provide a one page CV for each faculty member under this subspecialty only. Do not include CVs of other subspecialists. Programs seeking continued accreditation must use the Accreditation Data System (ADS) to enter these data (Update Faculty). Provide the required faculty information to complete the roster. To enter/edit the CV for the Program Director, click the CV folder and complete the 9 steps. For all other faculty, upload the current one-page CV in Portable Document Format (PDF) using the standard ACGME form or follow the 9-step CV process. The entered information will automatically appear in Part 1, Section 4 of the PIF. 8g4907.doc
  • RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60610 • www.acgme.org PROGRAM INFORMATION FORM - PEDIATRIC HEMATOLOGY-ONCOLOGY MEDICINE TABLE OF CONTENTS When you have the completed forms, number each page sequentially on the bottom of the page. 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. Name of Program: Program Number: 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) 3.C Years Residents Who Completed the Program 3.D Withdrawn / Dismissed Residents 3.E Scholarly Activity 3.F Duty Hours 3.G Faculty 4 Faculty Roster 4.A Faculty CVs 4.B List of Faculty Disciplines 4.C Part 2 Section Page(s) Background Information 5 Previous Citations or Concerns 5.A Changes 5.B Faculty Research 6 Resources 7 Program Curriculum 8 Block Diagram 8.A Goals and Objectives 8.B Collaboration Between Programs 8.C General Subspecialty Curriculum 8.D Conferences 8.E Scholarship Oversight Committee 8.F Fellow Research Activities 8.G ACGME Competencies 8.H Resident Moonlighting 9 8g4907.doc
  • Part 2 Section Page(s) Moonlighting and Oversight 9.A Evaluation 10 Fellow 10.A Faculty 10.B Program 10.C Part 3 Section Page(s) Other Professional Personnel 11 Facilities and Resources 12 Patient Data 13 Ambulatory Pediatric Hematology-Oncology Experience for All Years Of Training 14 List of Diagnoses 15 12-Month Summary - Inpatient Service 16 Outpatient Visits 17 12-Month Summary – Outpatient Service 18 Transplants 19 Narrative Description 20 General Description 20.A Inpatient Experiences 20.B Outpatient Experiences 20.C Core Curriculum 20.D Appendix A – Goals and Objectives Appendix B - Assessment tool(s) used by patient/families and allied health professionals for the evaluation of professionalism Appendix C – Program Level Letters of Agreement 8g4907.doc
  • RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60610 • www.acgme.org PROGRAM INFORMATION FORM - PEDIATRIC HEMATOLOGY-ONCOLOGY MEDICINE (Part 1) FOR INITIAL APPLICATION ONLY SECTION 1. GENERAL PROGRAM INFORMATION A. Accreditation Information Date: Title of Program: 10 Digit ACGME Program ID# (for accredited programs): Core Program Information Title of Core Program: Core Program Director: 10 Digit ACGME Program ID#: B. Program Director Information Name: Title: Address: City, State, Zip code: Telephone: FAX: Email: Date First Appointed as Program Director: Principal Activity Devoted to Resident Education? Term of Program Director Appointment: Date first appointed as faculty member in the program: Number of hours per week Director spends in: Clinical Supervision: Administration: Research: Didactics/Teaching: Primary Specialty Board Certification: Most Recent Date: Secondary Specialty Board Certification: Most Recent Date: Number of years spent teaching in GME in this specialty: Director based at primary teaching institution? ( ) YES ( ) NO 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 Core Program Director (and date): Signature of Designated Institutional Official (DIO) (and date): 8g4907.doc
  • SECTION 2. PARTICIPATING INSTITUTIONS Attach as Appendix C the program level letters of agreement for all the participating institutions. SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.) Name of Sponsor: Changed since the Last Review? ( ) YES ( ) NO Address: Single Residency Sponsor? ( ) YES ( ) NO City, State, Zip code: Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School) Ownership Type: (e.g., State, Corporation, Church) Name of Designated Institutional Official: 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 Fellows Rotation (in months) Year 1: Year 2: Year 3: 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) Name: Address: City, State, Zip Code: Type of Relationship with Program: Sponsor ( ) Major ( ) Clinical ( ) Other ( ) Does this institution also sponsor its own program in this specialty? Does it participate in any other ACGME accredited programs in this specialty? Distance between 2 & 1: Miles: Minutes: Type of Rotation Elective ( ) Required ( ) Both ( ) (select one) Length of Fellows Rotation (in months) Year 1: Year 2: Year 3: 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) 8g4907.doc
  • Name: Address: City, State, Zip Code: Type of Relationship with Program: Sponsor ( ) Major ( ) Clinical ( ) Other ( ) Does this institution also sponsor its own program in this specialty? Does it participate in any other ACGME accredited programs in this specialty? Distance between 3 & 1: Miles: Minutes: Type of Rotation Elective ( ) Required ( ) Both ( ) (select one) Length of Fellows Rotation (in months) Year 1: Year 2: Year 3: 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) Name: Address: 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 Fellows Rotation (in months) Year 1: Year 2: Year 3: 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) Name: Address: 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 Fellows Rotation (in months) Year 1: Year 2: Year 3: 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: 8g4907.doc
  • SECTION 3. RESIDENTS A. Number of Positions (for the current academic year) Positions Total Number of Requested Positions Number of Filled Positions* * Not applicable to new programs with no residents on duty. Count part time residents as 0.5 FTE. B. Actively Enrolled Residents (if applicable) List all residents actively enrolled in this program as of August 31 of current academic year (see Section 3.A). List names alphabetically within Year in Program. Place an (*) asterisk next to the name of each resident accepted as a transfer. Documentation of previous experience for transfer students should be available for review by the site visitor. Program Expected Years of Year of Med Year in Type of Specialty of Most Name Start Completion Prior Medical School School Program Position Recent Prior GME Date Date GME Graduation 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 8g4907.doc
  • Number of Residents on Leave of Absence from the Program Number of Residents Dismissed from the Program *Excludes residents preliminary complement year(s). D. Residents Completing Program in the Last Three Years (if applicable) List of residents who completed all training for this specialty based on the last academic year ending June 30, ____. Date Took First Stage of Date First Took Second Actual Date of Board Exam - Passed on Stage of Board Exam - Name Start Date Completion First Attempt Passed on First Attempt (Y/N/Unknown) (Y/N/Unknown) List of residents who completed all training for this specialty based on the last academic year ending June 30, ____. Date Took First Stage of Date First Took Second Actual Date of Board Exam - Passed on Stage of Board Exam - Name Start Date Completion First Attempt Passed on First Attempt (Y/N/Unknown) (Y/N/Unknown) List of residents who completed all training for this specialty based on the last academic year ending June 30, ____. Date Took First Stage of Date First Took Second Actual Date of Board Exam - Passed on Stage of Board Exam - Name Start Date Completion First Attempt Passed on First Attempt (Y/N/Unknown) (Y/N/Unknown) 8g4907.doc
  • E. Withdrawn Residents (if applicable) List residents who withdrew or were dismissed from the program for the last three years and provide the reason. Withdrawn or Name Start Date End Date Reason Dismissed 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) 1. Excluding call from home, what was the average number of hours on duty per week per resident for the last four week rotation(s)? 2. On average, how many days per week of in-house call (excluding home call and night float) were residents assigned for the last four week rotation(s)? 3. Excluding call from home, what was the longest shift (in hours) worked by any resident during the previous 4 week rotation(s)? 4. On average, do residents have 1 full day out of 7 free from educational and clinical responsibilities? If no, explain:........................................................................................................................( ) YES ( ) NO 5. Do residents have a 10 hour period between daily duty periods and after in-house call? . . .( ) YES ( ) NO If no, explain: 6. Do residents have appropriate duty hours when rotating on other clinical services, in accordance with the ACGME-approved program requirements? .....................................................................................................................( ) YES ( ) NO If no, explain: 8g4907.doc
  • . 8g4907.doc
  • SECTION 4. FACULTY / TEACHING STAFF A. Faculty Roster Identify the essential faculty members who are direct contributors to the program (Refer to PR for Pediatric Hematology/Oncology). First list the Pediatric Hematology/Oncology subspecialists, including the program director. Also identify any research mentors who participate in training. Then identify the key faculty member in the following disciplines (faculty should be listed in this order): (1) pediatric specialties (Pediatric Cardiology, Pediatric Critical Care, Pediatric Emergency Medicine, Pediatric Endocrinology, Pediatric Gastroenterology, Pediatric Infectious Diseases, Neonatal-Perinatal Medicine, Pediatric Nephrology, Pediatric Pulmonology, Pediatric Rheumatology), (2) other critical subspecialties It is understood that certification is not available in all the disciplines listed. The section on average hours per week spent on clinical supervision, administration, didactic teaching and research does not need to be completed for the faculty from other disciplines. Primary and Secondary Specialties / Field Average Hours Per Week Spent On Based Most Board Years as Primarily at Recent Clinical Didactic Name (Position) Degree Specialty / Field Certification Faculty in Admin Research Institution Certification Supervision Teaching (Y/N)† Specialty #* Date (PD) *as listed in Part 1, Section 2. † Certification for the primary specialty refers to ABMS Board Certification. Certification for the secondary specialty refers to sub-Board certification in a subspecialty or another specialty area.
  • B. Faculty Curriculum Vitae - Provide a one page CV for each faculty member under this subspecialty only. Do not include CVs of other subspecialists. First Name: MI: Last Name: Present Position: Medical School Name: Degree Awarded: Year Completed: Graduate Medical Education Program Name(s); include all residency and fellowships: Specialty/Field Date From: To: Certification and Re- Certification Information Current Licensure Data Specialty Certification Year Re-Certification Year State Date of Expiration Academic Appointments - List the past ten years, beginning with your current position. Start Date End Date Description of Position(s) Present Concise Summary of Role in Program: Current Professional Activities / Committees (Limit of 10): Selected Bibliography - Most representative Peer Reviewed Publications / Journal Articles from the last 5 years (limit of 10): Selected Review Articles, Chapters and/or Textbooks (Limit of 5): Participation in Local, Regional, and National Activities / Presentations (Limit of 5): If not board certified, explain equivalent qualifications:
  • C. List of Faculty Disciplines – Complete the following chart. Identify the number of persons from Section 4.A involved in each discipline. Number of Essential Faculty Discipline Institution Institution Institution Institution Institution #1 #2 #3 #4 #5 PEDIATRIC SUBSPECIALTIES Pediatric Cardiology Pediatric Critical Care Medicine Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Hematology/Oncology Pediatric Infectious Diseases Neonatal-Perinatal Medicine Pediatric Nephrology Pediatric Pulmonology Pediatric Rheumatology SPECIFIC TO PEDIATRIC HEMATOLOGY/ONCOLOGY SUBSPECIALTY Hematopathology, Immunopathology Neuro-Oncology Neuropathology Neurosurgery Nuclear Medicine Obstetrics/Gynecology Ophthalmology Orthopaedic Surgery Otolaryngology Pediatric Pathology Pediatric Radiology Pediatric Surgery Radiation Oncology Transfusion Medicine Urology
  • RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60610 • www.acgme.org COMMON SUBSPECIALTY PROGRAM INFORMATION FORM (Part 2) FOR INITIAL APPLICATION ONLY SECTION 5. BACKGROUND INFORMATION Provide a response for each of the points below. If a category is not applicable, list it and indicate N/A. A. Previous Citations or Concerns List each of the citations or concerns, if any, from the notification letter that was sent following the last survey and review of the program, and which contained an accreditation action, and briefly and concisely describe the steps that have been taken to correct the problem. The site visitor will review these citations and the progress made in addressing them during the visit. B. Changes Briefly describe major changes, other than those included in the response to previous citations and/or concerns (above), which have been implemented since the last survey and review. Include changes in sponsoring organization, participating hospitals, required rotations, resident complement, etc. Do not include changes to incorporate the competencies as this will be addressed later in the document.
  • SECTION 6. FACULTY RESEARCH (GPR III.B.4) 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 Years of Faculty investigator and role in funding awarded by funding grant (i.e. PI, Co-PI, Co- Project title Funding source peer review process (dates) investigator) 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.
  • SECTION 7. RESOURCES (GPR III.D) A. Library/Computer (GPR III.D.4) 1. Are library resources available? ...........................................................................................( ) YES ( ) NO 2. Do fellows have access to computer and electronic databases?..........................................( ) YES ( ) NO B. Research Resources (GPR III.D.5) 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
  • SECTION 8. PROGRAM CURRICULUM A. Block Diagram (GPR V.A.1) 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 Section 2 of this form. • 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. Example Month/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13 Research ED ED ED Anes Trauma ELEC ELEC ELEC Research Research Experience or 20% (C) 100% (C) 100%(C) 100% (C) 100% (C) 100% (C) 100% (C) 100% (C) 100% (C) 100% (R) 100% (R) VAC N/A rotations HOSP1 HOSP1 HOSP1 HOSP1 HOSP2 HOSP1 HOSP1 HOSP2 80% (R) HOSP2 HOSP1 HOSP1 70/20 70/10 70/10 80/24 85/30 70/30 70/30 80/30 Duty Hours IH IH IH IH IH IH IH H 60/20 * 60 * 60 *
  • FIRST YEAR BLOCK DIAGRAM Month/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13 Experience or rotations Duty Hours SECOND YEAR BLOCK DIAGRAM Month/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13 Experience or rotations Duty Hours THIRD YEAR BLOCK DIAGRAM Month/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13 Experience or rotations Duty Hours Total 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 (Insert text in box.): Limit response to 50 words
  • B. Goals and Objectives (GPR V.A.2) Attach it to the PIF as Appendix A, 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 ( ) NO experiences? Are they rotation and level specific? ( ) YES ( ) NO How are they distributed? ( ) Hard Copy ( ) Electronic or web-based ( ) Prior to Each Rotation ( ) Annually If not web-based, when are they distributed to fellows? ( ) Once in Handbook ( ) Other ( ) Prior to Each Rotation If not web-based, when are they distributed to faculty? ( ) Annually ( ) Other If web-based, do you send out reminders to access ( ) YES ( ) NO them? If yes, when do you send them? C. Collaboration between Programs (GPR V.A.3) Are there meetings among the core Program ( ) YES ( ) NO Director and subspecialty Program Directors? How often do these meetings occur? Who is typically involved in these meetings? (check ( ) Core program director all that apply) ( ) Subspecialty program director for this specialty ( ) Program directors from other subspecialties
  • D. General Subspecialty Curriculum (GPR.V.B) Participants Where Taught in Number of (place and X in the appropriate column) Curriculum? Structured Fellows in All Residents & (Name should Teaching Hours this Subspecialty Subspecialty match name in Dedicated to Topic Discipline Fellows Fellows Topic conference list) Area? Attend Attend Attend e.g., Biostatistics Research Course 14 X Basic science as related to the application in clinical subspecialty practice Clinical subspecialty content For the topics below, if the topic is not appropriate for your discipline (i.e., lab research for fellows in developmental and behavioral pediatrics), enter N/A into column 1. Biostatistics Lab research methodology (if appropriate) Clinical research methodology Study design Grant preparation Preparation of protocols for institutional review board Principles of evidence- based medicine/ Critical literature review Quality Improvement Teaching skills Professionalism/Ethics Cultural Diversity Systems-based practice (economics of healthcare, practice management, clinical outcomes, etc.)
  • E. Conferences (GPR V.D.2) 1. List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the subspecialty training program. Identify the "INSTITUTION" by using the corresponding number as appears on the first and second pages of this form. 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.) Hospital (HOSP1, Conference HOSP2, etc.) Frequency R/O Role of the Fellow 2. 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 words F. Scholarship Oversight Committee (GPR V.C) Is there a scholarship oversight committee for every ( ) YES ( ) NO fellow? How often does the committee meet with the fellow? # ______times per year Are there written guidelines outlining the responsibility of ( ) YES ( ) NO the oversight committee? G. Fellow Research Activities (GPR V.C.) 1. Describe how the program ensures a meaningful supervised research experience for the fellows, beginning in their first year and extending throughout their training. 2. If faculty outside the division are actively involved in mentoring the fellows, list and provide details. H. ACGME Competencies (GPR V.D.) 1. Practice-based Learning and Improvement (GPR V.D.3) a. 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) (2) (3) b. Outline the faculty development activities that are provided for acquainting the faculty with mentoring skills. Limit response to 75 words c. How does the program ensure fellow competence in using information technology to access, analyze, and apply best evidence to the care of patients? Limit response to 100 words d. Using a 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 • • e. Learning Plans Is each fellow required to have an individualized ( ) YES ( ) NO learning plan? ( ) No guidance, resident driven Who provides guidance to the fellow in completing this ( ) Fellow’s mentor plan (check all that apply)? ( ) Program Director ( ) Other (describe) ( ) Annually How often are these plans developed or updated? ( ) Semi- Annually ( ) Other (describe) f. List the clinical quality improvement activities in which fellows actively participate and identify who guides them in this process. Limit response to 150 words g. Describe (1) how fellows learn teaching skills, (2) what opportunities are available for teaching, (3) how the fellows’ skills are assessed, and (4) state whether there is a specific assessment tool to evaluate teaching skills and, if so, identify this tool. Limit response to 150 words (1) (2) (3) (4) 2. Interpersonal and Communication Skills (GPR V.D.4) a. Using the bulleted list below (add bullets as needed), identify the specific method(s) the program uses
  • to ensure that fellows achieve competence in effective communication (verbal and written) in a consultative role with other physicians, health care workers, and outside agencies. • • b. 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 c. 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) 3. Professionalism (GPR V.D.5) a. Using a 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 • • b. Explain how the following contribute to the evaluation of professionalism: (1) patients/families, and (2) members of the health care team. Attach as Appendix B the assessment tool that patients/families and members of the health care team use to evaluate professionalism (if different tools are used attach a copy of each). Limit response to 150 words (1) (2) 4. Systems-based Practice (GPR V.D.6) a. Teaching and Evaluation i. Address how the elements of this competency are taught and how they are evaluated. System errors are addressed in section 6b) and need not be included here. Limit response to 200 words ii. How does your program meet the requirement for exposure to administrative experience in the context of your subspecialty? Limit response to 200 words
  • iii. 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. iv. Describe the activity that fulfills the requirement for acknowledgement, examination and prevention of system-causes of medical errors, and state who guides/supervises fellows in this activity Limit response to 150 words v. Is there a policy defining the supervisory lines of responsibility and faculty back-up? ...............................................................................................................................( ) YES ( ) NO
  • SECTION 9. RESIDENT MOONLIGHTING A. Moonlighting and Oversight (GPR VI.D & VI.E) Is there a moonlighting policy? ( ) YES ( ) NO Is the policy distributed to all fellows? ( ) YES ( ) NO If moonlighting is permitted, is it monitored? ( ) YES ( ) NO Is there a duty hours policy? ( ) YES ( ) NO
  • SECTION 10. EVALUATION (GPR VII) A. Fellow (GPR VII.A) 1. Using the table below (1) provide the methods of evaluation used for assessing fellow competence in each of the six required ACGME Competencies and (2) identify the evaluators for each method (e.g.,” performance in patient care is evaluated by global forms completed by faculty, medical knowledge is assessed through the In-Training Examination and an evidence-based journal club evaluated by the PD etc.)” Insert rows as needed. Competency Methods of Evaluation Evaluator(s) Patient care Medical knowledge Practice-based learning & improvement Interpersonal & communication skills Professionalism Systems-based practice 2. Describe how the program acquaints fellows with the performance criteria on which they will be evaluated. Limit response to 100 words 3. Describe the system that is used to ensure that fellows are evaluated in writing in a timely manner by supervising faculty after each rotation. Limit response to 200 words 4. Describe the mechanism, the frequency, and by whom formal feedback is provided to the fellows. Limit response to 100 words B. Faculty (GPR VII.B) 1. Explain how the teaching faculty are evaluated and how fellows participate formally and regularly in the
  • process. Limit response to 100 words C. Program (GPR VII.C) 1. Using a bulleted list below, identify the types and sources of feedback received on the success of the program in accomplishing its goals, the adequacy of its resources, etc., and describe how this feedback is used for evaluating and improving the educational program. • • Is there a regular meeting to discuss program goals and the effectiveness in ( ) YES ( ) NO achieving them? 1) How frequently does the above meeting occur? per year 2) How many faculty participate? 3) How many fellows participate? 4) Is there documentation of these meetings (i.e., minutes)? ( ) YES ( ) NO
  • RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60610 • www.acgme.org PROGRAM INFORMATION FORM - PEDIATRIC HEMATOLOGY-ONCOLOGY MEDICINE (PART 3) FOR INITIAL APPLICATION ONLY SECTION 11. OTHER PROFESSIONAL PERSONNEL (GPR III.C) 1. List only the numbers of those who work in the Pediatric Hematology-Oncology training program: Number of staff in these categories Hospital 1 Hospital 2 Hospital 3 Psycho-Social support staff Social Service staff Pediatric Dietary Service/Nutrition staff Nurse Specialists and/or Physician Extenders (e.g., pediatric nurse practitioners and/or physician's assistants trained in this specialty) Pediatric occupational and physical therapists Respiratory therapists Other (specify) 2. Describe the involvement of the staff in each of these categories in the Pediatric Hematology-Oncology program:
  • SECTION 12. FACILITIES AND RESOURCES (GPR III.D.1; PR III) A. Outpatient and Inpatient (PR III.A) 1. Indicate the availability of the following: Hospital 1 Hospital 2 Hospital 3 Facility/Service (Yes/No) (Yes/No) (Yes/No) Are there separate divisions of hematology and oncology* Space in an ambulatory setting for optimal evaluation and care of patients An inpatient area with full pediatric and related services (including surgery and psychiatry) staffed by pediatric residents and faculty Full support services including radiology laboratory, nuclear medicine and pathology Pediatric intensive care unit Neonatal intensive care unit * Provide a description of the organization if separate divisions are indicated. Specifically state the administrative and teaching role of each division in the training program. 2. Using the hospital designated as Primary Hospital 1, provide the following information: Primary Hospital 1 only Number of Beds Inpatient Pediatrics exclusive of ICU PICU NICU 3. Provide a detailed explanation if NO is indicated for any of the facilities and/or services across all hospitals. B. Laboratories and Diagnostic Services (GPR III.D.2; PR III.B) Indicate the availability of the following: Hospital 1 Hospital 2 Hospital 3 Service Yes No Yes No Yes No DIAGNOSTIC RADIOLOGY 1. Angiography 2. Nuclear medicine capabilities 3. Computerized tomography 4. Ultrasonography 5. Magnetic resonance imaging
  • Hospital 1 Hospital 2 Hospital 3 Service Yes No Yes No Yes No DIAGNOSTIC RADIOLOGY 6. PET scanner PROCEDURAL EXPERIENCE 7. Bone marrow/PBSC transplantation 8. Solid organ transplantation 9. Renal hemodialysis 10. Limb-saving procedures ADMINISTRATIVE 11. Tumor registry 12. Tumor board Cancer rehabilitation program CLINICAL PROGRAMS 13. Transfusion medicine program 14. Hemophilia program 15. Sickle cell/hemoglobinopathy program FAMILY SUPPORT 16. Hospice program for children 17. Parent support group 18. Cancer rehabilitation program 19. Radiation Oncology facility 1. If NO is indicated for any facilities and/or services in the primary institution (Hospital 1) above, explain how the service is provided in either hospital 2 or 3 or in some other location. 2. Describe the clinical laboratory facilities available to fellows in support of patient care. Are they convenient to patient care areas? To what extent are they used by fellows? C. Support Services (GPR III.D.2) Place a check mark in the appropriate spaces where these particular services are available at the participating institutions in the program. This list is for screening purposes only. It does not include all tests or services though desirable for training, nor must all of the services listed be available for a program to be accredited. AVAILABLE AVAILABLE24 HOURS/DAY Hospital Hospital Hospital Hospital Hospital Hospital 1 2 3 1 2 3 1. Drug assays 2. Antibiotic 3. Radioisotopic cardiac imaging 4. Echocardiography 5. Diagnostic microbiology 6. Diagnostic virology 7. Hemoglobin electrophoresis 8. Tissue typing laboratory 9. Coagulation laboratory (factor assays, platelet function) 10. Karyotyping and molecular cytogenetics 11. Molecular genetics laboratory 12. Flow cytometry
  • SECTION 13. PATIENT DATA (GPR III.D.3; PR IV.A) Provide the requested information for the most recent 12 month period or academic year using the same timeframe for all patient and procedural data on subsequent pages. Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy): A. Inpatient Hospital 1 Hospital 2 Hospital 3 1. Total number of admissions for whom the pediatric hematology service assumed major clinical responsibility a. Average daily census of patients on the pediatric hematology- oncology service b. Number of new patients admitted each year(“new” refers to those who are being seen by hematologists/oncologists for the first time) c. Average length of stay of patients on the pediatric hematology- oncology service 2. Number of consultations by pediatric hematologists/oncologists on other inpatients a. Are consultations provided to the NICU? Yes or No If yes, how many? b. Are consultations provided to the PICU? Yes or No If yes, how many? 3. If the program does not have a sizable population of patients with non-oncologic hematologic disorders, such as one based in a cancer center, explain how fellows gain exposure to sickle cell disease, hemophilia, and other acute and chronic hematologic problems.
  • SECTION 14. 1AMBULATORY PEDIATRIC HEMATOLOGY-ONCOLOGY EXPERIENCE FOR ALL YEARS OF TRAINING (GPR III.D.3; PR IV.B) Number of Average Average Return Number Number Number of Number of Patients Other Teaching Duration of Sessions New Patients Per Fellow Trainees Attending Faculty Name of Experience Experience Per Week Per Fellow Per Per s Per Supervision Hospital/Other Setting Identifier (in wks/yr) Per Fellow Per Session Session Session Session Yes/No 1. 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. 2. Explain how fellows have the opportunity to provide outpatient care for patients whom they treated on the inpatient service.
  • SECTION 15. LIST OF DIAGNOSES (GPR III.D.3 and V.D.1; PR IV.B) List 150 consecutive inpatient admissions (A) and consultations (C)* from the general pediatric service to the Pediatric Hematology-Oncology service. Identify the time period during which these admissions/consultations occurred. The date range should occur within the same 12-month period used in section 13. Submit a separate list for each hospital that provides required rotations. Use additional pages as necessary. Hospital Name: Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy): Primary Reason for Hematologic/Oncologic Admission (i.e. Number of Diagnosis (i.e. Sepsis, Aplastic Patient ID days in Osteosarcoma, Crisis, A or C* Number Age hospital Thalassemia) Chemotherapy, etc. Outcome
  • SECTION 16. 12-MONTH SUMMARY - INPATIENT SERVICE (GPR III.D.3 and V.D.1; PR IV.B) Summarize how many pediatric patients with the following hematologic-oncologic problems were admitted to or consulted on by the Hematology-Oncology service at the primary hospital. This should cover the same 12-month period used on the previous pages. Extract the information from the list of diagnoses on section 15 of this form. FOR NEW APPLICATIONS FILL IN ONLY THE FIRST TWO COLUMNS. Hospital Name: Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy): Inpatients Number of patients Number seen by fellows Number on Number on hem/onc Number seen in hem/onc Number of Disorders service consultation service consultations 1. Leukemia, active treatment 2 Solid tumors, active treatment 3. Lymphomas, active treatment 4. Oncology patients in follow-up 5. Bone marrow failure 6. Disorder of red cell membrane and red-blood-cell metabolism 7. Autoimmune disorders including hemolytic anemia 8. Nutritional Anemia 9. Hemoglobinopathies 10. Thalassemia Syndromes 11. Disorders of white blood cells 12. Platelet disorders 13. Hemophilia and other inherited bleeding disorders 14. Other coagulation/hemostatic disorders 15. Congenital and acquired thrombotic disorders 16. Immunodeficiencies (congenital and acquired) 17. Other Disorders: (please specify)
  • SECTION 17. OUTPATIENT VISITS (GPR III.D.3; PR IV.A) Provide the requested information for the most recent 12 month period or academic year using the same timeframe for all patient and procedural data on subsequent pages. Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy): Ambulatory Visits Hospital 1 Hospital 2 Hospital 3 1. Is there a separate Hematology-Oncology clinic? Yes or No 2. If not, where are the ambulatory pediatric Hematology- Oncology patients seen (e.g. offices, clinics, location)? 3. Number of pediatric hematology-oncology ambulatory visits per year available to fellows. 4. Of this number, how many are new patients? (“new” refers to those who are being seen by members of the hematology-oncology service for the first time.): 5. Number of Pediatric hematology-oncology clinic sessions per week: 1st Year 2nd Year 3rd Year 6. Estimate the number of pediatric hematology-oncology clinics a fellow attends per year in the program. 7. If the experience is in a private office remote from the primary or affiliated institutions, 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 experience and fellow performance are monitored.
  • SECTION 18. 12-MONTH SUMMARY - OUTPATIENT SERVICE (GPR III.D.3; PR IV.B) Summarize how many visits and pediatric patients with the following hematologic-oncologic problems were seen or consulted on by the Hematology-Oncology service at the primary hospital. This should include all procedures in the same 12-month period used on the previous pages. FOR NEW APPLICATIONS FILL IN ONLY THE FIRST TWO COLUMNS. Hospital Name: Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy): Number of patients Number seen by fellows Number of Number of visits on visits on hem/onc Number of new hem/onc Number of new Disorders service patients service patients 1. Leukemia, active treatment 2 Solid tumors, active treatment 3. Lymphomas, active treatment 4. Oncology patients in follow-up 5. Bone marrow failure 6. Disorder of red cell membrane and red-blood-cell metabolism 7. Autoimmune disorders including hemolytic anemia 8. Nutritional Anemia 9. Hemoglobinopathies 10. Thalassemia Syndromes 11. Disorders of white blood cells 12. Platelet disorders 13. Hemophilia and other inherited bleeding disorders 14. Other coagulation/hemostatic disorders 15. Congenital and acquired thrombotic disorders 16. Immunodeficiencies (congenital and acquired) 17. Congenital and acquired thrombotic disorders 18. Other Disorders: (please specify)
  • SECTION 19. TRANSPLANTS (GPR V.D.1; PR IV.B) Indicate the number of transplants performed on patients 18 years or younger for the most recent 12 month period or academic year using the same time frame for all patient and procedural data as provided on subsequent pages. (Specify inclusive dates: from month/day/ year to month/day year.) Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy): Peripheral Blood Umbilical Diagnosis Allogeneic Autologous Bone Marrow Stem Cell Cord Leukemias Lymphomas solid tumors Hematologic disorders Immunologic disorders Metabolic disorders
  • SECTION 20. NARRATIVE DESCRIPTION – SPECIALTY EXPERIENCES (PR IV) A. General Description 1. Provide a general description of each year of training. B. Inpatient experiences 1. Describe the responsibilities that fellows have for inpatients when assigned to inpatient services. 2. Describe how and by whom fellows are supervised in the inpatient setting. 3. State how many hours per week the fellows participate in rounds with faculty. Describe this experience. C. Outpatient experiences (If applicable) 1. Describe the degree of responsibility fellows have for required outpatient care. 2. Describe the continuity of care experience fellows receive during their period of assignment to the outpatient clinic. To what extent do they have the opportunity to provide outpatient care for patients whom they treated on the inpatient service? 3. Describe how and by whom fellows are supervised in the outpatient setting. 4. Describe any additional outpatient facilities where fellows gain ambulatory experience, e.g. emergency department and other clinics. Include the nature of the experience, location, supervision and the educational rationale for each. D. Core Curriculum (PR IV.D) 1. Provide a description of the method by which fellows acquire skills in the following: 1. Performance and interpretation of bone marrow aspiration and biopsy; 2. Lumbar puncture with evaluation of cerebrospinal fluid; 3. Microscopic interpretation of peripheral blood films; and 4. Interpretation of other hematologic laboratory diagnostic tests. 2. Describe how fellows become familiar with all aspects of chemotherapy, surgical therapy and radiotherapy, including treatment protocols and management of complications, diagnosis and
  • treatment of infections in the compromised host, appropriate use of transfusion of the various blood components, including apheresis plateletpheresis and stem cell harvest and infusion.