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  1. 1. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • FOR CONTINUED ACCREDITATION – PEDIATRIC RADIOLOGY GENERAL INSTRUCTIONS REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the Program Information Form (PIF) is being completed for a currently accredited program, follow the provided instructions to create the correct form. Go to the Accreditation Data System found on the ACGME home page ( under Data Collection Systems. Using your previously assigned User ID and password, proceed to the PIF Preparation section on the left hand menu and update the Common PIF data. Most data are updated through annual updates, 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 in the bottom center of each page. Once the Common PIF is complete, proceed to the appropriate Residency Review Committee webpage to retrieve the Specialty Specific PIF for CONTINUED ACCREDITATION. Once the forms are complete, enter page numbers for the Continued PIF in the bottom center for each page that consecutively follows the Common PIF numbering, combine the Common PIF and the Continued Accreditation PIF and complete the Table of Contents (found with the Specialty Specific PIF instructions). After completing the PIF/documents, make four copies. They must be identical and final. Draft copies are not acceptable. The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two or three ring binders, spiral bound notebooks, or any other form of binding. Mail one set of the completed forms to the site visitor at least 14 days before the site visit. The remaining three sets should be provided to the 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 sign it. It must also be signed by the designated institutional official of the sponsoring institution. Review the Program Requirements for Residency Education in Pediatric Radiology. The Program Requirements and the Institutional Requirements may be downloaded from the ACGME website ( For questions regarding: -the completion of the form (content), contact the Accreditation Administrator. -the Accreditation Data System, email For a glossary of terms, use the following link – Pediatric Radiology i
  2. 2. Have the following documents available for the site visitor References to Common Program and Institutional Requirements are in parentheses The Designated Institutional Official should provide the following: 1. Policy for supervision of fellows (addressing fellow responsibilities for patient care, progressive responsibilities for patient management, and faculty responsibility for supervision) (CPR VI.B) 2. Program policies and procedures for fellows’ duty hours and work environment, including grievance and due process (CPR VI; IR II.D.4.e.; IR II.D.4.i.; IR III.B. 3.) 3. Moonlighting policy (CPR VI.E) 4. Documentation of monitoring of fellow duty hours to determine compliance with the requirements (CPR VI.C.1-3) 5. Documentation of internal review (date, participants’ titles, type of data collected, and date of review by the GMEC) (IR IV.) 6. Current Program Letters of Agreement (PLAs) (CPR I.B.1) The Program Director should provide the following: 1. Document delineating the eligibility criteria to enter the program (CPR III.A) 2. Document delineating the skills and competencies the fellow will be able to demonstrate at the conclusion of the program (CPR IV.A.1) 3. Evaluations: a) Objective assessments for the six competencies (Patient Care, Medical Knowledge, Practice-based learning & improvement, Interpersonal & Communication Skills, Professionalism, Systems-based Practice) showing input from multiple evaluators (faculty, peers, patients, self, and other professional staff) (CPR V.A.1.b.(1) and (2)) b) Documentation of fellows’ semiannual evaluations of performance with feedback (CPR V.A.1.b.(3)) c) Final (summative) evaluation of fellows, documenting performance during the final period of education and verifying that the fellow has demonstrated sufficient competence to enter practice without direct supervision (CPR V.A.2) d) Documentation of program evaluation and written improvement plan (CPR V.C) 4. Files of current fellows and most recent program graduates Single Program Sponsors only, have the following additional documents available for review by the site visitor: 1. Copy of the institutional statement that commits the necessary financial, educational, and human resources to support the GME program(s) and provide documentation that the statement has been approved by the governing body, the administration and the teaching staff. (IR I.B.2) 2. Copy of the fellow contract with the pertinent items required by the Institutional Requirements highlighted and numbered according to the Institutional Requirements (IR II.C-D) 3. Institutional policy for recruitment, appointment, eligibility, and selection of fellows (IR II.A) 4. Institutional policy for discipline and dismissal of fellows (IR III.B.7) Pediatric Radiology ii
  3. 3. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • 10 Digit ACGME Program I.D. #: Program Name: TABLE OF CONTENTS When you have completed the forms, number each page sequentially in the bottom center. Report this pagination in the Table of Contents and submit this cover page with the completed PIF. Common PIF1 Page(s) Accreditation Information Participating Sites Single Program Sponsoring Institutions (if applicable) Faculty/Resources Program Director Information Physician Faculty Roster Faculty Curriculum Vitae Non Physician Faculty Roster Program Resources Fellow Appointments Number of Positions Actively Enrolled Fellows (if applicable) Aggregated Data on Fellows Completing or Leaving the Program for the last 3 years (if applicable) Fellows Completed Program in the Last Three years (if applicable) Withdrawn and Dismissed Fellows (if applicable) Fellows Taking Leave of Absence from the Program Skills and Competencies Grievance Procedures Medical Information Access Evaluation (Fellows, Faculty, Program) Fellow Duty Hours Specialty Specific PIF Page(s) Other Residents/Fellows Patient Data Pediatric Procedures Narrative Description Facilities, Space and Equipment Formal Teaching Exercises Pediatric Radiology iii
  4. 4. 11RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • FOR CONTINUED ACCREDITATION – PEDIATRIC RADIOLOGY I. OTHER RESIDENTS/FELLOWS 1. List the accredited pediatric and pediatric subspecialty programs in the site and the number of residents/fellows in each. Accredited Programs Residents/Fellows 2. How many diagnostic radiology residents rotate per year through pediatric radiology? Indicate also the average length of the rotation. Diagnostic Radiology Residents Average Length Of Rotation Number of Pediatric radiology fellows for which approval is sought: 3. Describe the selection process for pediatric radiology fellows. Pediatric Radiology 1
  5. 5. II. PATIENT DATA Reporting Period (Recent 12- month period): From: To: Patient Examination Data Site #1 Site #2 Site #3 Out- patient In-patient Out- patient In-patient Out- patient In-patient Patients Examined TOTAL Adult Pediatric (Inc. neonatal) Diagnostic Examinations TOTAL Adult Pediatric (Inc. neonatal) Outpatient Only Outpatient Only Outpatient Only Number of Emergency Room Radiology Examinations (included above) Adult Pediatric (include neonatal) Pediatric Radiology 2
  6. 6. III. PEDIATRIC PROCEDURES CPT Codes Site #1 Site #2 Site #3 Head and Neck Skull, mandible, mastoids, paranasal sinuses, orbits, dental, temporomandibular, neck 70000-70360 Laryngography and Pharyngography 70373-70374 Salivary Gland/Sialography Totals Chest Routine and Multiple View Chests 71010-71035 Chest Biopsy 71036-71090 Ribs and Sternum 71100-71130 Totals Vertebral Column All regions, radiography of vertebral column 72010-120 72200-220 Myelography - cervical, thoracic, lumbar 72240-72271 Totals Extremities Upper Extremity 73000-140 Upper Extremity Arthrography 73040-041 73115-116 Lower Extremity 73525-526 73580-581 73615-616 Totals Abdomen and Gastrointestinal Abdomen 74000-022 Esophagus, Stomach, Duodenum 74210-241 Small Intestine 74245-260 Colon 74270-280 Cholecystography 74290-291 Cholangiography (all types) Special Procedures: Liver, Biliary Tree and Pancreas (e.g. ERCP) Cholangiography, percutaneous, transhepatic-complete 74320-321 Postoperative biliary duct stone removal 74327 Endoscopic catheterization of the biliary, pancreatic or both ductal systems, fluoroscopic monitoring and radiography 74328-330 Percutaneous and dilation procedures 74350-361 Totals Pediatric Radiology 3
  7. 7. CPT Codes Site #1 Site #2 Site #3 Vascular and Interventional* Angiocardiography Arthrography - thoracic and abdominal Extremity peripheral angiography - upper and lower Selective visceral angiography Angiography - carotid, vertebral, cerebral, and spinal Angiography - pulmonary Lymphography Venography - extremity, caval, and selective Transcatheter therapy - infusion Transcatheter therapy embolization Percutaneous transhepatic biliary procedures Percutaneous transrenal genitourinary procedures Percutaneous abscess drainages Percutaneous biopsies *CPT codes have been deleted from this section only. Totals Miscellaneous 76000-081 Tomography - Exclude Linear Tomograms Made as part of Urograms 76100-102 Cinefluorography - Exclude Cardiac Contrast Studies 76120-125 Other miscellaneous (see CT 39 and MRI #10 below) 76120-125 Totals Computed Tomography Head 70450-482 Face and Neck 70486-492 Thorax 71250-270 Vertebral Column 72125-133 72192-194 Extremities (1) Upper 73200-202 (2) Lower 73700-702 Abdomen 74150-170 Interventional, Abdomen (1) Stereotactic 76355 (2) Needle Biopsy 76360-375 Totals Magnetic Resonance Imaging Pediatric Radiology 4
  8. 8. CPT Codes Site #1 Site #2 Site #3 Head, Orbit, Neck 70540-551 Chest 71550 Vertebral Column 72141-144 Extremities 73220 and 73720 Abdomen & Pelvis 74181 Heart (myocardium) 75552 Bone 76400 Other (List on separate sheet) Totals Diagnostic Ultrasound Head and Neck 76500-536 Chest (1) Echography, chest- mediastinum 76601-604 (2) Echocardiography 76620-629 93300-320 (3) Doppler 76632 Abdomen and Retroperitoneum 76700-775 Pelvis 76805-857 Genitalia, male 76870 Extremities 76880 Vascular 76925 93850-960 Guidance Procedures 76930-999 Totals Nuclear Medicine Thyroid and Parathyroid 78000-018 78070 Adrenal 78075 Unlisted Endocrine 78099 Hematopoietic and Lymphatic 78102-199 Gastrointestinal 78201-299 (1) Gastrointestinal-Liver 78201-216 Musculoskeletal 78300-399 Cardiovascular 78414-499 (1) Cardiovascular-regional myocardial perfusion 78460-465 (2) Cardiovascular-gated equilibrium Imaging 78471-489 Respiratory 78580-599 Nervous System 78600-699 Genitourinary 78700-799 Miscellaneous 78800-999 Therapeutic 79000-999 Radioimmunoassay, Chemistry, Toxicology. Add extra page with 82000-84999 Pediatric Radiology 5
  9. 9. CPT Codes Site #1 Site #2 Site #3 breakdown of RIA procedures performed, if done in radiology department. Totals Pediatric Radiology 6
  10. 10. IV. NARRATIVE DESCRIPTION 1. Describe the clinical and didactic curriculum plan. A rotation schedule should be provided. 2. If the pediatric radiology program is sponsored by a diagnostic radiology residency program, explain the distinction between the residents and the pediatric radiology fellows in terms of clinical activities and level of responsibility. 3. If there are outside rotations, describe the fellows' duties and level of responsibility during each of the outside assignments. 4. How is clinical/didactic instruction provided in the performance of low dose pediatric procedures? 5. Explain how training is provided in each of these areas (assignment in each of these areas should include participation in and responsibility for dictation of reports): a) nuclear medicine b) magnetic resonance imaging c) pediatric neuroradiology d) pediatric angiography and interventional radiology e) pediatric ultrasonography Pediatric Radiology 7
  11. 11. 6. List the conferences that are attended by pediatric radiology fellows. Conference Frequency Responsible Individual or Service/Department 7. Describe the opportunities for fellows to participate in research. 8. Does the pediatric radiology fellow have responsibility for teaching residents or medical students? ( ) YES ( ) NO If so, describe Pediatric Radiology 8
  12. 12. V. FACILITIES, SPACE AND EQUIPMENT 1. Describe the following: a) Conference facilities and space b) Research space and laboratory facilities c) Office space for faculty/fellows 2. List the number of units available to fellows in each site. Include units in other departments, e.g., cardiology, GI and GU. Diagnostic Radiology Equipment Site #1 Site #2 Site #3 Radiographic units only (include chest units) Radiographic Fluoroscopic units Body Section Units (Tomography) Head Units Mobile (Bedside) Radiographic Units Mobile (Bedside) C-arm fluoroscopic units C.T. Units (Include date installed) a) Head Unit (separate) b) Body Unit (separate) c) Combined Head and Body Ultrasound (Sonographic Equipment) B-Scan Units (Compound) Separate Real Time Units Compound (B-Scan) plus Real Time Units Doppler Unit MRI Units Total Units on-site in hospital complex Units available off-site or mobile (describe) Nuclear Radiology Equipment In-Vitro Laboratory In Vivo Imaging/Counting a) Single or Multi Probe Counting Systems b) Tomographic Imaging Systems (Specify) Pediatric Radiology 9
  13. 13. Diagnostic Radiology Equipment Site #1 Site #2 Site #3 c) Cameras 1) Stationary, standard or large field 2) Mobile 3. Describe all special low dose roentgenographic/fluoroscopic facilities available for pediatric patients. Pediatric Radiology 10
  14. 14. VI. FORMAL TEACHING EXERCISES 1Enter the schedule of formal exercises for the most recent 12-month period. The specific title of lectures/sessions is requested. Reporting Period (Recent 12- month period): From: To: Topic Title Pediatric Radiology 11