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  1. 1. RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • FOR NEW APPLICATIONS ONLY - PROCEDURAL DERMATOLOGY GENERAL INSTRUCTIONS APPLICATIONS FOR A NEW PROGRAM: This Program Information Form (PIF) is for programs applying for INITIAL ACCREDITATION ONLY (for Continued Accreditation or re-accreditation, use the CONTINUED ACCREDITATION PIF in conjunction with the Web Accreditation Data System). All sections of the form applicable to the program must be completed in order to be accepted for review. The information provided should describe the proposed program. For items that do not apply indicate N/A in the space provided. Where patient numbers are requested, estimate what you expect will occur. If any requested information is not available, an explanation should be given and it should be so indicated in the appropriate place on the form. Once the forms are complete, number the pages sequentially in the bottom center. Send three complete copies to the executive director of the Residency Review Committee for Dermatology at the address above. They must be identical and final. Draft copies are not acceptable. The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two or three ring binders, spiral bound notebooks, or any other form of binding. The program director is responsible for the accuracy of the information supplied in this form and must sign it. It must also be signed by the designated institutional official of the sponsoring institution. Review the Program Requirements for Residency Education in Procedural Dermatology. The Program Requirements or 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 – Procedural Dermatology i
  2. 2. Attach the following documents to the application: 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, attach the following additional documents to the application: 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) Procedural Dermatology ii
  3. 3. RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 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) Skills and Competencies Grievance Procedures Medical Information Access Evaluation (Fellows, Faculty, Program) Fellow Duty Hours Specialty Specific PIF Page(s) Operative Procedures Outline of Fellow Assignments Narrative Description of the Program Institutional Support Responsibilities of the Program Director Other Specialties and Program Personnel The Educational Program Scholarly Activity Fellow Duty Hours & Working Environment Evaluation Supplement I - Goals and Objectives Procedural Dermatology iii
  4. 4. RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • FOR NEW APPLICATIONS ONLY - PROCEDURAL DERMATOLOGY Date: Title of Program: Core Program Information Title of Core Program: Core Program Director: 10 Digit ACGME Program ID#: Accreditation Status: Effective Date: Next Review Date: Last Review Date: Cycle Length: The signatures of the director of the program and the Designated Institutional Official attest to the completeness and accuracy of the information provided on these forms: Signature of Program Director (and Date): Signature of Core Program Director (and Date): Signature of Designated Institutional Official (DIO) (and Date): 1. Respond to previous citation(s) Provide a concise update on each previous citation and indicate how each has been addressed (if applicable). 2. Describe changes not mentioned above Provide a concise update explaining any major changes, not described in your response to question # 1, to the fellowship program since the last site visit (for example, changes in program format, fellow complement, program leadership, or participating sites). 3. Planned start date for the first class of fellows (answer only if this is a new application) Procedural Dermatology 1
  5. 5. B. PARTICIPATING SITES SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.) Name of Sponsor: Address: Single Program Sponsor? ( ) YES ( ) NO City, State, Zip code: Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School) Name of Designated Institutional Official: Mailing Address: Phone Number: Email: Name of Chief Executive Officer: PRIMARY SITE (Site #1) Name: Address: City, State, Zip Code: Clinical Site? ( ) YES ( ) NO Type of Rotation (select one) Elective ( ) Required ( ) Both ( ) Length of Fellow Rotations (in months) CEO/Director/Pfellow’s Name: Joint Commission Accredited? ( ) YES ( ) NO If no, explain: The Program Director must submit any participating sites routinely providing an educational experience, required for all fellows. Duplicate as necessary. PARTICIPATING SITE (Site #2) Name: Address: City, State, Zip Code: Integrated: ( ) YES ( ) NO Does this site also sponsor its own program in this subspecialty? ( ) YES ( ) NO Does it participate in any other ACGME-accredited programs in this subspecialty? ( ) YES ( ) NO Distance between #2 & #1: Miles: Minutes: Type of Rotation (select one) ( ) Elective ( ) Required ( ) Both Length of Fellow Rotations (in months) CEO/Director/Pfellow’s Name: Brief Educational Rationale: Procedural Dermatology 2
  6. 6. 1. Single Program Sponsoring Institutions (Institutions that sponsor a single core or subspecialty program, or a single core program and its subspecialties). For those institutions which are either a single-program sponsoring institution (e.g., medical genetics only), or an institution with multiple residencies accredited by the same Residency Review Committee (RRC), the institutional review will be conducted in conjunction with the review of the program. Only programs in these two categories are to complete the following institutional questions. a) Provide an institutional statement that commits the necessary financial, educational, and human resources to support the GME program(s) and provide documentation that the statement has been approved by the governing body, the administration and the teaching staff. (IR I.B.2) b) Describe the formal method by which a periodic evaluation of the program’s educational quality and compliance with the program requirements occurs. Explain how fellows and faculty in the program are involved in the evaluation process. (CPR V.C; IR IV) c) Describe how the institution complies with the Institutional Requirements regarding “Fellow Eligibility and Selection” and the development of appropriate criteria for the selection, evaluation, promotion and dismissal of fellows in accordance with the Program and Institutional Requirements. (IR II.A-B) d) Summarize how the institution complies with the ACGME Institutional Requirements regarding fellow support, benefits and conditions of employment to include the details of the fellow contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the fellow contract/agreement to the PIF but state when it is given to the fellows and applicants. Have a copy available for verification by the site visitor on the day of the survey with the various items required by the ACGME numbered according to the Institutional Requirements.) (IR II.C-D) e) Describe in detail the grievance (due process) procedure(s) that is available to fellows, including the composition of the grievance committee, and mechanisms for handling complaints and grievances related to actions which could result in dismissal, non-renewal of a fellow’s contract, or other actions that could significantly threaten a fellow’s intended career development. (IR II.D.4.c-d) Procedural Dermatology 3
  7. 7. C. FACULTY / RESOURCES 1. Program Director Information Name: Title: Address: City, State, Zip code: Telephone: FAX: Email: Date First Appointed as Program Director: Principal Activity Devoted to Fellow Education? Yes: No: Term of Program Director Appointment: Date first appointed as faculty member in the program: Number of hours per week Director spends in: Clinical Supervision: Administration: Research: Didactics/Teaching: Primary Specialty Board Certification: Most Recent Year: Subspecialty Board Certification: Most Recent Year: Number of years spent teaching in this subspecialty: a) Is the program director familiar with and does he/she oversee compliance with ACGME/RRC policies and procedures as outlined in the ACGME Manual of Policies and Procedures (found at .....................................................................................................................( ) YES ( ) NO b) Using the form provided in section C.3. provide a one page CV for the program director. 2. Physician Faculty Roster List physicians and other staff who supervise Dermatopathology fellows and contribute to their instruction. List the salaried positions first then volunteer. Provide a one page CV for each faculty member. Name (Position) Degree Based Mainly at Site # Primary and Secondary Specialties / Field Years as Faculty in Specialty Average Hours Per Week Devoted to Fellow Education Specialty / Field Board Certification (Y/N)† Recertification Date (PD) † Certification for the primary specialty refers to ABMS Board Certification. Certification for the subspecialty refers to ABMS sub-board certification. Procedural Dermatology 4
  8. 8. 3. Faculty Curriculum Vitae First Name: MI: Last Name: Present Position: Graduate Medical Education Program Name(s); include all residencies and fellowships: Certification and Re- Certification Information Current Licensure Data Specialty Certification Year Re-Certification Year State Date of Expiration (mm/yyyy) Academic Appointments - List the past ten years, beginning with your current position. Start Date (mm/yyyy) End Date (mm/yyyy) Description of Position(s) Present Concise Summary of Role in Program: Current Professional Activities / Committees: Selected Bibliography - Most representative Peer Reviewed Publications / Journal Articles from the last 5 years (limit of 10): Selected Review Articles, Chapters and/or Textbooks (Limit of 10 in the last 5 years): Participation in Local, Regional, and National Activities / Presentations - Abstracts (Limit of 10 in the last 5 years): If not ABMS board certified, explain equivalent qualifications for Review Committee consideration: 4. Non Physician Faculty Roster List alphabetically the non-physician faculty who provide required instruction or supervision of fellows in the program. Name (Position) Degree Based Primarily at Site # Subspecialty / Field Role In Program # of Years Teaching as Faculty in Subspecialty Procedural Dermatology 5
  9. 9. 5. Program Resources a) How will the program ensure that faculty (physician and nonphysician) have sufficient time to supervise and teach fellows? Include time spent in activities such as conferences, rounds, journal clubs, research, mentoring, teaching technical skills etc. if relevant. b) Briefly describe the educational and clinical resources available for fellow education. [The answer must include how specialty specific reference materials are accessible. It should also include resources provided by the program and the institution.] Procedural Dermatology 6
  10. 10. D. FELLOW APPOINTMENTS 1. Number of Positions (for the current academic year) Number of Requested Positions Number of Filled Positions* *Not applicable to new programs with no fellows on duty. Count part-time fellows as 0.5 FTE. If the number of filled positions exceeds the number of positions approved by the Review Committee, provide an explanation of this variance. 2. Actively Enrolled Fellows (if applicable) a) List alphabetically all fellows actively enrolled in this program as of August 31 of current academic year. Name Program Start Date Expected Completion Date Year in Program Years of Prior GME Specialty of Most Recent Prior GME Has completed an ACGME- accredited specialty program (Y/N) If no, explain b) Did you obtain documentation that each fellow has met the eligibility criteria? ( ) YES ( ) NO Procedural Dermatology 7
  11. 11. E. SKILLS AND COMPETENCIES Describe how fellows are informed about their assignments and duties during the fellowship. [The answer must confirm that there are skills and competencies that the fellow will be able to demonstrate at the conclusion of the program, and that these are distributed (hard copy, electronically, listserv, etc.) to all fellows.] F. GRIEVANCE PROCEDURES Describe how the program handles complaints or concerns the fellows raise. (The answer must describe the mechanism by which individual fellows can address concerns in a confidential and protected manner as well as steps taken to minimize fear of intimidation or retaliation.) G. MEDICAL INFORMATION ACCESS 1. Do fellows have access to specialty-specific and other appropriate reference material in print or electronic format? .............................................................................................( ) YES ( ) NO 2. Are electronic medical literature databases with search capabilities available to fellows? .........................................................................................................................( ) YES ( ) NO H. EVALUATION (FELLOWS, FACULTY, PROGRAM) 1. Are fellows provided with a description of the skills and competencies that they should be able to demonstrate by the conclusion of the program? ...............................................( ) YES ( ) NO 2. Does the faculty provide formative feedback in a timely manner?.....................( ) YES ( ) NO 3. Describe how evaluators are educated to use assessment methods for the six competencies so that fellows are evaluated fairly and consistently. Limit your response to 400 words. 4. Describe how fellows are informed of the performance criteria on which they will be evaluated. Limit your response to 400 words. 5. Describe how the fellows develop skills to locate, appraise, and assimilate evidence from scientific studies related to their patients’ health. Limit your response to 400 words. 6. Describe at least one change implemented during the last year due to fellow participation in quality improvement activities. Limit your response to 400 words. Procedural Dermatology 8
  12. 12. 7. Describe the mechanism used to provide the semiannual evaluations of fellows (e.g., who meets with the fellows and how the results are documented in fellow files). Limit your response to 400 words. 8. Describe the system for evaluating faculty performance as it relates to the educational program. Limit your response to 400 words. 9. Describe the mechanisms used for program evaluation, including how the program uses aggregated results of the fellows’ performance and/or other program evaluation results to improve the program. (Have the written plan of action available for review by the site visitor.) Limit your response to 600 words. I. FELLOW DUTY HOURS 1. Concisely describe how faculty members supervise fellows in patient care activities. 2. How will the program ensure that fellows comply with the ACGME duty hour standards? Be specific as regards the duty hour weekly limit, time spent on-call, days free each week, length of duty shifts, periods of rest between duty shifts, and moonlighting policies, as applicable. 3. How are fellow duty hours monitored? 4. How are identified fellow duty hour violations addressed? Procedural Dermatology 9
  13. 13. RESIDENCY REVIEW COMMITTEES FOR DERMATOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • FOR NEW APPLICATIONS ONLY - PROCEDURAL DERMATOLOGY I. OPERATIVE PROCEDURES Provide number of dermatologic procedures performed in a recent 12 month period in each site identified in the Common PIF. If more than four sites are involved in the program, duplicate the form as needed. 12-Month Period Covered by Statistics From: To: #1 #2 #3 #4 Total Excision - Benign Lesion Excision - Malignant Lesion Nail procedures Repair (closure) simple / intermediate / complex Grafts (split or full) Flaps Ambulatory phlebectomy / vein surgery Dermabrasion Chemical Peel: superficial-epi Chemical Peel: deep dermal Tumescent liposuction Hair removal laser Vascular lesion laser Pigmented lesion laser Laser (ablation, resurfacing) Non-ablative rejuvenation Intense pulsed light Mohs micrographic surgery Mohs micrographic surgery (complex / large) Sclerotherapy Hair transplantation Soft Tissue Augmentation / Skin Fillers Rhinophyma correction Lip excision / wedge / vermilionectomy Scar revision (acne scar or procedure not otherwise listed) Botulinum toxin chemodeinnervation Other Procedural Dermatology 10
  14. 14. II. OUTLINE OF FELLOW ASSIGNMENTS Provide a typical weekly schedule for a program fellow using the chart below. Monday Tuesday Wednesday Thursday Friday Saturday Sunday AM PM Procedural Dermatology 11
  15. 15. III. NARRATIVE DESCRIPTION OF THE PROGRAM The questions which follow provide programs with an opportunity to systematically describe the manner in which they comply with accreditation requirements. Responses should be concise and focused. During the site visit, residents, faculty, and others will be asked for comment on the information provided. As a result, those who will be interviewed should read the PIF prior to their meeting with the site visitor. A. Institutional Support 1. Program Sponsorship and Affiliation a) If the program is sponsored by an institution that also sponsors a Dermatology residency, how do the two program directors monitor the interaction of residents and fellow to ensure appropriate educational experiences for both? b) If the program is not affiliated with an accredited Dermatology residency, explain why. Note: Programs that are not sponsored by institutions that also sponsor other programs must document compliance with the ACGME's institutional requirements. 2. Describe the space dedicated to the performance of dermatologic surgery, including Mohs micrographic frozen section laboratories and patient examination areas. Are program's laboratory facilities accredited? If so, identify the accreditation agency(ies). 3. Summarize fellow access to (a) a major medical library, (b) electronic retrieval of information and medical databases, and (c) on-site collection of texts and journals at each site. B. Responsibilities of the Program Director 4. How does the program director select, supervise, and evaluate the teaching staff and other program personnel at each site participating in the program? Has a local site director been identified in each site? How does the director monitor resident supervision at each site? 5. Has the program implemented procedures regarding fellow grievances during the last five years? If yes, provide a concise summary. 6. How does the program monitor fellow stress, including mental or emotional conditions inhibiting performance or learning? What arrangements does the program have for the provision of counseling and psychological support services for fellow? Procedural Dermatology 12
  16. 16. C. Other Specialties and Program Personnel 7. Concisely describe the opportunities fellows have to work with personnel from other specialties. 8. Concisely summarize the technical, clerical, and other non-physician personnel who provide support for the administrative and educational conduct of the program. Is the support of the program in this area satisfactory at all sites? D. The Educational Program 9. Describe the didactic component of the program. Include a list of the conferences that were held during the last year, including those that were devoted to each of the three components of the body of knowledge which serve as the basis for procedural dermatology: cutaneous oncologic surgery, cutaneous reconstructive surgery, and cutaneous cosmetic surgery. Provide the date, location, audience and specific topic of each session. 10. Concisely describe fellow education in related disciplines such as surgical anatomy, sterilization of equipment, aseptic technique, anesthesia, closure materials, instrumentation, cardiopulmonary resuscitation, and wound healing. PR V.B.2. 11. How does the program ensure that fellows have opportunity to develop competence in pre-operative evaluation of patients? Include comment on the manner in which fellows gain experience in the identification of a) patients whose conditions should be treated by dermatologic surgical techniques and b) those who should be referred to other specialists. 12. How does the program ensure that fellows have opportunity to gain experience in the post-operative follow up care of patients? 13. Describe the manner in which faculty instruct and supervise fellows during the performance of dermatologic surgical procedures. How are fellows given the opportunity to assume increasing responsibility as they gain experience and develop more advanced skills. 14. Summarize fellow education and experience in laboratory management and slide review. 15. Summarize fellow education and experience in the area of quality improvement activities. Procedural Dermatology 13
  17. 17. E. Scholarly Activity 16. Summarize program research activity, including comment on each of the following: a) List the staff who provide stimulation and supervision of clinical or laboratory research activity by residents and identify their particular area(s) of expertise. b) List the publications in refereed journals (during the last 3 years) by program residents. Provide titles, co-authors, dates with resident name in bold font. c) List the research presentations (during the last three years) that resulted from resident research activity during the program. 17. Describe the time free of clinical duties that is provided for resident participation in clinical or laboratory research. F. Fellow Duty Hours & Working Environment 18. Describe the manner in which the program ensures the fellows' call schedule is in compliance with V.F.3. of the program requirements. G. Evaluation 19. Describe the manner in which the program director and other members of the teaching staff participate in a quality improvement review of the frozen section slides. 20. Describe the manner in which program personnel (including at least one fellow) review, at least once each year, program effectiveness. How are evaluations of fellow performance utilized in this process? Procedural Dermatology 14
  18. 18. SUPPLEMENT I - GOALS AND OBJECTIVES Attach a copy of the educational goals and objectives for each required rotation or major assignment. Procedural Dermatology 15