RESIDENCY REVIEW COMMITTEE FOR INTERNAL MEDICINE                             515 N State, Ste 2000, Chicago, IL 60610 • (3...
1RESIDENCY REVIEW COMMITTEE FOR INTERNAL MEDICINE                             515 N State, Ste 2000, Chicago, IL 60610 • (...
RESIDENCY REVIEW COMMITTEE FOR INTERNAL MEDICINE                             515 N State, Ste 2000, Chicago, IL 60610 • (3...
SECTION 6. FACILITIES AND RESOURCES FOR TRAININGUse the institution numbers and names as they appear in Part 1, Section 2....
SECTION 7. ADMINISTRATION OF THE TRANSPLANT HEPATOLOGY FELLOWSHIP PROGRAM1. Is there is a single program director responsi...
SECTION 8. OTHER PROFESSIONAL FACULTY IN TRANSPLANT HEPATOLOGYProvide the following information for all other PHYSICIAN fa...
NAME                           SPECIALTY   1   YEAR CERT   SPECIALTY   2   YEAR CERT   SPECIALTY   3   YEAR CERT   HRS/WK ...
SECTION 9. ROTATION/ASSIGNMENT SCHEDULEInstruction: Provide a rotation schedule that describes the rotations for a typical...
SECTION 10. EDUCATIONAL PROGRAMA. Curriculum     1. Is there a written curriculum for the fellowship program? ...............
SECTION 10. EDUCATIONAL PROGRAMA. Subspecialty ExperienceIndicate how fellows will obtain experience and if they will be r...
B. Subspecialty Didactic Experience     1. Will fellows receive formal didactic instruction in the following content areas...
SECTION 11. AMBULATORY EXPERIENCEProvide information for the fellows continuity experience and patient distribution. List ...
SECTION 12. TRANSPLANT HEPATOLOGY RESEARCH 1. What percentage of the key clinical faculty (listed in Part 1) participate i...
SECTION 13. EVALUATIONA. Fellow Evaluation     Using the table below: (1) provide the methods of evaluation that will be u...
7. Will the supervising teaching attending review the performance of the fellow with him or her at the        completion o...
SECTION 14 NARRATIVE1.         List the outstanding or special features of the program.2.         List those aspects of th...
SECTION 15. DOCUMENTS CHECKLISTInstructions: Please send a copy of each of the following documents. If the document contai...
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RESIDENCY REVIEW COMMITTEE FOR INTERNAL MEDICINE

  1. 1. RESIDENCY REVIEW COMMITTEE FOR INTERNAL MEDICINE 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5496 • www.acgme.org PROGRAM INFORMATION FORM FOR TRANSPLANT HEPATOLOGY FOR NEW APPLICATIONS ONLYINSTRUCTIONSAPPLICATION FOR A NEW PROGRAM: This form is for use by programs making Initial Application Only (forre-accreditation, use the Continued Accreditation PIF and the Accreditation Data System). All applications for anew program must be initiated by the Sponsoring Institution Designated Institutional Official (DIO) using theAccreditation Data System (ADS) found on the ACGME home page (www.acgme.org). The Program InformationForm (PIF) is separated into 2 parts. Part 1 is to be completed online after the DIO completes the initialapplication step and provides a user ID and password to the Program Director. Using the assigned user ID andpassword the Program Director must complete the 8 step process and print all 4 sections of the PIF Part 1.Complete Part 2 of the PIF using your preferred word processor only after Part 1 has been completed. CombinePart 1 and Part 2, number the pages consecutively on the upper right corner, beginning with Part 1 Section 1,complete the Table of Contents (found with the Part 2 instructions), and obtain all required signatures. Mail threecopies to the Review Committee at the address above.All sections of the form applicable to the program must be completed in order to be accepted for review. Theinformation provided should describe the proposed program. For items that do not apply, indicate N/A in thespace provided. Where patient numbers are requested, estimate what you expect will occur. If any requestedinformation is not available, an explanation should be given and it should be so indicated in the appropriate placeon the form.The Institutional Requirements and the Program Requirements may be downloaded from the ACGME website(www.acgme.org). Before completing the PIF, please review the Program Requirements for Residency Educationin Transplant Hepatology and, the General Requirements for Residency Education in Subspecialties of InternalMedicine.For questions/problems regarding: - the site visit, contact the writer of the letter announcing the site visit. - the completion of the form (content), contact the Accreditation Administrator. - the Accreditation Data System data entry, email WebADS@acgme.org.For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.aspThe forms are designed for use by single institution as well as multi-institution programs. The Program Director isresponsible for the collection of data and other information from each participating institution. All the informationis to be consolidated and reported on a single set of forms which must be signed by the Program Director andDesignated Institutional Official. If more space is required to respond to an item, expand the text boxes asnecessary. The information provided should be complete but concise and should not include unrequestedmaterial such as reprints, brochures, computer printouts, catalogs, or lengthy CVs.SPECIFIC INSTRUCTIONSFACULTY DATA: List alphabetically and by site the physician faculty to include the following: a minimum of twokey clinical faculty, including the program director, who devotes at least 10 hours per week to fellow education. Ifthe program is approved for more than four positions, list additional faculty if required based on the requirementfor a minimum faculty to fellow ratio of 1:1.5. In addition, supply a one page CV for each faculty listed.residency-review-committee-for-internal-medicine3822.doc
  2. 2. 1RESIDENCY REVIEW COMMITTEE FOR INTERNAL MEDICINE 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5496 • www.acgme.org PROGRAM INFORMATION FORM FOR TRANSPLANT HEPATOLOGYProgram Name:TABLE OF CONTENTSWhen you have the completed forms, number each page consecutively in the upper right hand corner. Starton Part 1, Section 1 of the PIF. Report this pagination in the Table of Contents and submit this page with thecompleted PIF. 1Part 1 Section Page(s)General Program Information 1 Accreditation Information 1.A Program Director Information 1.BParticipating Institutions 2Resident Complement 3Faculty / Teaching Staff 4 Faculty Roster 4.A Faculty Curriculum Vitae (standard 1-page form) 4.B Part 2 Section Page(s)Background Information 5 Sponsoring Institution/Single or Limited Residency Institution (see ACGME Institutional 5.A Requirements) Competency Assessment 5.BFacilities and Resources for Training 6Administration of the Transplant Hepatology Fellowship Program 7Other Professional Faculty in the Transplant Hepatology Fellowship Program 8Rotation/Assignment Description 9Educational Program 10Ambulatory Experience 11Transplant Hepatology Research 12Evaluation 13Narrative 14Documents Checklist 15residency-review-committee-for-internal-medicine3822.doc
  3. 3. RESIDENCY REVIEW COMMITTEE FOR INTERNAL MEDICINE 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5496 • www.acgme.org PROGRAM INFORMATION FORM FOR TRANSPLANT HEPATOLOGY FOR NEW APPLICATIONS - (Part 2)SECTION 5. BACKGROUND INFORMATIONA. Sponsoring Institution/Single or Limited Residency Institution (see ACGME Institutional Requirements – if applicable) For those institutions with multiple residencies accredited by the same Residency Review Committee, the institutional review will be conducted in conjunction with the review of the program. Only programs in this category are to complete the following institutional questions. Complete only if "single/limited site sponsor" field in Part 1, Section 2 is YES. 1. 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 (Appendix 11). 2. 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. 3. Describe how the institution complies with the Institutional Requirements regarding “Resident 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. 4. Summarize how the institution complies with the ACGME Institutional Requirements regarding fellow support, benefits and conditions of employment to include the details of the resident contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the resident contract/agreement to the PIF but state when it is given to the residents 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.) 5. 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 resident’s contract, or other actions that could significantly threaten a fellow’s intended career development.B. Competency Assessment Provide a brief summary of the steps your program will take to implement and evaluate each of the six ACGME general competencies. (Appendix 3)residency-review-committee-for-internal-medicine3822.doc
  4. 4. SECTION 6. FACILITIES AND RESOURCES FOR TRAININGUse the institution numbers and names as they appear in Part 1, Section 2. to complete this facilities checklist forall participating institutions used for routine rotations.Checklist Institution #1 Institution #2 Institution #3 Institution #4 Institution #5Number of liver transplantsperformed each yearNumber of liver biopsiesperformed each yearNumber of allograft liverbiopsies performed each yearUNOS-approved transplant ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOprogramInterventional radiologyfacilities to:Perform balloon angioplasty ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOPerform transjugularintrahepatic portal systemic ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOshuntAre the following available:Fellow office ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOOutpatient clinic facilities ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOAdequate clinic support staff ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOOn-site medical library ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOAfter-hours access to reference ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOmaterialsAccess to electronic medicaldata base and computerized ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOliterature searchAccess to medical records at ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOtime of outpatient visitAccess to medical recordsavailable to inpatient teaching ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOservice in a timely mannerOn-call facilities:Sleeping rooms ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOFood facilities ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOAccredited programs in:Internal Medicine ( ) YES ( ) NOGastroenterology ( ) YES ( ) NO1. Interactions with Other Disciplines: a. Do fellows and faculty share patient co-management responsibilities with transplant surgeons from the preoperative phase to the outpatient period?......................................................................( ) YES ( ) NO b. Does the program ensure close interactions and education with an experienced liver transplant pathologist? ........................................................................................................................( ) YES ( ) NO c. Does the program use a multidisciplinary approach to issues in donor selection and evaluation and in recipient criteria? ................................................................................................................( ) YES ( ) NO2. Will fellows be provided autopsy reports after autopsies are completed on their patients? .......( ) YES ( ) NOresidency-review-committee-for-internal-medicine3822.doc
  5. 5. SECTION 7. ADMINISTRATION OF THE TRANSPLANT HEPATOLOGY FELLOWSHIP PROGRAM1. Is there is a single program director responsible for the transplant hepatology fellowship program? ...................................................................................................................................................( ) YES ( ) NO2. Does the sponsoring institution provide adequate salary support for the program director for the administrative activities of the program?...........................................................................................................( ) YES ( ) NO3. Does the salary support prevent the program director from the need to generate income to support the administrative activities of the program?....................................................................................( ) YES ( ) NO4. Are there adequate inpatient facilities (e.g., conference rooms, on-call rooms) for the transplant hepatology fellowship program? ..................................................................................................................( ) YES ( ) NO5. Are there adequate facilities in the ambulatory settings (i.e. exam rooms, meeting/conference room, work area) for patient care and the educational components of the program? ..................................( ) YES ( ) NO6. Does the program director have sufficient authority to: a. Determine number of fellows?.............................................................................................( ) YES ( ) NO b. Determine fellow rotations – including amount of fellow off-site time?.................................( ) YES ( ) NO c. Control fellow work load – including number of patients – on all rotations at principal teaching hospital?..... ............................................................................................................................................( ) YES ( ) NO d. Control teaching space and other facilities relevant to the training program?......................( ) YES ( ) NO e. Select teaching attendings based on fellow evaluations?....................................................( ) YES ( ) NO f. Determine fellowship curriculum, including content of conferences fellows usually attend?( ) YES ( ) NOIf the answer to any of the above questions is no, please explain below.residency-review-committee-for-internal-medicine3822.doc
  6. 6. SECTION 8. OTHER PROFESSIONAL FACULTY IN TRANSPLANT HEPATOLOGYProvide the following information for all other PHYSICIAN faculty who will participate in the transplant hepatology program but devote less than 10 hoursper week, on average, to the training program. Duplicate page if necessary.residency-review-committee-for-internal-medicine3822.doc
  7. 7. NAME SPECIALTY 1 YEAR CERT SPECIALTY 2 YEAR CERT SPECIALTY 3 YEAR CERT HRS/WK WKS/YR ROLE IN PROGRAM: NAME SPECIALTY 1 YEAR CERT SPECIALTY 2 YEAR CERT SPECIALTY 3 YEAR CERT HRS/WK WKS/YR ROLE IN PROGRAM: NAME SPECIALTY 1 YEAR CERT SPECIALTY 2 YEAR CERT SPECIALTY 3 YEAR CERT HRS/WK WKS/YR ROLE IN PROGRAM: NAME SPECIALTY 1 YEAR CERT SPECIALTY 2 YEAR CERT SPECIALTY 3 YEAR CERT HRS/WK WKS/YR ROLE IN PROGRAM: NAME SPECIALTY 1 YEAR CERT SPECIALTY 2 YEAR CERT SPECIALTY 3 YEAR CERT HRS/WK WKS/YR ROLE IN PROGRAM:residency-review-committee-for-internal-medicine3822.doc
  8. 8. SECTION 9. ROTATION/ASSIGNMENT SCHEDULEInstruction: Provide a rotation schedule that describes the rotations for a typical fellow. Do not include vacation blocks. Use a distinct title for eachrotation that allows the Committee to understand the educational nature of the rotation, e.g., Inpatient Liver Transplant. Do not use abbreviations or localterminology (e.g. “Blue 1”). Please define all required experiences. Indicate elective rotations with the term “elective”.PLEASE PROVIDE A ROTATION SCHEDULE NARRATIVE THAT ACCURATELY DESCRIBES EACH ROTATION IN YOUR PROGRAM. (APPENDIX4) 1 2 3 4 5 6 7 8 9 10 11 12 Rotation Institution/Site Duration of Experience (weeks or months)Average Number ofHours on Duty per WeekNumber of Full Days off per week During thisRotation/Assignment Frequency of In House Night Call(Q3, Q4, etc.) Direct PatientResponsibility (Yes or No)residency-review-committee-for-internal-medicine3822.doc
  9. 9. SECTION 10. EDUCATIONAL PROGRAMA. Curriculum 1. Is there a written curriculum for the fellowship program? ....................................................( ) YES ( ) NO 2. Does the written curriculum define the educational goals and objectives of the rotation/assignment based on the Competencies?.........................................................................................................( ) YES ( ) NO 3. Is there a written curriculum for each major rotation or learning experience?......................( ) YES ( ) NO 4. Will the written curriculum be distributed to fellows and faculty?.........................................( ) YES ( ) NO 5. Will the rotation goals and objectives be reviewed by faculty with the fellows at the start of each new rotation and assignment?....................................................................................................( ) YES ( ) NOB. Required Conferences 1. Provide information about the following required conferences: Monthly Frequency Core curriculum conference series Clinical case conference Research conference Journal club 2. Does the program include instruction in the following topics either as separate presentations or integrated into the core curriculum conference series? a. Clinical ethics......................................................................................( ) YES ( ) NO b. Medical genetics..................................................................................( ) YES ( ) NO c. Quality assessment and improvement.................................................( ) YES ( ) NO d. Patient safety.......................................................................................( ) YES ( ) NO e. Risk management................................................................................( ) YES ( ) NO f. Preventive medicine............................................................................( ) YES ( ) NO g. Pain medicine......................................................................................( ) YES ( ) NO h. End-of-life care....................................................................................( ) YES ( ) NO i. Physician impairment..........................................................................( ) YES ( ) NO j. Critical assessment of medical literature.............................................( ) YES ( ) NO k. Medical informatics..............................................................................( ) YES ( ) NO l. Clinical epidemiology...........................................................................( ) YES ( ) NO m. Biostatistics.........................................................................................( ) YES ( ) NOresidency-review-committee-for-internal-medicine3822.doc
  10. 10. SECTION 10. EDUCATIONAL PROGRAMA. Subspecialty ExperienceIndicate how fellows will obtain experience and if they will be required to demonstrate competence in the followingprogram content areas: Formal Clinical Demonstrate Instruction Experience Competence SPECIFIC PROGRAM CONTENT (Y/N) (Y/N) (Y/N) Prevention, evaluation and management of acute and chronic end stage liver disease (includes genetic disorders involving the liver, alcoholic and non-alcoholic steatohepatitis) Comprehensive management of critically ill patients awaiting transplant with complications including: Refractory ascites Hepatic hydrothorax Hepato-renal syndrome Hepatopulmonary and portal pulmonary syndromes Refractory portal hypertensive bleeding Diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-transplantation, surgical and non-surgical approaches Management of chronic viral hepatitis in the pre-, peri- and post- transplantation settings Management of fulminant liver failure Psychosocial evaluation of transplant candidates, in particular those with history of substance abuse Transplant immunology including blood group matching, histocompatibility, tissue typing and malignant complications of immunosuppression Drug hepatotoxicity Interaction of drugs with the liver Nutritional support of patients with liver disease Use of interventional radiology in diagnosis and management of portal hypertension, as well as biliary and vascular complications Ethical considerations relating to liver transplant donors Performance of at least 30 percutaneous liver biopsies Indications, contraindications and complications of liver allograft biopsies Interpretation of at least 200 native and allograft liver biopsies Appropriate use of ultrasound localized, laparoscopy-guided and transjugular liver biopsiesresidency-review-committee-for-internal-medicine3822.doc
  11. 11. B. Subspecialty Didactic Experience 1. Will fellows receive formal didactic instruction in the following content areas: Formal Instruction SPECIFIC PROGRAM CONTENT (Y/N) Pathogenesis, manifestations and complications of end-stage liver disease and hepatic transplantation Appropriate use of laboratory tests and procedures Anatomy, and physiology related to the liver and biliary tract Pharmacology related to the liver and biliary tract Pathology related to the liver and biliary tract Molecular virology related to the liver and biliary tract Natural history of chronic liver disease Factors involved in nutrition and malnutrition and its management Cost-effective use of special instruments, tests and therapy in the diagnosis and management of liver disorders Principles and practice of pediatric liver transplantation Principles and application of artificial liver support Clinical research issues and transplant hepatology Principles of living donor selectionC. Subspecialty Clinical Experience Will each fellow (Y/N) Participate in the primary evaluation, presentation and discussion of at least 10 potential transplant candidates? Provide follow-up for at least 20 new liver transplant recipients for a minimum of 3 months from the time of transplantation? Actively participate in the transplant recipients’ medical care including the management of acute cellular rejection, recurrent disease, infectious diseases and biliary tract complications? Serve as an integral member of the transplantation team? Participate in making decisions about immunosuppression? Participate in the follow-up of 20 or more liver transplant recipients 1 year post-transplant? Provide a minimum of six month follow-up for each of these liver transplant patients? Acquire a working knowledge of the organizational and logistic aspects of liver transplantation including the role of nurse coordinators and other support staff, organ procurement , and UNOS policies? Learn the principles of donor selection and rejection? Participate as an observer in one deceased donor procurement and three liver transplant surgeries?D. Inpatient and Consultation Teaching 1. What is the total teaching time that will be spent in combined management and teaching rounds per week? _________________residency-review-committee-for-internal-medicine3822.doc
  12. 12. SECTION 11. AMBULATORY EXPERIENCEProvide information for the fellows continuity experience and patient distribution. List each experience indicating the name of the experience (e.g.Continuity Clinic), the hospital or other training site identifiers, duration of the experience, number of sessions per week per fellow, average number ofpatients per session, average number of other trainees and teaching attendings and whether faculty supervision will be provided for each experience.Please provide a narrative which describes how fellows will gain experience in the longitudinal care of patients seen in consultation. (Appendix5) Name of Experience ID Duration Sessions Avg # Avg # Avg # Faculty Per Week Patients Other Teaching Supervision Seen Per Trainees Attendings/ On Site Session Present Session (Yes/ No)residency-review-committee-for-internal-medicine3822.doc
  13. 13. SECTION 12. TRANSPLANT HEPATOLOGY RESEARCH 1. What percentage of the key clinical faculty (listed in Part 1) participate in research in the fellowship program? 2. What is the number of papers published in peer-reviewed professional journals by key clinical faculty members from the transplant hepatology program during the last three years? (Please do not include: Case reports, abstracts, presentations, papers submitted/ not published, publications in non-peer-review journals, or publications published more than three years ago. Count each paper only once. Count each book chapter only once. Peer review publication = indexed in Pub Med (or Medline). If not in Pub Med, program must supply evidence of peer review) 3. What is the number of peer-reviewed grants by the key clinical faculty in the past three years? 4. Will all fellows who participate in a research project have a faculty preceptor?......................( ) YES ( ) NOresidency-review-committee-for-internal-medicine3822.doc
  14. 14. SECTION 13. EVALUATIONA. Fellow Evaluation Using the table below: (1) provide the methods of evaluation that will be used to assess fellow competence in each of the six required ACGME competencies and (2) identify the evaluators for each method (e.g.,” performance in patient care will be evaluated by global forms completed by faculty”). 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 1. Will written records be kept of the following: a. Evaluation of fellows for each rotation...........................................................................( ) YES ( ) NO b. Evaluation of fellows longitudinal experience (at least every 6 mos.)........................... ( ) YES ( ) NO c. Semi-annual review of fellow evaluations by the program director................................( ) YES ( ) NO d. Other counseling sessions of a fellow by the program director.....................................( ) YES ( ) NO 2. Will the written records for each fellow be readily accessible for the fellow to review?........( ) YES ( ) NO 3. Will the written records be maintained in the program files to substantiate future judgments in hospital credentialing, board certification, agency licensing and in other bodies of actions?............( ) YES ( ) NO 4. Will the program director review fellow procedure logs in order to document that each fellow has performed the minimum number and achieved competence in invasive procedures?.........( ) YES ( ) NO 5. In the event of an adverse annual evaluation, will the fellow be offered an opportunity to address judgments of academic deficiency or misconduct before an appropriately constituted clinical competence committee? .............................................................................................................................................( ) YES ( ) NO 6. Will the subspecialty program director meet with each fellow at least twice a year to review their performance and counsel them?.........................................................................................( ) YES ( ) NOresidency-review-committee-for-internal-medicine3822.doc
  15. 15. 7. Will the supervising teaching attending review the performance of the fellow with him or her at the completion of each rotation?................................................................................................( ) YES ( ) NO 8. Will the program director prepare a final evaluation for each fellow which includes a review of the fellow’s performance and verifies that the fellow has demonstrated sufficient professional ability to practice competently and independently?.........................................................................................( ) YES ( ) NOB. Faculty Evaluation 1. Will teaching attendings be evaluated by the fellows whom they supervise at the end of each rotation, and during each longitudinal experience? .................................................................................( ) YES ( ) NO 2. Will these evaluations be written and confidential? ............................................................( ) YES ( ) NO 3. Will the results of these evaluations be communicated on a regular basis, at least annually, to faculty members? ...........................................................................................................................( ) YES ( ) NO 4. Will the program director use the results of these evaluations to counsel faculty and select faculty for teaching assignments? .......................................................................................................( ) YES ( ) NOC. Program Evaluation 1. Will there be a regular meeting, at least annually, to discuss program goals and objectives and the effectiveness in achieving them? ........................................................................................( ) YES ( ) NO 2. Will this meeting include at a minimum, the program director, representative faculty and at least one fellow? ................................................................................................................................( ) YES ( ) NO 3. Will fellows provide an annual evaluation of the program as a whole and the effectiveness of the teaching program? ............................................................................................................................( ) YES ( ) NOresidency-review-committee-for-internal-medicine3822.doc
  16. 16. SECTION 14 NARRATIVE1. List the outstanding or special features of the program.2. List those aspects of the program and/or its component institutions/other training sites and faculty that warrant strengthening.residency-review-committee-for-internal-medicine3822.doc
  17. 17. SECTION 15. DOCUMENTS CHECKLISTInstructions: Please send a copy of each of the following documents. If the document contains the name of apatient, fellow or faculty member, please obliterate the persons name in order to maintain confidentiality. Pleaselabel each document with the document number, listed below. If the document does not exist, provide anexplanation for its absence in the Narrative (Section 14). Check if APPENDICES Enclosed 1. Program affiliation agreement(s) with other hospitals and non-hospital training settings where fellows rotate 2. For each training site, a description of the lines of responsibility among fellows at various stages in training, and attending physicians, on each type of teaching service 3. A brief summary of the steps your program will take to implement and evaluate each of the six ACGME general competencies (from Section 5.B) 4. Rotation schedule narrative (from Section 9) 5. Longitudinal care experience (from Section 11) 6. Copy of core curriculum conference schedule 7. Sample of log book for documenting fellow procedures 8. Evaluation forms used by faculty to evaluate fellow performance 9. Evaluation forms used by fellows to evaluate faculty teaching skills 10. Evaluation forms used by fellows to evaluate the program 11. Single Site Sponsor Letter of Agreement (from Section 5.A) (-if applicable)residency-review-committee-for-internal-medicine3822.doc

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