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  1. 1. THE RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • FOR CONTINUED ACCREDITATION– PEDIATRIC NEPHROLOGY 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 Nephrology. 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 – pages1743.doc i
  2. 2. Please have the following documents available for the site visitor: References to Common Program and Institutional Requirements are in parentheses. 1. Policy for supervision of residents (addressing resident responsibilities for patient care, progressive responsibilities for patient management, and faculty responsibility for supervision) (CPR IV.A.4) 2. Program policies and procedures for residents’ duty hours and work environment (CPR II.A.4.j) 3. Moonlighting policy (CPR II.A.4.j; CPR VI.F) 4. Documentation of internal review (date, participants’ titles, type of data collected, and date of review by the GMEC) 5. Overall educational goals for the program (CPR IV.A.1) 6. Competency-based goals and objectives for each assignment at each educational level (CPR IV.A.2) 7. Current Program Letters of Agreement (PLAs) (CPR I.B.1) 8. Files of current residents who have transferred into the program, if applicable (including documentation of previous experiences and summative competency-based performance evaluations) (CPR III.C.1) 9. Evaluations of residents at the completion of each assignment (CPR V.A.1.a) 10. Evaluations showing use of multiple evaluators (faculty, peers, patients, self, and other professional staff) (CPR V.A.1.b.(2)) 11. Documentation of residents’ semiannual evaluations of performance with feedback (CPR II.A.4.g; V.A.1.b.(4)) 12. Final (summative) evaluation of residents, documenting performance during the final period of education and verifying that the resident has demonstrated sufficient competence to enter practice without direct supervision (CPR V.A.2) 13. Completed annual written confidential evaluations of faculty by the residents (CPR V.B. 3) 14. Completed annual written confidential evaluations of the program by the residents (CPR V.C.1.d. (1)) 15. Completed annual written confidential evaluations of the program by the faculty (CPR V.C.1.d.(1)) 16. Documentation of program evaluation and written improvement plan (CPR V.C) 17. Documentation of resident duty hours (CPR II.A.4.j; VI.D.1-3) 18. Files of current residents and most recent program graduates Added documents for some programs: 1. Single RRC Sponsors only: a) Copy of the resident contract with the pertinent items from the Institutional Requirements and Master Affiliation Agreements (IR II.D.4) b) Institutional policies and procedures for residents’ duty hours and work environment (CPR II.A.4.j; CPR VI.C; IR II.D.4.i; IR III.B.3) c) Institutional policy for recruitment, appointment, eligibility, and selection of residents (IR II.A) d) Institutional policy for discipline and dismissal of residents, including due process (IR II.D.4.e; IR III.B.7) pages1743.doc ii
  3. 3. pages1743.doc iii
  4. 4. THE RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 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 the completed 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 Sponsoring Institution/Single or Limited Residency Institution (If applicable) Faculty/Teaching Staff Program Director Information Physician Faculty Roster Faculty Curriculum Vitae Non Physician Faculty Roster Resident Appointments Number of Positions Actively Enrolled Residents (if applicable) Aggregated Data on Residents Completing or Leaving the Program for the last 3 years (if applicable) Residents Completing Program in the Last 3 years (if applicable) Transferred, Withdrawn, and Dismissed Residents (if applicable) Evaluation Resident Duty Hours Pediatric Subspecialty PIF Page(s) Faculty Research Research Resources Program Curriculum Block Diagram Goals and Objectives Collaboration Between Programs General Subspecialty Curriculum Conferences Scholarship Oversight Committee Fellow Research Activities pages1743.doc 1
  5. 5. Specialty Specific PIF Page(s) Other Professional Staff Facilities and Services Facilities Services and Laboratories Support Services Patient Care Patient Data Ambulatory Pediatric Nephrology Experience for All Years of Training List of Diagnoses 12-Monh Summary – Inpatient Services 24-Month Summary: Patient Procedures Medical Knowledge Transplantation and Dialysis Inpatient Experiences Outpatient Experiences Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based Practice Appendix A – Goals and Objectives pages1743.doc 2
  6. 6. THE RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • COMMON SUBSPECIALTY PROGRAM INFORMATION FORM FACULTY RESEARCH 1. Complete the table below regarding the involvement of faculty in research. Add rows as necessary. # of current # of current research projects # presentations IRB Total # of with peer review at national # publications approved current funded funding (subset of scientific in peer review research research total # in previous meetings in the journals in the projects projects column) last 5 years last 5 years Program Director: Key Faculty: Mentors Who Are Not Key Faculty: 2. List active research projects in the subspecialty. Put an “X for funding awarded by Years of Faculty investigator and role peer review funding in grant (i.e. PI, Co-PI, Co- Project title Funding source process (dates) investigator) pages1743.doc 3
  7. 7. 3. To enable the Committee to assess the scholarly environment of the program, provide a list of scholarly publications and presentations at regional, national and international meetings by faculty and fellows within the program for the last five years only. Do not duplicate citations. Underline the names of subspecialty fellows. List journal articles and presentations (abstracts, workshops, invited talks) separately under those headings. RESEARCH RESOURCES 1. Does the program provide research laboratory space and equipment? (if appropriate) ..............................................................................................................................( ) YES ( ) NO 2. Does the program provide financial support for research?....................................( ) YES ( ) NO 3. Does the program provide computer and statistical consultation services?...........( ) YES ( ) NO pages1743.doc 4
  8. 8. PROGRAM CURRICULUM 1. Block Diagram The purpose of a block diagram is to give the Residency Review Committee an overview of what takes place during each year of training. EXPERIENCES OF ROTATIONS • In each one month or 4 week block indicate the following: (1) the learning activity (i.e., Trauma) or vacation, (2) percentage of clinical (C) and research (R) time (i.e., 50% C; 50% R) (3) the site in which the activity occurs (i.e., HOSP1, HOSP 2 or OTHER – clinical site or office) as designated in 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 ED ED Trauma ELEC ELEC ELEC Research ED Anes Research Research Experience or 100% 100% 100% 100% 100% 100% 20% (C) 100% (C) 100% (C) 100% (R) 100% (R) VAC N/A rotations (C) (C) (C) (C) (C) (C) 80% (R) HOSP1 HOSP1 HOSP2 HOSP1 HOSP1 HOSP1 HOSP2 HOSP1 HOSP1 HOSP2 HOSP1 70/20 70/10 70/10 80/24 85/30 70/30 70/30 80/30 Duty Hours 60/20 * 60 * 60 * IH IH IH IH IH IH IH H pages1743.doc 5
  9. 9. 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 pages1743.doc 6
  10. 10. 2. Goals and Objectives A complete set of goals and objectives must be available for the site visitor. Choose as a sample the goals and objectives for one clinical rotation and attach it to the PIF as Appendix A (do not append all of the goals and objectives). For new applications, submit the complete set of goals and objectives. Place an ‘X” in the box before the applicable response. Are there goals and objectives for all training ( ) YES ( ) NO experiences? Are they rotation and level specific? ( ) YES ( ) NO How are they distributed? ( ) Hard Copy ( ) Electronic or web-based If not web-based, when are they distributed to ( ) Prior to Each Rotation ( ) Annually fellows? ( ) Once in Handbook ( ) Other ( ) Prior to Each Rotation If not web-based, when are they distributed to ( ) Annually faculty? ( ) Other If web-based, do you send out reminders to access ( ) YES ( ) NO them? If yes, when do you send them? 3. Collaboration between Programs Are there meetings among the core Program ( ) YES ( ) NO Director and subspecialty Program Directors? If yes, have minutes available for site visitor confirmation How often do these meetings occur? Who is typically involved in these meetings? ( ) Core program director (check all that apply) ( ) Subspecialty program director for this specialty ( ) Program directors from other subspecialties pages1743.doc 7
  11. 11. 4. General Subspecialty Curriculum Participants (place and X in the appropriate Where Taught in Number of column) Curriculum? Structured Fellows in All Residents & (Name should Teaching Hours this Subspecialty Subspecialty match name in Dedicated to Topic Discipline Fellows 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.) pages1743.doc 8
  12. 12. 5. Conferences Have Conference Schedule Available For Review By Site Visitor. Do Not Append Conference Schedule. a) List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the subspecialty training program. Identify the "SITE" by using the corresponding number as appears on the 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.) Conference Site # Frequency R/O Role of the Fellow b) Describe the mechanism that is used to assure fellow attendance at required conferences. State the degree to which faculty attendance is expected, and how this is monitored. Limit response to 50 words 6. Scholarship Oversight Committee a) Is there a scholarship oversight committee for every fellow?........................( ) YES ( ) NO If yes, have names of committee members for each fellow available for site visitor confirmation. b) How often does the committee meet with the fellow?...............................# ( ) times per year c) Are there written guidelines outlining the responsibility of the oversight committee? If yes, have the guidelines available for site visitor confirmation...................( ) YES ( ) NO 7. Fellow Research Activities a) Describe how the program ensures a meaningful supervised research experience for the fellows, beginning in their first year and extending throughout their training. b) If faculty outside the division are actively involved in mentoring the fellows, list and provide details. pages1743.doc 9
  13. 13. THE RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • PROGRAM INFORMATION FORM - PEDIATRIC NEPHROLOGY STAFF, FACILITIES AND SERVICES A. Other Professional Staff List only the numbers of those who work in the Pediatric Nephrology training program: Site 1 Site 2 Site 3 Staff trained in Psycho-Social support Staff trained in Social Service Staff trained in Pediatric Dietary Service/Nutritionist Nurse Specialists and/or Physician Extenders (e.g., pediatric nurse practitioners and/or physician's assistants trained in this specialty’s pediatric techniques) Other (specify) B. Facilities 1. Indicate the availability of the following: Facility/Service Site 1 Site 2 Site 3 (Yes/No) (Yes/No) (Yes/No) 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 Pediatric intensive care unit Neonatal intensive care unit 2. If NO is indicated for any facilities and/or services across all sites, provide an explanation below. pages1743.doc 10
  14. 14. C. Services and Laboratories 1. Indicate the availability of the following: Site 1 Site 2 Site 3 Services (Yes/No) (Yes/No) (Yes/No) Pathology Service: Is there an accredited pathology residency training program? Are pediatric pathologists available to the program? Are there pathologists with special interests and training in renal pathology? Do the fellows have an opportunity to perform and participate in related autopsies? Does the pathology service meet the education and service needs of the pediatric nephrology training program? Diagnostic Laboratories: Electron microscopy Immunology Immunopathology Coagulation Histocompatibility 2. If NO is indicated for any facilities and/or services across all sites above, provide an explanation below. pages1743.doc 11
  15. 15. D. Support Services 1. Place a check mark in the appropriate spaces if these particular services are available at each of 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 Available 24 Hours/Day Site 1 Site 2 Site 3 Site 1 Site 2 Site 3 1. Drug levels 2. Microchemistries 3. Micro pH and blood gases 4. Electrocardiography 5. Diagnostic bacteriology 6. Diagnostic virology 7. Hemoglobin electrophoresis 8. Immunoglobulins 9. Amino acid screening (urinary and blood) 10. Ultrasonography 11. CT 12. Nuclear medicine capabilities 13.Electroencephalography 14. Blood ammonia determinations 2. Describe the clinical laboratory facilities available to fellows in support of patient care. How convenient are they to patient care areas? To what extent are they used by fellows? pages1743.doc 12
  16. 16. I. PATIENT CARE A. Patient Data Provide the following information for the most recent 12-month period. Note the same timeframe should be used throughout the forms. Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy): Inpatient Site 1 Site 2 Site 3 1. Total number of admissions for whom the pediatric nephrology service assumed major clinical responsibility a) Average daily census of patients on the pediatric nephrology service b) Number of new patients admitted each year(“new” refers to those who are being seen by members of the nephrology service for the first time) c) Average length of stay of patients on the pediatric nephrology service 2. Number of consultations by pediatric nephrology 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? If applicable, provide the following information for the most recent 12-month academic or calendar year for each site used to provide a specific required experience, such as transplant, cardiology, intensive care, etc. Duplicate this table as necessary. Site 1 Site 2 Site 3 Name of service: Total number of fellows and residents on the service Total number of admissions to the service Number of new patients admitted each year (“new” refers to those who are seen by members of the service for the first time.) Average length of stay of patients on the service Average daily census of patients on the service, including consultations pages1743.doc 13
  17. 17. B1.Ambulatory Pediatric Nephrology Experience for All Years Of Training Number of Number of Average Number of New Return Number Duration of Sessions Patients Per Patients Per Teaching Faculty Name of Experience Experience Per Week Fellow Per Fellow Per Attendings Supervision Site/Other Setting Identifier (in wks/yr) Per Fellow Session Session Per 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. pages1743.doc 14
  18. 18. C. List of Diagnoses List 150 consecutive inpatient admissions (A) and consultations (C)* by the Pediatric Nephrology service. Identify the time period during which these admissions/consultations occurred. The date range should occur within the same 12-month period used in I.A.. Submit a separate list for each site that provides required rotations. Use additional pages as necessary. Site Name: Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy): Patient ID Number of A or days in C* Number Age Site Nephrology Diagnosis pages1743.doc 15
  19. 19. D. 12-Month Summary - Inpatient Services Summarize how many pediatric patients with the following nephrology problems were admitted to or consulted on by the Nephrology service at the primary site. This should cover the same 12-month period used on the previous pages. Extract the information from the list of diagnoses on I.A. of this form. FOR NEW APPLICATIONS FILL IN ONLY THE FIRST TWO COLUMNS. Site Name: Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy): Inpatients Number of patients Number seen by fellows Number on Number Number on Nephrology seen in Nephrology Number of Renal Disorders service consultation service consultations 1. Congenital Anomalies of the Genitourinary Tract 2. Hypertension 3. Renal Disorders in Systemic Disease 4. Renal Infections 5. Acute Renal Failure 6. Chronic Renal Failure 7. Renal Transplantation 8. Neoplasms of Kidney 9. Fluid and Electrolyte and acid base Disorders 10. Acute and Chronic Glomerular Diseases 11. Renal Tubular Disorders 12. Nephrolithiasis 13. Acute & Chronic Interstitial Nephritis 14. Perinatal and neonatal conditions including genetic disorders 15. New end-stage renal disease 16. Voiding dysfunction and urologic disorders 17. Renal dysplasia and cystic disease of the kidney 18. Inherited renal disorders 19. Other Chronic Renal Disorders (please specify) pages1743.doc 16
  20. 20. E. 24-Month Summary: Patient Procedures Provide patient data for the most recent 24-month period for which records can be obtained. Site Name: Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy): Indicate the number available of the following at each of the sites participating in the program. Site 1 Site 2 Site 3 Dialysis: 1. Total number of new and chronic dialysis patients cared for by the pediatric service in the past 2 years: a) Hemodialysis b) Continuous ambulatory peritoneal dialysis c) Continuous cyclic peritoneal dialysis d) Intermittent peritoneal dialysis 2. Total number of acute dialysis treatments performed in the past 2 years: a) Acute renal failure b) Poisoning Total number of patients that fellows are exposed to that utilize home dialysis treatment modalities: Renal Transplantation: 3. Total number of patients referred for transplantation in the past 2 years: a) Living related donor b) Cadaver Other Procedures: 4. Continuous arteriovenous or venovenous hemofiltration 5. Hemoperfusion procedures for poisonings 6. Renal Biopsy pages1743.doc 17
  21. 21. II. MEDICAL KNOWLEDGE A. Transplantation and Dialysis 1. Describe how the fellows gain experience in: 1) evaluation and selection of transplant candidates; 2) preoperative evaluation of preparation of transplant recipients; 3) recognition and medical management of surgical and non-surgical complications of transplantation; 4) exposure to dialysis therapy, including extracorporal therapies that include a) evaluation and selection of patients for continuous renal replacement therapies; b) long-term follow-up with patients undergoing chronic dialysis; c) understanding of the principles and practices of both hemodialysis and peritoneal access; d) understanding of the special nutritional requirements of hemodialysis of patients. 2. Describe how the fellows gain technical experience in: 1) urinalysis; 2) percutaneous biopsy of both native and transplanted kidneys; 3) peritoneal dialysis; 4) acute and chronic dialysis hemofiltration; 4) renal ultrasound. B. Inpatient experiences 1. Describe the responsibilities that the fellows have for inpatients requiring acute and chronic care when assigned to inpatient services. 2. Describe how and by whom the fellows are supervised. 3. State how many hours per week they participate in rounds with faculty. Describe this experience. C. Outpatient experiences 1. Describe the degree of responsibility the fellows have for required outpatient care. 2. Describe the continuity of care experience they 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 longitudinal experience provided in therapy of acute renal failure and end stage renal disease, including hemodialysis, continuous arteriovenous hemofiltration, peritoneal dialysis and transplantation. If hemodialysis continuous hemofiltration or peritoneal dialysis experiences are not available or do not provide adequate experiences in these areas as the primary site (Site one), pages1743.doc 18
  22. 22. explain how the fellows receive adequate experiences at site two or three. Who supervises them at site two or three? 4. Describe how and by whom the fellows are supervised in the outpatient setting. 5. 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. pages1743.doc 19
  23. 23. III. PRACTICE-BASED LEARNING AND IMPROVEMENT Examples of Learning Activities: didactic lecture, assigned reading, seminar, self-directed learning module, conference, small group discussion, workshop, online module, journal club, project, case discussion, one-on-one mentoring, or other examples of learning activities. 1. Describe one learning activity in which fellows engage to identify strengths, deficiencies, and limits in their knowledge and expertise (self-reflection and self-assessment); set learning and improvement goals; identify and perform appropriate learning activities to achieve self-identified goals (life-long learning). Limit your response to 400 words. 2. Describe one example of a learning activity in which fellows engage to develop the skills needed to use information technology to locate, appraise, and assimilate evidence from scientific studies and apply it to their patients’ health problems. The description should include: a) locating information b) using information technology c) appraising information d) assimilating evidence information (from scientific studies) e) applying information to patient care Limit your response to 400 words. 3. Give one example and the outcome of a planned quality improvement activity or project in which at least one fellow participated in the past year that required the fellow to demonstrate an ability to analyze, improve and change practice or patient care. Describe planning, implementation, evaluation and provisions of faculty support and supervision that guided this process. Limit your response to 400 words. 4. Describe how fellows: a) develop teaching skills necessary to educate patients, families, students, and other residents; b) teach patients, families, and others; and c) receive and incorporate formative evaluation feedback into daily practice. (If a specific tool is used to evaluate these skills have it available for review by the site visitor.) Limit your response to 400 words. 5. Describe the process for mentoring the fellows. Address the following items for each type of mentor if more than one is assigned to each fellow (i.e., if there is a separate research mentor). Describe (1) how mentors are selected, (2) how often the mentor meets with the mentee and (3) the guidelines that are provided for topics to be addressed during meetings between mentors and mentees. Limit response to 150 words (1) pages1743.doc 20
  24. 24. (2) (3) 6. Outline the faculty development activities that are provided for acquainting the faculty with mentoring skills. Limit response to 50 words 7. Learning Plans Is each fellow required to have an individualized learning plan? (If yes, please have learning plans ( ) YES ( ) NO available for site visitor verification.) ( ) No guidance, resident driven Who provides guidance to the fellow in ( ) Fellow’s mentor completing this plan (check all that apply)? ( ) Program Director ( ) Other (describe) ( ) Annually How often are these plans developed or updated? ( ) Semi- Annually ( ) Other (describe) 8. List the clinical quality improvement activities in which fellows actively participate and identify who guides them in this process. Limit response to 150 words 9. Using the bulleted list below (add bullets as needed) identify specific ways in which the program fosters reflection, self-assessment, and practice improvement for fellows. Limit response to 150 words • • pages1743.doc 21
  25. 25. IV. INTERPERSONAL AND COMMUNICATION SKILLS 1. Describe one learning activity in which fellows develop competence in communicating effectively with patients and families across a broad range of socioeconomic and cultural backgrounds, and with physicians, other health professionals, and health related agencies. Limit your response to 400 words. 2. Describe one learning activity in which fellows develop their skills and habits to work effectively as a member or leader of a health care team or other professional group. In the example, identify the members of the team, responsibilities of the team members, and how team members communicate to accomplish responsibilities. Limit your response to 400 words. 3. Explain (a) how the completion of comprehensive, timely and legible medical records is monitored and evaluated, and (b) the mechanism for providing fellows feedback on their ability to competently maintain medical records. Limit your response to 400 words. 4. How do fellows learn to achieve competence in conducting a family meeting to deliver critical/complex information about patient diagnosis, prognosis and /or treatment. Answer by using a specific example to illustrate. Limit response to 150 words 5. Describe (1) how the fellow’s written communication (including but not limited to progress notes, consults, and letters to referring physicians) is reviewed and (2) how feedback is given regarding its quality. Limit response to 150 words (1) (2) 6. Using the bulleted list below (add bullets as needed) identify the specific methods the program uses to ensure that fellows achieve competence in effective communication (verbal & written) in a consultative role with other physicians, health care workers and outside agencies. Limit response to 150 words • • pages1743.doc 22
  26. 26. V. PROFESSIONALISM 1. Describe at least one learning activity, other than lecture, by which fellows develop a commitment to carrying out professional responsibilities and an adherence to ethical principles. Limit your response to 400 words. 2. How does the program promote professional behavior by the fellows and faculty? Limit your response to 400 words. 3. How are lapses in these behaviors addressed? Limit your response to 400 words. 4. Explain how the following contribute to the evaluation of professionalism: (1) patients/families, and (2) members of the health care team. Limit response to 150 words (1) (2) 5. Using the bulleted list below (add bullets as needed) identify specific methods the program uses to teach and evaluate the elements of professional competence. Limit response to 100 words • • pages1743.doc 23
  27. 27. VI. SYSTEMS-BASED PRACTICE 1. Describe the learning activity(ies) through which fellows achieve competence in the elements of systems-based practice: work effectively in various health care delivery settings and systems, coordinate patient care within the health care system; incorporate considerations of cost- containment and risk-benefit analysis in patient care; advocate for quality patient care and optimal patient care systems; and work in interprofessional teams to enhance patient safety and care quality. Limit your response to 400 words. 2. Describe an activity that fulfills the requirement for experiential learning in identifying system errors. Limit your response to 400 words. a. Identify who guides/supervises fellows in this activity. Limit response to 75 words 3. Address how the elements of this competency are taught and how they are evaluated. System errors need not be addressed here. Limit response to 200 words 4. How does your program meet the requirement for exposure to administrative experience in the context of your subspecialty? Limit response to 200 words 5. Give an example of how fellows are expected to navigate the “system”, that is identify/access resources, make referrals, and coordinate services for patients within your subspecialty practice. pages1743.doc 24
  28. 28. APPENDIX A - GOALS AND OBJECTIVES Append a sample of the goals and objectives for one rotation. pages1743.doc 25