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  1. 1. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5027 • PROGRAM INFORMATION FORM - ENDOVASCULAR SURGICAL NEURORADIOLOGY (ESN) FOR CONTINUED ACCREDITATION GENERAL INSTRUCTIONS REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the program information form is being completed for a currently accredited program, use the Continued Accreditation PIF in conjunction with the Web Accreditation Data System (Web ADS). Follow the provided instructions to create the correct PIF Go to the Web Accreditation Data System (Web ADS) found on the ACGME home page (, using your previously assigned username and password, update your program and fellow data, retrieve Part 1 of the PIF under the Site Visit Information section, complete the shaded items (as appropriate), print all sections of Part 1 of the PIF and sign the form. If you find items displayed incorrectly change your data using ADS update sections; in some instances you may need to contact your DIO for the entry of updated information. Next proceed to the section under the RRC for Diagnostic radiology to retrieve Part 2 of the PIF for continued accreditation in either Word or WordPerfect. Complete Part 2 of the PIF using your preferred word processor (only after Part 1 has been completed). Combine Part 1 and Part 2, number the pages consecutively on the upper right corner, beginning with Part 1 Section 1 and complete the Table of Contents (found with the Part 2 instructions). Mail one set of the forms to the site visitor at least 10 working days before the site visit. An additional copy should be held to permit corrections that may be required as the site visit proceeds. After the visit, three copies must be mailed to the Executive Director at the above address. The Program Director is responsible for the composition and accuracy of the information supplied in this form and must sign it. It must also be signed by the Department Chairman/Chief of Service and the Designated Institutional Official of the sponsoring institution. Incomplete forms will not be accepted for review. Send 4 complete copies to the Executive Director of the RRC at the address given above. Supply information which will indicate when you expect the program to be activated. The data and description given must be realistic and evidence should be included that your expectations are reasonable. The Institutional Requirements, the Program Requirements and the PIF may be downloaded from the ACGME Website ( For questions regarding the site visit, contact the writer of the letter announcing the site visit. For questions regarding the completion of the form (content), contact the Accreditation Administrator (Phone: 312-755-5028) or the Committee Coordinator (Phone: 312-755-5036) For word processing questions/problems, contact the ACGME Help Desk at 312-755-7494 or email For technical questions about Part 1 of the PIF, email For a glossary of terms, use the following link – SPECIFIC INSTRUCTIONS PART 1, SECTION 4: Staff participating in the training of fellows. Include faculty who perform endovascular surgical neuroradiology, and neurosurgeons, radiologists, and neuroradiologists who do not perform endovascular surgical neuroradiology procedures, but will participate in the program. In Section 4.B provide an abbreviated one page CV for each key faculty member. Programs seeking continued accreditation must use the Accreditation Data System (ADS) to enter these data. The entered information will automatically appear in Part 1, Section 4 of the PIF. residency-review-committee-for-diagnostic-radiology4121.doc
  2. 2. SPONSORING INSTITUTION: Please review carefully the following statement from the Program Requirements for the Subspecialties of Diagnostic radiology: Residency education programs in the subspecialties of diagnostic radiology may be accredited only in institutions that either sponsor a residency education program in diagnostic radiology accredited by the ACGME or are integrated by formal agreement into such programs. Close cooperation between the subspecialty and residency program directors is required. For purposes of completing the application, this means that: a) If the program is conducted in the institution in which there is an ACGME-accredited residency program, the signature of the Director of the core Diagnostic radiology program will suffice to document sponsorship by the core program. b) If the program is conducted in an institution other than that of the core residency program, a formal signed integration agreement between the two institutions must also be provided (Appendix 1). PARTICIPATING HOSPITALS: All hospitals offering required rotations or experiences should be listed. One hospital should be designated as the primary/parent hospital and identified as "Institution #1". If multiple hospitals are used, append letters of agreement which describe the trainees’ activities including the content of the experience, duration, supervision, and patient numbers (Appendix 2). SURVEY/SITE VISIT: Do not revise the form or submit any additional information after the site visit unless you have discussed the changes with the Executive Director of the RRC. The following documents should be available for perusal by the site visitor on the day of the visit: a. written goals and objectives for all curricular components and evidence of their distribution. b. trainee contract/agreement c. documentation of trainee eligibility for appointment to the program d. evidence of evaluation of trainees, faculty, and program e. the full conference schedule with names of presenters, topics and when presented f. written descriptions of supervisory lines of responsibility letters of agreement with participating facilities. residency-review-committee-for-diagnostic-radiology4121.doc
  3. 3. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5027 • PROGRAM INFORMATION FORM - ENDOVASCULAR SURGICAL NEURORADIOLOGY (ENS) TABLE OF CONTENTS When you have the completed forms, number each page sequentially in the upper right hand corner. Start on Part 1, Section 1 of the PIF. Report this pagination in the Table of Contents and submit this cover page with the completed PIF. 1Part 1 Section Page(s) General Program Information 1 Accreditation Information 1.A Program Director Information 1.B Participating Institutions 2 Fellow Complement 3 Number of Positions 3.A Faculty / Teaching Staff 4 Faculty Roster 4.A Key Faculty Curriculum Vitae 4.B Part 2 Section Page(s) Background Information 5 Previous Citations or Concerns 5.A Changes 5.B Sponsoring Institution/Single or Limited Residency Institution 5.C Fellows in Training 6 Patient Data 7 Narrative Description of Training Program 8 Bibliography 9 Facilities and Space 10 Formal Teaching Exercises 11 Equipment 12 residency-review-committee-for-diagnostic-radiology4121.doc
  4. 4. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5027 • PROGRAM INFORMATION FORM - ENDOVASCULAR SURGICAL NEURORADIOLOGY (ENS) (Part 2) FOR CONTINUED ACCREDITATION SECTION 5. BACKGROUND INFORMATION A. Previous Citations or Concerns (if applicable) List the citations from the last RRC accreditation action and discuss how each cited area has been corrected. If documentation is required, provide a specific reference to information provided in the Program Information Forms such as the PSOL, etc., or append additional information supporting the narrative. If no citations were listed, indicate this in your response. B. Changes (if applicable) Briefly describe major changes, other than those included in the response to previous citations and/or concerns (above) that have been implemented since the last survey and review. Include changes in sponsoring organization, participating hospitals, required rotations, fellow complement, faculty or facilities. C. Sponsoring Institution/Single or Limited Residency Institution (see ACGME Institutional Requirements - if applicable) For those institutions which are either a single-program institution (e.g., diagnostic radiology only), or an institution 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 these two categories are to complete the following institutional questions: 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 3). 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 “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. 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 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 residency-review-committee-for-diagnostic-radiology4121.doc
  5. 5. 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 fellow’s contract, or other actions that could significantly threaten a fellow’s intended career development. residency-review-committee-for-diagnostic-radiology4121.doc
  6. 6. SECTION 6. FELLOWS IN TRAINING 1. For each of the fellows listed in Section 3.B provide detail information regarding prior Diagnostic Radiology or Neurosurgery Program completion. List in the same order as Section 3.B. Last Name Program Name of Specialty Residency/Date Completed Program Name of Clinical Neurosurgery or Basic Radiology Experience/Date Completed Program Name of Neuroradiology Fellowship/Date Completed * For Neurological Surgery graduates, enter Basic Radiology experience. For Diagnostic Radiology graduates, enter Clinical Neurosurgery experience 2. Describe the selection process for Endovascular Surgical Neuroradiology fellows. 3. If there are training programs in the institution in any of the following areas, please provide the data indicated: # of Faculty # of Fellows # of Subspecialty Fellows Diagnostic Radiology Neuroradiology Neurosurgery Vascular Neurosurgery Vascular/Stroke 4. If the trainee is from a neurosurgical background, describe the experience of the neurosurgical trainee in basic radiological skills, including the fundamentals of imaging physics and radiation biology. 5. Attach a log of angiograms performed by ENS fellows during the preparatory year in neuroradiology. Include indications for the procedures’ success rates, outcomes and complication rates (according to the Cooperative Study between the ASNR, ASOTIN, and SCVIR: Quality Improvement Guidelines for Adult Diagnostic Neuroangiography AJNR 2000:21:146-150.) residency-review-committee-for-diagnostic-radiology4121.doc
  7. 7. SECTION 7. PATIENT DATA Reporting Period (Recent 12-month period): From: To: A. Capacity Institution #1 (Primary Teaching Institution) Institution #2 Institution #3 Institution #4 Hospital Bed Capacity Hospital Admissions (total) Adult Pediatric No. of Neurosurgery Admissions No. of Neurology Admissions Diagnostic Radiology Examinations Adult Pediatric B. Neurovascular Cases Documentation (procedure logs) for all invasive procedures performed by trainees should be available at the time of the site visit. Institution #1 Institution #2 Institution #3 Institution #4 Total Treated Surgically Treated by ENS Approach Total Treated Surgically Treated by ENS Approach Total Treated Surgically Treated by ENS Approach Total Treated Surgically Treated by ENS Approach Aneurysms Brain arteriovenous malformations Brain, Pial Arteriovenous fistulas (e.g. Vein of Galen) Dural arteriovenous fistulas Tumors: Cerebral parenchymal Dural, extradural (including meningioma) Microcatheter Drug Delivery (i.e., intra-arterial chemotherapy) Occlusive vascular diseases residency-review-committee-for-diagnostic-radiology4121.doc
  8. 8. Institution #1 Institution #2 Institution #3 Institution #4 Total Treated Surgically Treated by ENS Approach Total Treated Surgically Treated by ENS Approach Total Treated Surgically Treated by ENS Approach Total Treated Surgically Treated by ENS Approach Angioplasty procedures: Intracranial (Atherosclerosis) Extracranial Strokes: Arterial recanalization Hemorrhagic Venous Sinus Recanalization Stent Procedures: Intracranial Extracranial Vasospasm: Drug infusion Balloon Dilation Spinal arteriovenous malformations Spinal dural arteriovenous fistulae Primary & metastatic spinal tumors (intraspinal and vertebral separately) Spinal biopsy and percutaneous interventions, including vertebroplasty Other Total Major ESNR Procedures C. Head and Neck Institution #1 Institution #2 Institution #3 Institution #4 Total Treated Surgically Treated by ENS Approach Total Treated Surgically Treated by ENS Approach Total Treated Surgically Treated by ENS Approach Total Treated Surgically Treated by ENS Approach Maxillofacial vascular malformation Tumors of head and neck Epistaxis residency-review-committee-for-diagnostic-radiology4121.doc
  9. 9. D. Diagnostic Institution #1 Institution #2 Institution #3 Institution #4 Cerebral Angiograms Procedures ICA ECA Vertebral Artery Intraoperative Venograms Spinal Angiography Arterial balloon occlusion tests Physiological functional angiography (including WADA tests) residency-review-committee-for-diagnostic-radiology4121.doc
  10. 10. SECTION 8. NARRATIVE DESCRIPTION OF TRAINING PROGRAM The narrative is an important component of the program information form. Respond in full to each of the following questions. Append additional sheets as needed. 1. Indicate the duration of the program and provide a rotation schedule with block diagram. PR II. 2. How is it assured that the subspecialty program in Endovascular Surgical Neuroradiology does not have an adverse impact, as by dilution of the available clinical material, on the education of the diagnostic radiology, neuroradiology, neurosurgery, and neurology fellows in the institution? PR in the Subspecialties I.D. 3. Describe the opportunities fellows have to carry out the following under close supervision. PR VI.2. a. perform clinical preprocedure evaluations of patients b. interpret preliminary diagnostic studies c. consult with clinicians on other services e. perform diagnostic and therapeutic endovascular surgical neuroradiology procedures f. generate procedural reports g. participate in short-term and long-term postprocedure follow-up care, including neurointensive care. 4. Describe how continuity of care preprocedure and postprocedure is achieved in the program. In particular, describe how time is allocated and monitored for outpatient or clinical work (pre- and post-hospital care). Include management of the patient in the intensive care unit. PR VI.2. 5. Describe how the program provides adequate opportunity for fellows to participate in and personally perform and analyze a broad spectrum of endovascular procedures in adults, children and neonates. PR VI.2. 6. Explain fellow responsibility for invasive procedures. How is graded responsibility assured? Does responsibility include pre- post-procedural patient care? PR VI.2. 7. Are fellows required to maintain documentation of the invasive cases in which they have been the performing proceduralist? How often does the program director review the logs with the fellows? Fellow procedure logs documenting involvement in adult and pediatric Endovascular Surgical Neuroradiology should be available for review by the surveyor. PR VII. 8. Do trainee duty hours fall within the requirements for being on-call no more than every third night and having one day out of seven free of hospital duties? What is the average number of on-call hours during a seven day period? PR XIII 9. If there are outside rotations, indicate how much time will be spent at affiliated institutions and describe the trainees' duties and level of responsibility during each of the outside assignments. PR in the Subspecialties I.C. 10. Explain how the program provides didactic and/or clinical instruction or experience in each of the following areas. PR VI.B. a. neuroanatomy b. neurology c. neurosurgery d. neuropathology e. neuro critical care 11. Describe the opportunities for fellows to attend and participate in clinical conferences in neuroradiology, neurology and neurosurgery. PR VI.B. 12. List the conferences that are attended by Endovascular Surgical Neuroradiology fellows. PR VI.B. a. Journal club b. Morbidity and Mortality residency-review-committee-for-diagnostic-radiology4121.doc
  11. 11. c. Neuropathology conferences d. Neuroanatomy conferences e. Neurology or Neurosurgery conferences f. Interdepartmental conferences: g. Others (specify): 13. What opportunities are there for the fellows to attend scientific meetings in Endovascular Surgical Neuroradiology? PR VI.B. 14. Describe the opportunities for fellows to participate in research. PR X 15. Will the Endovascular Surgical Neuroradiology fellow have responsibility for teaching fellows or medical students? If so, describe. PR XII. 16. Describe the method of fellow evaluation, including who performs the evaluation and how often each fellow's performance is reviewed and discussed with the fellow. (Append blank copies of forms used.) PR XIV.A. 17. Are fellows periodically given the opportunity to evaluate the faculty and training program? Describe the mechanism and indicate intervals. PR XIV. B-C. 18. Describe the mechanism for the institution’s periodic internal review and evaluation of the training program. IR I.B.c. residency-review-committee-for-diagnostic-radiology4121.doc
  12. 12. SECTION 9. BIBLIOGRAPHY List publications by Endovascular Surgical Neuroradiology faculty for the previous five (5) years. Underline those in which there has been fellow participation (underline fellows' names). residency-review-committee-for-diagnostic-radiology4121.doc
  13. 13. SECTION 10. FACILITIES AND SPACE Describe the following: 1. Conference facilities and space 2. Research space and laboratory facilities 3. Radiographic-fluoroscopic room with tilt table 4. Facilities for storing catheters, guidewires, contrast materials, embolic agents 5. Space for image display and interpretation 6. Office space for faculty/trainees 7. Library - space/resources: Total number of titles: Number of titles added during the last 12 months: Total number of journal subscriptions: residency-review-committee-for-diagnostic-radiology4121.doc
  14. 14. SECTION 11. FORMAL TEACHING EXERCISES 1Enter the schedule of formal exercises for the most recent one year period. The specific title of lectures/sessions is requested. Topic Title residency-review-committee-for-diagnostic-radiology4121.doc
  15. 15. SECTION 12. EQUIPMENT Indicate whether each institution has the following units and the number that are available: Institution #1 Institution #2 Institution #3 Institution #4 Intraoperative ultrasound Imaging workstation dedicated to endovascular applications Angiographic unit (indicate if digital) C-Arm with digital subtraction (indicate how many in radiology and in the operating room) Single plane (include the size of the intensifiers) Biplane (include the size of the intensifiers) Magnetic Resonance Scanners Computed Tomography Scanners residency-review-committee-for-diagnostic-radiology4121.doc