continued accreditation.doc.doc

THE RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY515 N State, Ste 2000, Chicago, IL 60654 (312) 755-5000 www.acgme.org

FOR CONTINUED ACCREDITATION

GENERAL INSTRUCTIONS

REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDIATION 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 (www.acgme.org) 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. 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.

Review the Program Requirements for Residency Education in Neurology. The Program Requirements and the Institutional Requirements may be downloaded from the ACGME website (www.acgme.org):

For questions regarding:

-the completion of the form (content), contact the Accreditation Administrator.

-the Accreditation Data System, email [email protected].

For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp

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.

Neurology Continued Accreditation PIF i

http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp

http://www.acgme.org/

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.j.4.; CPR VI.C.; IR II.D.4.i.; IR III.B. 3.)

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

Single Program Sponsors only:

1. A copy of the resident contract with the pertinent items from the institutional requirements and Master Affiliation Agreements

2. Institutional policy for recruitment, appointment, eligibility, and selection of residents (IR II.A.)

3. Institutional policy for discipline and dismissal of residents, including due process (IR II.D.4.e.; IR III.B.7.)

Neurology Continued Accreditation PIF ii

THE RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY515 N State, Ste 2000, Chicago, IL 60654 (312) 755-5000 www.acgme.org

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 PIF Page(s)Accreditation InformationParticipating Sites

Sponsoring Institution/Single or Limited Residency Institution (If applicable)Faculty/Teaching Staff

Program Director InformationPhysician Faculty RosterFaculty Curriculum VitaeNon Physician Faculty RosterNon Physician Faculty Curriculum Vitae

Resident AppointmentsNumber of PositionsActively 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)

EvaluationResident Duty Hours

Specialty Specific PIF Page(s)Patient Care

Clinical & Basic ScienceMedical Knowledge

Related Services-Training ExperiencesClinical Teaching-InpatientClinical Teaching-OutpatientEducational ProgramResident Research ProjectsResident Publications

Practice-Based Learning & ImprovementInterpersonal & Communication SkillsProfessionalismSystems-Based PracticeCurriculumOther Non-Neurology Clinical FacultyOther Resident Information

Other Neurology Trainees

Neurology Continued Accreditation PIF iii

Specialty Specific PIF Page(s)Other Residents in Training

Facilities and ResourcesFacilitiesSupporting FacilitiesSeminars and Conferences

EvaluationResident EvaluationImpaired StressResident Stress

Appendix A - Goals and Objectives

Neurology Continued Accreditation PIF iv

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY515 N State, Ste 2000, Chicago, IL 60654 (312) 755-5000 www.acgme.org

SPECIALTY SPECIFIC PROGRAM INFORMATION FORM

I. PATIENT CARE

A. Clinical and Basic Science

Site # 1 2 3 4 5 6 7 8NEUROIMAGINGMonths resident assignedResponsibilities of resident:NEUROPATHOLOGY Statistical data (past year)CNS surgical specimens submittedMuscle biopsiesNerve biopsiesSpecimens submitted from outside facilitiesMonths Resident AssignedResponsibilities of resident:EMGName of director(s)Number of patients per yearEMG: adult/childOtherMonths Resident AssignedResponsibilities of resident:EEGName of director(s)Number of studies per yearEEG: adult/childOtherMonths Resident AssignedResponsibilities of resident:

Neurology Continued Accreditation PIF 1

II. MEDICAL KNOWLEDGE

A. Related Services- Training Experiences

Discipline

Number of faculty, with special expertise in this discipline,

available to neurology residents on a regular basis

Nature of interaction with neurology residents

neuro-ophthalmology

neuromuscular disease

cerbrovascular disease

epilepsy

movement disorders

critical care

clinical neurophysiology

behavioral neurology

neuroimmunology

infectious disease

neuro-otology

neuroimaging

neuro-oncology

pain management

neurogenetics

child neurology

the neurology of aging

sleep disorders

psychiatry


B. Clinical Teaching – Inpatient

1. Inpatient Data

Site # 1 2 3 4 5 6 7 8BED CAPACITYNeurology beds

AdultsChildren

ADMISSION DATA (past year)Total admissions to hospitalTo neurology servicesAdultsChildrenPercent malePercent femaleAverage daily neurology censusAverage length of stay

TYPICAL INPATIENT TEAMFacultyNeurology residentsRotating ResidentsOther traineesStudentsNurse clinicians

2. Teaching Rounds and Inpatient Service

a) Describe the frequency that teaching rounds are held each week for patients on the neurology service. Describe the complement of the team making attending rounds. Describe the duties of the neurology residents and of residents rotating from other services.

b) If there are separate teaching rounds whose purpose is distinct from patient care, e.g., Professor’s rounds, describe their nature and frequency.

c) What is the role of the adult neurology resident in the management of child neurology patients? Note the location of the inpatient child neurology rotation.

d) Describe how neurology residents participate in the education of other residents, medical students, nurses, and other health care personnel on the inpatient service.


e) Describe how therapeutic and diagnostic options including the cost of diagnostic tests, procedures and therapies and their results of the diagnostic tests are discussed on teaching rounds.

3. Specify how the neurology resident directly manages neurology inpatients.

a) Describe how the teaching service is organized, e.g., one senior attending, one PG-2, PG-4, one from internal medicine, one from family medicine.

b) Describe the structure for supervision of patient care in relation to resident participation, responsibility for decision making and teaching, including how residents are afforded progressive responsibility.

c) Who writes orders on inpatients?

d) Does a neurology resident write notes on all or only some of the patients? Note differences that may relate to (a) economic status of patient; (b) status of the responsible physician, either full- or part-time, and whether or not hospital-based; (c) exclusion of residents from responsibility in management of any patients.

e) Are all patients of the teaching staff available for resident education?

f) How is continuity of care ensured? E.g. does the neurology resident maintain care throughout the hospitalization; does the neurology resident see their patients on weekends, and if not how is the continuity of care maintained; does the resident see patients admitted to them in clinic follow-up?

4. Emergency Room

a) Describe resident responsibility, frequency of service, and type of supervision in the emergency room, indicating how the resident participates in the management of patients with acute neurological disorders in the emergency department.


b) Number of ER patients per year seen in consultation by neurology at each site and the percentage seen by neurology residents.

Site # 1 2 3 4 5 6 7 8# ER Patients Seen in Consultation% of Patients Seen by Residents

5. List the intensive care units (neurology and non-neurology) at each site where adult neurology residents participate in the management of patients with the weekly number of neurology patients admitted to the ICU and the weekly number evaluated by neurology residents.

ICU NameSite #

1 2 3 4 5 6 7 8

6. Inpatient Statistics

Provide the number of inpatients in each of the following diagnostic categories that were available in the program for the past year. Each patient should be listed only once in the most appropriate category.

Site # 1 2 3 4 5 6 7 8Diagnostic CategoryDisorders of cranial nervesDisorders of cord, nerve root and plexusMuscle diseaseAutoimmune and vasculitic disordersInfectionsEpilepsySleep disordersSyncope and other alterations of consciousnessStroke and related disordersNeoplastic diseaseMovement disorderDisorders of cognitive functionOther degenerative diseasesMultiple SclerosisMetabolic diseasesEndocrine disordersTraumaDrugs and other toxic disordersPsychiatric disorders


Site # 1 2 3 4 5 6 7 8Nutritional deficiencyDisorders of intracranial pressurePainTotal

7. Clinical Teaching – Inpatient Consultations

a) Inpatient Teaching Consultations

Site # 1 2 3 4 5 6 7 8Number of inpatient consultations per yearAdultChildrenPercent seen by neurology residentsAdultChildrenAverage monthly consultation team size

FacultyNeurology residentsRotating residentsOther traineesStudentsNurse clinicians

b) Consultation Diagnostic Categories

1) Provide the number of consults in each of the following diagnostic categories that were available in the program for the past year. Each patient should be listed only once in the most appropriate category.

Site # 1 2 3 4 5 6 7 8DIAGNOSTIC CATEGORYDisorders of cranial nervesDisorders of cord, nerve root and plexusMuscle diseaseAutoimmune and vasculitic disordersInfectionsEpilepsySleep disordersSyncope and other alterations of consciousnessStroke and related disordersNeoplastic diseaseMovement disorderDisorders of cognitive functionOther degenerative diseasesMultiple SclerosisMetabolic diseases


Site # 1 2 3 4 5 6 7 8Endocrine disordersTraumaDrugs and other toxic disordersPsychiatric disordersNutritional deficiencyDisorders of intracranial pressurePainTotal

2) If there are separate consultations services, describe the frequency that teaching rounds are held each week for patients on the consult service. Describe the complement of the team making attending rounds. Describe the duties of the neurology residents and of residents rotating from other services


C. Clinical Teaching—Outpatient

1. Neurology resident outpatient experience can include block time and longitudinal time in the outpatient clinics described under curriculum and the continuity clinic described below (add boxes for other specialty clinics).

Site # 1 2 3 4 5 6 7 8GENERAL NEUROLOGY CLINIC

SPECIALTY CLINICSCLINIC NAME:

Number of clinics per monthAverage number of visits per clinicPercent visits seen by neurology residents

CLINIC NAME:Number of clinics per monthAverage number of visits per clinicPercent visits seen by neurology residents



2. Outpatient Clinics

a) For block and non-continuity longitudinal clinics, list the following as averages per resident per clinic half-day:

# new patients seen# follow-up patients

seen Staff/resident ratio

PG-2 year

PG-3 year

PG-4 year

b) What is the role of the resident in the management of adult neurology outpatients?

c) What is the role of the resident in the management of child neurology outpatients?


d) For the continuity longitudinal clinic, list the following as averages per resident per clinic half-day:

# new patients seen# follow-up patients

seen Staff/resident ratio

PG-2 year

PG-3 year

PG-4 year

e) List each block of time when the resident does not see patients in his/her continuity clinic

f) What is the number of continuity clinic patients followed for two years or more, by individual residents?

g) How do you assure that patients with a wide variety of chronic neurological disease are followed long term by the residents?

3. Outpatient Diagnostic Categories

Provide the number of outpatients in each of the following diagnostic categories that were available in the program for the past year. Each patient should be listed only once in the most appropriate category.

Site # 1 2 3 4 5 6 7 8DIAGNOSTIC CATEGORYDisorders of cranial nervesDisorders of cord, nerve root and plexusMuscle diseaseAutoimmune and vasculitic disordersInfectionsEpilepsySleep disordersSyncope and other alterations of consciousnessStroke and related disordersNeoplastic diseaseMovement disorderDisorders of cognitive functionOther degenerative diseasesMultiple SclerosisMetabolic diseasesEndocrine disordersTraumaDrugs and other toxic disorders


Site # 1 2 3 4 5 6 7 8Psychiatric disordersNutritional deficiencyDisorders of intracranial pressurePainTotal

D. Educational Program

1. What teaching responsibilities do neurology residents have?

2. Outline resident responsibility and frequency on night call at each site.

3. What provision is there to assure increasing patient responsibility and professional maturation of residents?

E. Resident Research Projects

Describe the research projects, supervisors and their specialties, and the nature of resident involvement in departmental research during the past five years.

List by name those residents who participated in such research, the duration of their assignment, and whether full-time or part-time.

Resident Name Duration of the Assignment Full-time or Part-time

F. Resident Publications

List the publications of residents from the section/division during the past 3 years (not manuscripts submitted or in preparation).


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 residents 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 residents 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 informationb) using information technologyc) appraising informationd) assimilating evidence information (from scientific studies)e) applying information to patient care


3. Give one example and the outcome of a planned quality improvement activity or project in which at least one resident participated in the past year that required the resident 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.


4. Describe how residents:

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.)



IV. INTERPERSONAL AND COMMUNICATION SKILLS

1. Describe one learning activity in which residents 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.


2. Describe one learning activity in which residents 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.


3. Explain (a) how the completion of comprehensive, timely and legible medical records is monitored and evaluated, and (b) the mechanism for providing residents feedback on their ability to competently maintain medical records.



V. PROFESSIONALISM

1. Describe at least one learning activity, other than lecture, by which residents develop a commitment to carrying out professional responsibilities and an adherence to ethical principles.


2. How does the program promote professional behavior by the residents and faculty?


3. How are lapses in these behaviors addressed?



VI. SYSTEMS-BASED PRACTICE

1. Describe the learning activity(ies) through which residents 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.


2. Describe an activity that fulfills the requirement for experiential learning in identifying system errors.



VII. CURRICULUM

Describe in block form the typical curriculum for residents by months, not weeks, including the site (#1,2,3,4) and the experience on each rotation during the PG-3 through PG-5 years. Exclude mention of vacation time.

Curricular components may be offered in blocks or longitudinally. An example of the latter is a regularly scheduled clinic attended over a period of time while assigned to other rotations. Those components offered in block assignments each year should be recorded in the block template. Those offered longitudinally should be recorded separately in the longitudinal templates by year.

Both block and longitudinal components can be applied toward FTE minimums described in the Program Requirements. For example, one half-day per week for ten months of a longitudinal clinic would count for one month. Three months of the six-month outpatient rotation requirement are met by two and one-half years (30 months) of weekly continuity clinic attendance during hospital or other non-outpatient services. Three months of outpatient clinic that include a weekly continuity clinic would meet another three months of the six-month requirement.

SAMPLE BLOCK ROTATIONS - PG-2

July AugustSeptemb

erOctober

November

December

January February March April May June

Adult Neurology Unit 1






Adult Neurology Clinic 1




Clinical Neurophys-iology2

Clinical Neurophys-iology2

SAMPLE LONGITUDINAL EXPERIENCES - PG-2

Type Of Experience* Weekly Structured Number Of WeeksAmount of Time (FTE)

Adult Continuity Clinic 1/2 day each week 52 weeks 23 daysMovement disorder clinic 1/2 day each week 52 weeks 4 daysEEG reading 1/2 day each week 8 weeks 4 days

BLOCK ROTATIONS – PG-1 YEAR IF THE PROGRAM IS A 4-YEAR PROGRAMJuly August September October November December January February March April May June

LONGITUDINAL EXPERIENCES - PG-1

Type Of Experience* Weekly Structured Number Of WeeksAmount of Time

(FTE)

BLOCK ROTATIONS - PG-2July August September October November December January February March April May June

LONGITUDINAL EXPERIENCES – PG-2


(FTE)





(FTE)




(FTE)


VII. OTHER NON-NEUROLOGY CLINICAL FACULTY

Discipline/service

Are faculty available to interact with the neurology residents? (Y/N)

Site 1 Site 2 Site 3 Site 4

Medicine

Cardiology

Critical Care Medicine

Endocrinology

Gastroenterology

Genetics

Hematology

Infectious Diseases

Nephrology

Pulmonary

Oncology

Rheumatology/Immunology

Other (specify)

Neuropathology

Neuroradiology

Neurorehabilitation

Ophthamology

Psychiatry

Psychology

Surgical:

Neurosurgery

Otolaryngology


VIII. OTHER RESIDENT INFORMATION

A. Other Neurology Trainees

1. List those trainees who do not meet the American Board of Psychiatry and Neurology preliminary training requirements before beginning in the program’s Neurology Residency. Indicate trainees who are training in Child neurology with an asterisk

NameYear in

Program

Years of Prior

GME

Specialty of Prior

TrainingMedical School

Yr. of Medical School

Graduation

Program Start Date

Expected Completion

Date

2. Have each of these trainees been told in writing that they are ineligible to take the ABPN board examination for certification in Neurology? ........................................................( ) YES ( ) NO

If the answer is no explain below.

B. Other Residents in Training

List the graduate medical education (GME) residents (fellows) from other ACGME-accredited programs who rotated through neurology during the last academic year.

Specialty & Years of GME (e.g. PGY 2 Medicine)

Number of these Residents in the Last year

Months Each Resident in Neurology

Neurology Assignment (ward,

clinic, other) Site

Child NeurologyPG-

MedicinePG-

NeurosurgeryPG-

Physical Medicine & RehabilitationPG-

PsychiatryPG-

Family PracticePG-

TransitionalPG-

OtherPG-


IX. FACILITIES AND RESOURCES

A. Facilities

1. Briefly describe the physical facilities at each site for the inpatient and outpatient examination and care of neurology patients.

2. Facilities and resources for training.

Are the following office space and resources available? Site # Site # Site # Site # Site #a) Faculty Offices and Facilities

Neurology Faculty OfficesSecretary Office space for Neurology

b) Resident Offices and ResourcesDoes each resident have his/her own office?Are the offices for groups of residents?Do the offices have computers and Computer internet search capabilities?Do the residents have secretarial support?Does the resident have a designated telephone number for patients to call?Does the resident have access to other offices equipment such as copiers, slide projectors, equipment or services to make slides, illustration services?

3. Briefly describe clinical laboratory facilities at each site, including mechanisms for reporting of test results.

4. Briefly describe conference facilities at each site.

5. Briefly describe the space provided for neurology faculty and resident research at each site.

6. For each site briefly describe how the charts or medical records are made available for inpatients, outpatients, and consultation use.


B. Supporting Facilities

Indicate whether the facilities and resources listed below are ‘AVAILABLE’ for each participating site.

Diagnostic Resources Site # Site # Site # Site # Site #a) Electrodiagnosis:

EEGAmbulatory EEGsVideo-EEG MonitoringIntraoperative MonitoringEvoked Potentials- visual, auditory, somatosensoryEMG/NCVSingle Fiber Studies

b) Diagnostic Radiological servicesMRI and MRAMRSSPECTPET

c) Cytogenetics and Genetic testing

Related Diagnostic and Therapeutic Services Site # Site # Site # Site # Site #a) Psychiatric Servicesb) Genetic Counseling Service c) Interventional Neuroradiologyd) occupational therapye) Pain managementf) Rehabilitation medicineg) Physical therapyh) Radiation Oncology service and

facilities i) Psychology Servicesj) Social Servicesk) Speech


C. Seminars and Conferences

1. Basic science lecture schedule.

2. Since clinical and technical lectures in elective rotations such as EEG, EMG, neuroradiology, etc. do not meet the basic science didactic requirements; identify specific basic science lectures during such rotations. Indicate which are lectures are mandatory for neurology residents.

3. List clinical conferences for neurology residents in each site. Name the faculty member assigned to the conference. Indicate which conferences are mandatory for neurology residents.

4. List of the courses, conferences and/or lectures given in each of the subspecialties of neurology, including neuropathology, neuro-ophthalmology, neuroradiology, EEG, EMG, rehabilitation, psychiatry/psychology. Indicate for each if neurology resident attendance is mandatory.

5. Is there a journal club?

Specify attendance by resident and faculty, the frequency of meeting, and the organization of the club. If there is no journal club, what substitutes for it?


X. EVALUATION

A. Resident Evaluation

Does the program perform a formal, observed clinical evaluation exercise (CEX) on residents at least once during the first two years of their training? ......................................................( ) YES ( ) NO

B. Impaired Residents

How does the program deal with impaired residents?

C. Resident Stress

How does the does the program monitor resident stress, provide counseling and support services to residents?


APPENDIX A - GOALS AND OBJECTIVES

Attach a sample of the goals and objectives for one assignment


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