neuroimaging

NEUROIMAGINGPROGRAM ACCREDITATION APPLICATION

PROGRAM INFORMATION FORM (PIF)

FOR NEW APPLICATIONS ONLYLast revised: 09-03-08

A. INTRODUCTION

The mission of the United Council for Neurologic Subspecialties (UCNS) is to provide an accreditation and certification process for fellowship training programs with the goals of enhancing the quality of training in neurologic subspecialties and the quality of patient care. The Accreditation Council (AC) strives to develop evaluation methods and processes that are valid, effective, fair, open and ethical. The AC is a voluntary accreditation organization and functions as a council of the UCNS. To be an accredited program by the UCNS, compliance with the program requirements is monitored through completion of the Program Information Form (PIF). In creating this form, the AC has referenced the model used by the Accreditation Council for Graduate Medical Education (ACGME).

B. INSTRUCTIONSAPPLICATION FOR NEW PROGRAM: This form is for use by programs making an initial application only.

All programs, new and existing, must complete the entire Program Information Form.

For new training programs where statistical data are not available, e.g., number of graduates, you should mark the section as “NA” (not applicable).

The PIF template and Appendix A-G template should be downloaded and completed off-line. The PIF template question fields should not be altered. The space in text and tables for responses will expand to accommodate your program’s needs. The page numbers will automatically reformat. Once completed, submit the PIF form and Appendices A-G document electronically via e-mail to the UCNS at [email protected]. The UCNS will send a confirmation acknowledging receipt of the application. Should you require additional space in specific fields, please e-mail the UCNS.

The Program Director is responsible for the content of the completed form and the information will not be considered complete without the Program Director’s signature. All sections of the form applicable to the program must be completed in order to be accepted for review. If any requested information is not available, an explanation should be given in the appropriate place on the form.

Many items require a composed response to a specific question. Please respond briefly and concisely.

The form also includes requests for the following additional data. Please use the Appendix A-G template to provide this information.

Appendix A: participating institution letter from Department Chair(s) of the participating institution (not the full affiliation agreement; not Program Letter of Agreement)

Appendix B: one page curriculum vitae (Program Director and faculty)Appendix C: written goals and objectives by year and rotation

UCNS Program Accreditation Application of 20Neuroimaging 2008

mailto:[email protected]

Appendix D: list of clinical conferences at each institution; list of clinical lectures, conferences, courses in other areas; list of other lectures

Appendix E: list of Neuroimaging meetings attended by fellowsAppendix F: list of research projects by fellowsAppendix G: list of publications by fellows

Please do not attach any unnecessary materials such as reprints, brochures, annual reports, schedules, minutes of meetings and conferences, etc. The UCNS considers only the information requested on the PIF form and provided in the appendices. Any extra material not requested will be discarded.

C. APPLICATION FEE

The UCNS has two program application categories: New Applicant and Continuing Applicant. You are applying for program accreditation as a New Applicant.

New Applicant $3150 Application Fee ($1150 first-year accreditation fee + $2000 non-refundable application fee)

The accreditation year is the academic year, July 1 through June 30. An annual accreditation fee of $1150 will be assessed. Fees are subject to change.

D. PAYMENT

The UCNS accepts checks (or money orders) only at this time. Please submit payment in US funds (payable to United Council for Neurologic Subspecialties) to the UCNS Executive Office, 1080 Montreal Avenue, Saint Paul, MN 55116. Please indicate the subspecialty and name of the program on the payment.

E. APPLICATION DEADLINE

The UCNS accepts applications throughout the year and reviews applications twice per year, in the spring and fall. Your application must be submitted and payment received by July 1, 2008, for fall 2008 review and accreditation for the 2009 academic year. The next deadline is December 31, 2008, for spring 2009 review and accreditation for the 2009 academic year.

F. PROGRAM SITE REVIEW

A site review of the program will not normally be required for the first application of programs. Should the UCNS determine that a site visit is necessary; you will be notified and provided the additional necessary information.

G. ADMINISTRATIVE STAFF CONTACTS FOR QUESTIONS

Contact the UCNS Executive Office with questions: UCNS Executive Office, 1080 Montreal Ave., St. Paul, MN 55116 Tel: 651-695-2816 Fax: 651-361-4916 E-mail: [email protected].

H. GLOSSARY OF TERMSA glossary of terms used in the Program Requirements and PIF can be found on the UCNS website at www.ucns.org.


http://www.ucns.org/


I. TABLE OF CONTENTS

Section

1 Program Information

1.A Program Identification

1.B Program Director Information

2 Institutional Affiliates

3 Fellow Information

3.A Number of Positions

3.B Actively Enrolled Fellows

3.C Aggregate Data on Fellows Completing or Leaving the Program for the Last Three (3) Years

3.D Fellows Completing the Program in the Last Three Years

4 Personnel

4.A Program Director

4.B Program Teaching Faculty

4.C Other Teaching Faculty

5 Facilities and Resources

5.A Facilities

5.B Library Facilities

6 Educational Program

6.A Curriculum

6.B Seminars and Conferences

6.C Educational Program

6.D Educational Policies

7 Research and Scholarly Activity

7.A Fellow Meeting Attendance

7.B List of Research Projects by Fellows

7.C List of Publications by Fellows

7.D Scholarly Activity Summary

8 Evaluation

8.A Fellow Evaluation

8.B Faculty Evaluation

8.C Program Evaluation

8.D Curriculum Development

8.E Curriculum Evaluation

9 SignaturesAppendix A: participating institution letter(s) from department chair(s) of participating institution(s)

(not the full affiliation agreement; not Program Letter of Agreement)Appendix B: one page curricula vitae (Program Director and faculty)

Appendix C: written goals and objectives by year and rotationAppendix D: list of clinical conferences at each institution; list of clinical lectures, conferences,

courses in other areas; list of other lecturesAppendix E: list of Neuroimaging meetings attended by fellowsAppendix F: list of research projects by fellowsAppendix G: list of publications by fellows


SECTION 1. PROGRAM INFORMATION

A. Program Identification

Date:

Title of Program:

Does your program currently have fellows? YES NO

If yes, how many fellows do you/will you have each year?

How many years is the fellowship?

10 Digit UCNS Program ID# (for office use only):

B. Program Director (PD) Information

Name:

Title:

Address:

City, State, Zip code:

Telephone: FAX: Email:

Date Program Director First Appointed:

Term of Program Director Appointment:

Primary Specialty Board Certification: Most Recent Certification Date:

Secondary Specialty Board Certification: Most Recent Certification Date:

Number of years spent teaching in GME in this subspecialty:

Is the Program Director a full-time staff member of the sponsoring institution? YES NODoes the Program Director hold a current license to practice medicine in the state of the sponsoring institution? YES NOIs the Program Director ABMS or RCPSC certified in neurology or child neurology; neurosurgery, radiology or nuclear medicine? YES NOIs the Program Director certified by the UCNS or possess appropriate equivalent qualifications? YES NOIs the Program Director based at primary teaching institution?

YES NO

How many hours per week does the Program Director spend in:Clinical Supervision:

Administration: Research: Didactics/Teaching:

Is Program Director also Department Chair?

YES NO

If No, Chair Name:


SECTION 2. INSTITUTIONAL AFFILIATES (Program Requirements II, A, B)

SPONSORING INSTITUTION: (Institution #1) -The university, hospital, or foundation that has ultimate responsibility for this programName of Sponsor: Address: Is there a sponsoring core residency program?

YES NOCity, State, Zip code:

Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School):

Ownership Type: (e.g., State, Corporation, Church):

Is Institution ACGME Accredited Yes No Length of Accreditation: Next Review Date:

Name of Individual Responsible for Oversight of Training at this Institution (Program Director):

Does SPONSOR have an affiliation with a medical school (could be the sponsoring institution)?

YES NO

If Yes

Name of Medical School #1:

Name of Medical School #2:

PRIMARY INSTITUTION (Institution #2) If different than the sponsoring institution

Name:

Address:

City, State, Zip Code: Name of Individual Responsible for Oversight of Training at this Institution: (Site Coordinator):


PARTICIPATING INSTITUTION (Institution #3)

Name:

Address:

City, State, Zip Code: Distance between Institutions 1 & 3:

Miles: Minutes:

Type of Rotation (select one)

Elective Required Both

Length of Fellows Rotation (in months) Year 1: Year 2:

Name of Individual Responsible for Oversight of Training at this Institution (Site Coordinator):


Brief Educational Rationale for Use of this Institution:


PARTICIPATING INSTITUTION (Institution #4) If more than two participating institutions, e-mail [email protected].

Name:

Address:

City, State, Zip Code: Distance between Institutions 1 & 4:

Miles: Minutes:

Type of Rotation (select one)

Elective Required Both

Length of Fellows Rotation (in months) Year 1: Year 2:

Name of Individual Responsible for Oversight of Training at this Institution (Site Coordinator):


Brief Educational Rationale for Use of this Institution:

RELATED CORE PROGRAM IN NEUROLOGY

Name of Institution or Hospital:

Address:

City, State, Zip Code: Date Program Approved for Accreditation:

Next Review Date:

Name of Program Director:

Total Number of Faculty:



SECTION 3. FELLOWS INFORMATION

A. Number of Positions (For the current academic year)

Positions Year 1 Year 2 Total

Number of Requested Positions

Number of Filled Positions*

*For established programs without currently active fellows, complete table with 0 and indicate here when last fellow finished: For programs that have never had fellows, complete with “N/A”.

B. Actively Enrolled Fellows (if applicable) (Program Requirements III)

1. List all fellows actively enrolled in this program as of August 31 of current academic year (see Section 3.A). List names alphabetically within ‘Year in Program.’ Indicate fellows accepted as transfer with an asterisk (*).

YEAR ONE

Name Name of Medical School

Name of Prior GME Training

Program

*ABMS or RCPSC Eligible or Certified?

UCNS Board Eligible upon Graduation?

YES NO YES NO YES NO YES NO YES NO YES NO

*Completed ACGME- or RCPSC-accredited residency training in neurology or child neurology, neurological surgery, radiology, or nuclear medicine.

YEAR TWO

Name Name of Medical School

Name of Prior GME Training

Program

*ABMS Eligible or Certified?

UCNS Board Eligible upon Graduation?

YES NO YES NO YES NO YES NO YES NO YES NO

*Completed ACGME- or RCPSC-accredited residency training in neurology or child neurology, neurological surgery, radiology, or nuclear medicine.

2. Are you planning to train non-ACGME or non-RCPSC trained fellows? If yes, be aware that non-UCNS certifiable trainees must be included in the faculty to fellow ratio. What effect will this have on your faculty to fellow ratio?


C. Aggregate Data on Fellows Completing or Leaving the Program for the Last Three (3) Years (if applicable)

Based on academic year ending:June 30, (indicate year)

June 30, (indicate year)

June 30, (indicate year)

Number of Graduates

Number of Fellows Who Withdrew from the Program

Number of Fellows Who Transferred Out of the Program Number of Fellows on Leave of Absence from the Program

Number of Fellows Dismissed from the Program

D. Fellows Completing Program in the Last Three Years (if applicable)

List of fellows who completed all training for this subspecialty in the academic year ending June 30, .

Name Start Date Actual Date of Completion Practice Position UCNS Certified?

YES NO

YES NO

YES NO



YES NO

YES NO

YES NO



YES NO

YES NO

YES NO


SECTION 4. FACULTY AND PERSONNEL

A. Program Director (Program Requirements IV, A, B)

1. Describe the Program Director’s qualifications in Neuroimaging. Indicate appropriate qualifications in clinical, educational and administrative abilities, and experience in his/her field?

2. Give a brief description of the Program Director’s responsibilities and activities. Attach a one page curriculum vitae (Appendix B) for the Program Director. CVs using the NIH Biographical Sketch

format will be accepted as long as they provide current hospital staff privileges.


B. Program Teaching Staff—Neuroimaging (Program Requirements IV, C, D, E)

List all members of the program responsible for core training in Neuroimaging. For those with dual appointments, identify primary appointment (neurology or other department) in parentheses. See Section 2 for institution numbers.

Name, Degree, Title and Position

Role in Curriculum

Location by

Institution #1,2,3,4

Full-Time

If part-time, state Current

Certification*Wks/Yr

Hrs/Wk

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Attach a one page curriculum vitae (Appendix B) for each of the faculty listed above. CVs using the NIH format Biographical Sketch format will be accepted as long as they provide current hospital staff.

If additional rows are needed to list more than 18 faculty, please e-mail to [email protected].

*Indicate certification by ABMS or RCPSC and the specialties in which certified. Indicate certification by UCNS and the subspecialty in which certified.



C. Other Teaching Staff

List other teaching staff regularly involved in teaching fellows, including consultants and basic science faculty. Note their department, title and certifying credentials, and supervisory responsibilities to the program. See Section 2 for institution numbers.

Name, Degree, TitleAnd Position

Role in Curriculum

Location by

Institution #1,2,3,4

Full-Time

If part-time, state Current

Certification* Wks/Yr

Hrs/Wk

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Attach one page curriculum vitae (Appendix B) for members with major teaching responsibilities (use Appendix B form). CVs using the NIH Biographical Sketch format will be accepted as long as they provide current hospital staff privileges.

If additional rows are needed to list more than 18 faculty, please e-mail to [email protected].

*Indicate certification by ABMS or RCPSC and the specialties in which certified. Indicate certification by UCNS and the subspecialty in which certified.



SECTION 5. FACILITIES AND RESOURCES(Program Requirements V, F)

A. Facilities

1. Facilities and resources for training

See Section 2 for institution numbers.

Are the following office space and resources available?

Faculty and ResourcesInst

1Inst

2Inst

3Inst

4

a. Neuroimaging Faculty Offices and Facilities YES

NO YES NO

YES NO

YES NO

Is there administrative support for the Fellowship & Program Director?

YES NO

YES NO

YES NO

YES NO

b. Fellow Offices and Resources YES

NO YES NO

YES NO

YES NO

Does each fellow have his/her own office? YES

NO YES NO

YES NO

YES NO

Are the offices for groups of fellows? YES

NO YES NO

YES NO

YES NO

Is there dedicated administrative support for fellows? YES

NO YES NO

YES NO

YES NO

Does the fellow have access to other office equipment such as copiers, slide projectors, PowerPoint, video projection equipment or services to make slides, illustration services?

YES NO

YES NO

YES NO

YES NO

c. Laboratory Facilities YES

NO YES NO

YES NO

YES NO

d. Magnetic Resonance Scanner YES

NO YES NO

YES NO

YES NO

e. If available, is MRS capable of performing echoplanar imaging? YES NO

YES NO

YES NO

YES NO

f. Computed Tomography Scanner YES

NO YES NO

YES NO

YES NO

g. Space for Image Display and Interpretation YES

NO YES NO

YES NO

YES NO

h. Facilities for Physiological Monitoring YES

NO YES NO

YES NO

YES NO

i. Facilities for Emergency Ventilation and Cardiac Life Support YES

NO YES NO

YES NO

YES NO

j. Space, in or adjacent to Examination Room, for Storage of Supplies Used in Invasive Neuroimaging Procedures

YES NO

YES NO

YES NO

YES NO

2. Briefly describe conference facilities that will be used for Neuroimaging conferences at each institution.

3. Briefly describe the space provided for Neuroimaging program faculty and fellow research at each institution. (Program Requirements V, F)


B. Library Facilities

Use the table below to describe the institutional and departmental library holdings and other reference resources at each institution.

See Section 2 for institution numbers.

Are the following facilities and resources available?

Library FacilitiesInst

1Inst

2Inst

3Inst

4a. Journals

Access to Medline YES NO

YES NO

YES NO

YES NO

b. Computer Databases Available YES NO

YES NO

YES NO

YES NO

Access in Hospital YES NO

YES NO

YES NO

YES NO

Access in Library YES NO

YES NO

YES NO

YES NO

24 Hour Access YES NO

YES NO

YES NO

YES NO

Access to Major Texts and Full Text Journals YES NO

YES NO

YES NO

YES NO

Internet Search Capabilities YES NO

YES NO

YES NO

YES NO

c. Library Available on Site YES NO

YES NO

YES NO

YES NO

Library with Major Texts in all Areas of Medicine on Site or Nearby

YES NO

YES NO

YES NO

YES NO

Interlibrary Loan Capability YES NO

YES NO

YES NO

YES NO

Textbook Availability YES NO

YES NO

YES NO

YES NO

Major Neuroimaging Texts on Wards YES NO

YES NO

YES NO

YES NO

Major Neuroimaging Texts in Clinic YES NO

YES NO

YES NO

YES NO

Teleconference Capability YES NO

YES NO

YES NO

YES NO

d. Neuroimaging Teaching File with Case Histories and Images with 500 Entry Minimum. (Can Be Electronic)

YES NO

YES NO

YES NO

YES NO


SECTION 6. EDUCATIONAL PROGRAM

A. Curriculum

Curricular components may be offered in blocks or longitudinally. Many programs will have a mixture of both. An example of the former is a 4-week or month long rotation to a particular training area. An example of the latter is a regularly scheduled clinic attended over a period of time while also assigned to block rotations. Those components offered in block assignments each year should be recorded in the block templates. Those clinical experiences offered longitudinally should be recorded separately in the longitudinal templates by year. You should not include conferences, lectures or other didactic experiences in the longitudinal template.

Include the goals and objectives for each of these curricular assignments and the program’s overall goals and objectives as Appendix C.

BLOCK ROTATIONS –YEAR 1

July August September October November December January February March April May June

For programs structured as 13 4-week blocks rather than as calendar months, request a 13 column table from [email protected]

LONGITUDINAL EXPERIENCES - YEAR 1

Type Of Experience Weekly effort Number Of Weeks total Total effort based on 1 year


Does the fellowship offer a second year? YES NOIf YES, please complete the following.

Include the goals and objectives for each of these curricular assignments and the program’s overall goals and objectives as Appendix C.

2. Have these goals and objectives been provided to the fellows? YES NO

BLOCK ROTATIONS - YEAR 2

July August September October November December January February March April May June

For programs structured as 13 4-week blocks rather than as calendar months, add another column to the table and rename blocks 1-13.

LONGITUDINAL EXPERIENCES – YEAR 2

Type Of Experience Weekly effort Number Of Weeks total Total effort based on 1 year


B. Seminars and Conferences (Program Requirements V, C)

1. Attach a schedule of clinical conferences for fellows in each institution (Appendix D). Name the faculty member assigned to the conference. Indicate which conferences are mandatory for fellows.

2. Attach a list of the courses, conferences and/or lectures given in each of the other areas required in the program (Appendix D).

3. Attach a list of lectures not already supplied, such as lectures by visiting neuroscientists (Appendix D).

4. Is there a journal club? YES NO

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

C. Educational Program

1. What teaching responsibilities do fellows have?

2. Document how the program has integrated the six Accreditation Council for Graduate Medical Education (ACGME) core competencies (www.acgme.org) listed below into the didactic and clinical curriculum. Describe the method(s) used to evaluate fellow performance in each area (e.g. 360 degree evaluations; patient surveys; portfolios; record review; simulations; standardized oral exams; standardized patients; written examinations; etc.)

a. Patient care

b. Medical knowledge

c. Practice-based learning and improvement

d. Interpersonal and communication skills

e. Professionalism

f. Systems-based practice


http://www.acgme.org/

3. Clinical Components (Program Requirements V, D). Provide the amount of time required.

TYPE OF EXPERIENCE LOCATION INTHE PROGRAM

(Institution #)

AMOUNT OF TIME

MRI CT Other imaging modalities

4. Document how fellows are provided with direct experience in progressive responsibility in the performance of integrative neuroimaging.

5. Estimate number of images fellows will interpret and provide written reports on.

a. MRI images and written reports:

b. CT images and written reports:

6. Core Content

Document how the program will teach the following areas of study.

a. Technical Aspects/Physics

b. Clinical Aspects/Applications

D. Educational Policies (Program Requirements V, F)

1. Describe how the Program Director supervises fellows in each clinical setting.

2. Describe how compliance with ACGME duty hours is maintained (www.acgme.org). Please submit a copy of the policy on duty hours and a call schedule.

SECTION 7. RESEARCH AND SCHOLARLY ACTIVITY

A. Fellow Meeting AttendanceComment on how many and how often fellows attend local, regional, and national Neuroimaging meetings. Provide a list of meetings that fellows have attended over the past three years, showing the fellows by name, as Appendix E.

B. List of Research Projects by FellowsList the research projects by fellows from the Neuroimaging program during the past 3 years as Appendix F.


http://www.acgme.org/

C. List of Publications by FellowsList the publications by fellows from the Neuroimaging program during the past 3 years as Appendix G. (not manuscripts submitted or in preparation)

D. Scholarly Activity Summary (if applicable)

Based on Academic Year Ending June 30, . June 30, . June 30, .Number of Nationally Peer-Reviewed Published Articles Authored or Co-Authored by Fellows in the Past Year

Number of Fellow Presentations at Regional or National Meetings in the Past Year

SECTION 8. EVALUATION (Program Requirements VI, A)

A. Fellow Evaluation

1. Describe the methods for fellow evaluation used in the program.

2. Fellow Feedback and RecordsDescribe how and by whom feedback to fellows is provided and what remedial actions are taken in cases of deficiency. What kind of records of fellow evaluations does the program maintain?

3. Final EvaluationDoes the Program Director provide a final evaluation for each fellow who completes theprogram? If not, please explain. YES NO

4. Impaired FellowsWhat policies are in place for dealing with impaired fellows?

5. Fellow StressHow does the program monitor fellow stress, provide counseling and support services to fellows?

B. Faculty Evaluation (Program Requirements VI, B)Describe the system by which the faculty is evaluated. Are written evaluations by fellows used in this process? If not, please explain. YES NO


C. Program Evaluation (Program Requirements VI, C)Describe the system by which the program is evaluated.

D. Curriculum Development

1. Describe how written evaluations by fellows are used in the curriculum development process.

2. Describe the participation by fellows in the curriculum development and evaluation process.

3. Describe who participated in the development of written goals and objectives for the required experiences and state the time of most recent revision.

D. Curriculum Evaluation

1. Describe the criteria used in assessing the extent to which goals and objectives (Appendix C) are met.

2. Explain how often the goals and objectives are reviewed and how they are evaluated.

3. Describe how the performance by graduates on the certifying examinations is used to evaluate the effectiveness of the program and to modify the goals and objectives.


SECTION 9. SIGNATURES

If this form was completed by the Program Coordinator, please provide the following information:

Program Coordinator’s Name:

Telephone Number: E-mail:

The signatures below attest to the completeness and accuracy of the information provided. Please insert an electronic signature, or sign and fax this page to the UCNS Executive Office at 651-361-4916.Insertion of an electronic signature:

By typing your name in the space provided, you are submitting the electronic equivalent of a legal signature. You are also asserting that you completed the application. To verify the contents of the application, the signatory must enter his/her name in the space provided. Acceptable “signatures” should be preceded and followed by the forward slash (/) symbol. Acceptable “signature” should be as follows: /John Doe/.

Neuroimaging Program Director

Name:

Signature: Date:

Department Chair

Name:

Signature: Date:

Please use the Appendices A-G template for submitting Appendices A-G.


neuroimaging

Education

page curriculum vitae

rotation elective required

program requirements vi

program requirements iv

major neuroimaging texts

accredited residency training

ucns executive office

full affiliation agreement