RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY

RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY515 N State, Ste 2000, Chicago, IL 60654 www.acgme.org

NEURORADIOLOGY PROGRAM INFORMATION FORM

FOR NEW APPLICATIONS

GENERAL INSTRUCTIONS

This form is for use by programs making Initial Application Only (for re-accreditation, use the Continued Accreditation PIF and the Accreditation Data System). All sections of the form applicable to the program must be completed in order to be accepted for review. The information provided should describe the proposed program. For items that do not apply indicate N/A in the space provided. If any requested information is not available, an explanation should be given and it should be so indicated in the appropriate place on the form. Mail the completed application to the Residency Review Committee at the above address.

The Program Requirements, the Institutional Requirements, and Program Information Form (PIF) may be downloaded from the ACGME Website (www.acgme.org) and should be reviewed carefully.

For questions regarding the completion of the form (content), contact the Accreditation Administrator (Phone: 312-755-5042)

For Accreditation Data System questions, contact or email [email protected].

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

Program Letters of Agreement (PLA): Attach at the end of the PIF a letter of agreement (PLA) for each participating site providing an assignment.

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 DIO of the sponsoring institution.

SPECIFIC INSTRUCTIONS

Sponsoring Institutions: 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 diagnostic radiology 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 Diagnostic Radiology program and the Musculoskeletal Radiology program must also be provided.

Participating Sites: For accredited programs the entry on the PROGRAM TITLE line should correspond to the title of the program in the current Graduate Medical Education Directory. If a change in title is being requested, this should be included in a cover letter accompanying the forms. For new applications the requested title should

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

be the title of the core Diagnostic Radiology residency program. All program titles are subject to editing to conform to ACGME policies.

All sites offering required rotations or experiences should be listed. One site should be designated as the primary clinical site and identified as Site #1”. If multiple sites are used, append letters of agreement which describe the trainees’ activities including the content of the experience, duration, supervision, and patient numbers.

SURVEY/SITE VISIT:

1. 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.

2. The following documents should be available for perusal by the site visitor on the day of the visit:

written goals and objectives for all curricular components and evidence of their distribution. trainee contract/agreement documentation of trainee eligibility for appointment to the program evidence of evaluation of trainees, faculty, and program the full conference schedule with names of presenters, topics and when presented written descriptions of supervisory lines of responsibility

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NEURORADIOLOGY- PROGRAM INFORMATION FORM

Program Name:

TABLE OF CONTENTS

When you have the completed forms, number each page sequentially in the lower center. 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.

Part 1 Section Page(s)

General Program Information 1

Participating Institutions 2

Fellow Complement 3

Faculty / Teaching Staff 4

Part 2 Section Page(s)

Background Information 5

Personnel 6

Patient Data 7

Narrative Description of Training Program 8

Bibliography 9

Facilities and Space 10

Formal Teaching Exercises 11

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PROGRAM INFORMATION FORM (Part 1)

FOR NEW APPLICATIONS ONLY-NEURORADIOLOGY

SECTION 1. GENERAL PROGRAM INFORMATION

A. Accreditation Information

Date:

Title of Program:

10 Digit ACGME Program ID# (for accredited programs):

Accreditation Status: Effective Date:

Original Accreditation Date: Accredited Length of Training:

Program Requires Prior GME: ( ) YES ( ) NO Last Site visit Date: Cycle Length:The signatures of the director of the program and the Designated Institutional Official attest to the completeness and accuracy of the information provided on these forms:Signature of Program (and Date):

Signature of Designated Institutional Official (DIO) (and Date):

B. Program Director Information

Name: Title:

Address:

City, State, Zip code:

Telephone: FAX: Email:

Date First Appointed as Program Director In This Program?

Date First Appointed as Faculty Member In this Program?

Term of PD Appointment: Principal Activity Devoted to Resident Education?

Primary Specialty Board Certification: Most Recent Date:

Secondary Specialty Board Certification: Most Recent Date:

Number of Hours Per Week Director Spends In:Clinical Supervision: Administration: Research: Didactics/Teaching:

Is the PD based at the primary teaching institution?:

( ) YES ( ) NONumber of years Director has taught GME in this specialty:

New Program Director Since Last Review: Name of Previous Director:

Term of Previous DirectorIs Program Director also Department Chair?

( ) YES ( ) NO If No, Chair Name:

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SECTION 2. PARTICIPATING SITES

SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.)

Name of Sponsor:

Address: Single Program Sponsor? ( ) YES ( ) NO

City, State, Zip code:

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

Name of Designated Institutional Official: Mailing Address: Phone Number:

Email:

Name of Chief Executive Officer:

Does SPONSOR have an affiliation with a medical school (could be the sponsoring institution)? ( ) YES ( ) NOIf yes, name the medical school below and have an affiliation agreement that describes the effect of these arrangements on this program available. Name of Medical School #1:

Name of Medical School #2:

PRIMARY Clinical Site (Site #1)

Name:

Address:

City, State, Zip Code:

Type of Relationship with Program: Sponsor ( ) Major ( ) Clinical ( ) Other ( )

Type of Rotation Elective ( ) Required ( ) Both ( ) (select one)

Length of Resident Rotation (in months) Year 1:

Joint Commission Approved

Content of Educational Experience:

PARTICIPATING Site (Site #2)Select one (if applicable)

INTEGRATED ( )Name:

Address:



Does this institution also sponsor its own program in this specialty?

Does it participate in any other ACGME accredited programs in this specialty?

Distance between 2 & 1: Miles: Minutes:



Joint Commission approved:


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INTEGRATED ( )Name:

Address:










PARTICIPATING Site (Site#4)Select one (if applicable)

INTEGRATED ( )Name:

Address:











INTEGRATED ( )Name:

Address:










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SECTION 3. RESIDENT COMPLEMENT

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

Positions Total

Number of Requested Positions

Number of Filled Positions*

* Not applicable to new programs with no residents on duty.

B. Actively Enrolled Residents (if applicable)

List all residents actively enrolled in this program as of August 31 of current academic year (see Section 3.A). List names alphabetically within Year in Program. Place an (*) asterisk next to the name of each resident accepted as a transfer. Documentation of previous experience for transfer students should be available for review by the site visitor.

NameProgram

Start Date

Expected Completion

Date

Year in Program

Years of Prior GME

Specialty of Most Recent Prior GME

Medical SchoolYear of Med

School Graduation

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

Based in academic year ending:June 30, __

(indicate year)June 30, __

(indicate year)June 30, __

(indicate year)Number of Graduates Who Started in Program Year 1 and Finished this Program*Number of Graduates Regardless of Whether They Began in this Program*

Number of Residents That Completed Preliminary Year(s)

Number of Residents Who Withdrew from the Program

Number of Residents Who Transferred Out of the Program

Number of Residents on Leave of Absence from the Program

Number of Residents Dismissed from the Program

*Excludes residents preliminary complement year(s).

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

List of residents who completed all training for this specialty based on the last academic year ending June 30, ____.

Name Start DateActual Date of

Completion

Date Took First Stage of Board Exam - Passed on

First Attempt (Y/N/Unknown)

Date First Took Second Stage of Board Exam -

Passed on First Attempt (Y/N/Unknown)



Completion







Completion





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E. Transferred, Withdrawn and Dismissed Residents (if applicable)

List of Residents Who transferred to Another Program (From the Current Academic Year and the Previous 5 Years)

Name Start Date End Date Transferred to Which Specialty

List of Residents Who Withdrew or Were Dismissed (From the Current Academic Year and the Previous 5 Years)

Name Start Date End Date Status Reason (up to 50 characters)

F. Scholarly Activity (not applicable)

G. Duty Hours (if applicable)

1. Excluding call from home, what was the average number of hours on duty per week per resident for the last four week rotation(s)?

2. On average, how many days per week of in-house call (excluding home call and night float) were residents assigned for the last four week rotation(s)?

3. Excluding call from home, what was the longest shift (in hours) worked by any resident during the previous 4 week rotation(s)?

4. On average, do residents have 1 full day out of 7 free from educational and clinical responsibilities?If no, explain:........................................................................................................................ ( ) YES ( ) NO

5. Do residents have a 10 hour period between daily duty periods and after in-house call? . . .( ) YES ( ) NOIf no, explain:

6. Do residents have appropriate duty hours when rotating on other clinical services, in accordance with the ACGME-approved program requirements? .........................................................................( ) YES ( ) NOIf no, explain:

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SECTION 4. FACULTY / TEACHING STAFF

A. Faculty Roster - Calculate the number of faculty required for your program, based on the requirement for one full time equivalent faculty member at the parent institution and integrated sites for each resident in the program. List alphabetically and by site the faculty counted by the program to meet this requirement. In addition, supply a one page CV for each faculty listed

Primary and Secondary Specialties / Field Average Hours Per Week Spent On

Name (Position) DegreeBased

Primarily at Site #*

Specialty / FieldBoard

Certification (Y/N)†

Most Recent

Certification Date

No. of Years

Teaching in This

Specialty

Clinical Supervisio

n Admin

Didactic Teaching

Research

(PD)

† Certification for the primary specialty refers to ABMS Board Certification. Certification for the secondary specialty refers to sub-Board certification. If the secondary specialty is a core ACGME specialty (e.g., Internal Medicine, Pediatrics, etc.), the certification question refers to ABMS Board Certification.

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B. Faculty Curriculum Vitae -

First Name: MI: Last Name:

Present Position:

Medical School Name:

Degree Awarded: Year Completed:

Graduate Medical Education (including internships, residencies and fellowships):

Program Name Specialty/Field Date From: To:

Certification and Re- Certification Information Current Licensure Data

Specialty Certification Year Re-Certification Year State Date of Expiration

Academic Appointments - List the past ten years, beginning with your current position.

Start Date End Date Description of Position(s)

Present

Concise Summary of Role in Program:

Current Professional Activities / Committees: (Limit of 10 in the last 5 years)

Selected Bibliography - Most representative Peer Reviewed Publications / Journal Articles from the last 5 years (limit of 10):

Selected Review Articles, Chapters and/or Textbooks (Limit of 10 in the last 5 years):

Participation in Local, Regional, and National Activities / Presentations/Abstracts/Grants (Limit of 10 in the last 5 years):

If not board certified, explain equivalent qualifications for RC consideration:

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PROGRAM INFORMATION FORM (Part 2)

FOR NEW APPLICATIONS ONLY-NEURORADIOLOGY

SECTION 5. BACKGROUND INFORMATION

A. Previous Citations or Concerns (if applicable)

List the citations from last RRC accreditation if applicable and describe briefly the steps that have been taken to address the citations or suggestions made by the RRC. If documentation is required, provide a specific reference to the information provided in the PIF or append additional support materials. If no citation were listed, inculcate this in the 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, resident complement, and facility or facilities.

C. Sponsoring Institution/Single or Limited Residency Institution (see ACGME Institutional Requirements)

For those institutions which are either a single-program institution (e.g. Diagnostic Radiology), 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. Complete only if "single/limited site sponsor" field in Part 1, Section 2 is yes.

1. Provide an institutional statement that commits the necessary financial, educational and human resources to support the GME program(s) and provide documentation that the statement has been approved by the governing body, the administration and the teaching staff (Insert 1).

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 residents and faculty in the program are involved in the evaluation process.

3. Describe how the institution complies with the Institutional Requirements regarding “Resident Eligibility and Selection” and the development of appropriate criteria for the selection, evaluation, promotion and dismissal of residents in accordance with the Program and Institutional Requirements.

4. Summarize how the institution complies with the ACGME Institutional Requirements regarding resident support, benefits and conditions of employment to include the details of the resident contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the resident contract/agreement to the PIF but state when it is given to the residents and applicants. Have a copy

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available for verification by the site visitor on the day of the survey with the various items required by the ACGME numbered according to the Institutional Requirements.)

5. Describe in detail the grievance (due process) procedure(s) that is available to residents, including the composition of the grievance committee, and mechanisms for handling complaints and grievances related to actions which could result in dismissal, non-renewal of a resident’s contract, or other actions that could significantly threaten a resident’s intended career development.

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SECTION 6. PERSONNEL

1. Describe the selection process for neuroradiology trainees.

2. If there are training programs in the site in any of the following areas, please provide the data indicated:

# MEDICAL PERSONNEL # RESIDENTS # FELLOWS

Neurology

Neurosurgery

Neuropathology

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SECTION 7. PATIENT DATA

Reporting Period: (Recent 12-month period) FROM: TO:

SITE #1 SITE #2 SITE #3Hospital Bed Capacity

Hospital Admissions (total)

Adult

Pediatric

Number of Neurosurgery Admissions

Number of Neurology Admissions

Diagnostic Radiology Examinations

Neuroradiology Examinations (total)

Adult

Pediatric

Neuroradiology Examinations-Noninvasive

Plain films:

Skull

Facial bones

Cervical spine

Thoracic spine

Lumber spine

CT: Brain

Extracranial head and neck

TMJ

Cervical spine

Thoracic spine

Lumber spine

MRI: Brain

Extracranial head and neck

TMJ

Cervical spine

Thoracic spine

Lumber spine

Noninvasive doppler of carotid

PET

SPECT

Transcranial neurosonography

Neuroradiology Procedures-Invasive*

Myelography: Cervical

Thoracic

Lumbosacral

Complete

CT myelograms

Cerebral angiograms: Intracranial

Extracranial

Spinal angiography

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SITE #1 SITE #2 SITE #3Embolization procedures:

External carotid

Internal carotid/vertebral/ or complex

Angioplasty procedures: Head and neck

*Invasive Procedures: Documentation (procedure logs) for all invasive procedures performed by trainees should be available at the time of the site visit.

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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.

2. How is it assured that the subspecialty program in neuroradiology does not have an adverse impact, as by dilution of the available clinical material, on the education of the diagnostic radiology residents in the site?

3. Explain trainee responsibility for invasive procedures. How is graded responsibility assured? Does responsibility include pre- post-procedural patient care?

4. Are trainees required to maintain documentation of the invasive cases in which they have been the performing radiologist? How often does the program director review the logs with the trainees?

5. Describe trainee participation in neuroangiographic procedures and indicate the average number of procedures performed by each trainee.*

6. Describe trainee experience in pediatric neuroradiology.

7. Explain trainee responsibility for plain film interpretation (e.g., skull, spine, facial bones, etc.)

8. Exposure to positron emission tomography (PET) and magnetic resonance spectroscopy is desirable. Indicate whether these modalities are available and describe how trainees participate in these studies.

9. What non neuroradiology responsibilities do trainees have (e.g., general radiology, angiography coverage, etc.). Specify the amount of time trainees spend on any non neuroradiology service.

10. Trainee procedure logs documenting involvement in adult and pediatric neuroradiology should be available for review by the surveyor.

11. 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?

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12. If there are outside rotations, indicate how much time will be spent at affiliated sites and describe the trainees' duties and level of responsibility during each of the outside assignments.

13. Explain how the program provides didactic and/or clinical instruction or experience in each of the following areas.

a. neurologyb. neurosurgeryc. neuropathologyd. otolaryngologye. ophthalmology

14. Describe the opportunities for trainees to attend and participate in clinical conferences in other specialties, such as neurology and neurosurgery.

15. Explain how the following subjects are covered by didactic instruction:

a. radiation physicsb. MR physicc. radiation biologyd. pharmacology of radiographic contrast materials

16. List the conferences that are attended by neuroradiology trainees.

CONFERENCES ATTENDED BY NEURORADIOLOGY TRAINEES:

Conference Frequency Responsible individual or service/Department

17. Are neuroradiology teaching files available? Describe.

18. What opportunities are there for the trainees to attend scientific meetings in neuroradiology?

19. Describe the opportunities for trainees to participate in research.

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20. Will the neuroradiology trainee have responsibility for teaching residents or medical students? ..................................................................................................................................................... ( ) YES ( ) NO

If so, describe.

21. Describe the method of trainee evaluation, including who performs the evaluation and how often each trainee's performance is reviewed and discussed with the trainee. (Append blank copies of forms used.)

22. Are trainees periodically given the opportunity to evaluate the training program? Describe the mechanism and indicate intervals.

23. Describe the mechanism for periodic interval (institutional) review and evaluation of the training program.

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SECTION 9. BIBLIOGRAPHY

List publications by faculty for the previous five (5) years. Underline those in which there has been trainee participation.

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SECTION 10. FACILITIES AND SPACE

1. Describe the following:

a. Conference facilities and space

b. Research space and laboratory facilities

c. Office space for faculty/trainees

d. Library - description:

Total number of titles:

Total number of Journal Subscriptions:

Number of titles added during the last 12 months:

2. EQUIPMENT: List the number and date of units available to neuroradiology trainees in each site:

SITE #1 SITE # 2 SITE #3Magnetic Resonance Imager:

CASUAL

CT Scanner:

Angiographic Unite (indicate if digital):

Ultrasonic equipment

Doppler

Intraoperative

Transcranial

SPECT

PET

MR Spectroscopy

Tomographic Imaging Systems

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SECTION 11. FORMAL TEACHING EXERCISES

Enter the schedule of formal exercises for the most recent one year period. The specific title of lectures/sessions is requested.

Topic Title

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RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY

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