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Geriatric NeurologyPROGRAM ACCREDITATION APPLICATION

PROGRAM INFORMATION FORM (PIF)FOR NEW APPLICATIONS ONLY

Revised: December 2013

A. INTRODUCTION

The mission of the United Council for Neurologic Subspecialties (UCNS) is to provide an accreditation process for fellowship training programs with the goals of enhancing quality training in neurologic subspecialties and quality patient care. The Accreditation Council strives to develop evaluation methods and processes that are valid, effective, fair, open, and ethical. The Accreditation Council 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 Accreditation Council has referenced the model used by the Accreditation Council for Graduate Medical Education (ACGME).

B. INSTRUCTIONS

APPLICATION FOR NEW PROGRAM: This form is for use by programs submitting an initial application for provisional accreditation only.

All programs must complete the entire Program Information Form. Many items require a composed response to a specific question. Please respond briefly and concisely. Do not attach any unnecessary materials such as reprints, brochures, annual reports, schedules (unless otherwise requested), minutes of meetings and conferences, etc. UCNS considers ONLY the information REQUESTED in the PIF and in the appendices. Any extra material will be discarded. All forms and templates that are provided MUST be used. Failure to comply with the rules stated above will delay the review process and may result in the denial of the program’s application for accreditation.

For new training programs where statistical data is not available, e.g., the number of graduates, you should mark that section as “NA” (not applicable). Processes and curricula projected for a program should be described in present tense, as though already in operation. Programs must demonstrate that processes for the education, evaluation, etc. of fellows are in place.

The PIF and Appendix A-I templates must be downloaded and completed off-line. The PIF question fields may 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. Should you require additional rows in specific tables, please e-mail UCNS. Once the PIF and Appendices A-I are completed, submit them as Word documents via e-mail to UCNS at [email protected]. UCNS will send a confirmation acknowledging receipt of the application. The program director is responsible for the content of the completed form, and the information will not be considered complete without all required signatures and the appropriate payment. 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 must be given in the appropriate place on the form.

UCNS Program Accreditation Application of 19Geriatric Neurology ©2013

mailto:[email protected]?subject=Accreditation%20Application

Appendix A: Institution letter(s) [template provided]Appendix B: Curricula vitae (program director and all faculty) [template provided] NIH biosketches and complete

curricula vitae are NOT acceptedAppendix C: Graphic display of the curriculum [template provided]Appendix D: Program rotation goals and objectives [template provided]Appendix E: Formal didactics [template provided]Appendix F: Clinical components [template provided]Appendix G: Duty hours complianceAppendix H: Fellow meeting attendance, research projects, publications, and scholarly activity [template provided]Appendix I: Evaluation form samples

C. APPLICATION FEE

You are applying for program accreditation as a New Applicant.

New Applicant $2,000 non-refundable application fee

The accreditation year is the academic year, July 1 through June 30. An annual accreditation fee will be assessed at $1,500 for all accredited programs. Fees are subject to change.

D. PAYMENT

UCNS accepts checks (or money orders) only at this time. Credit cards and electronic fund transfers are not accepted. Please submit payment in US funds (payable to United Council for Neurologic Subspecialties) to UCNS, 201 Chicago Avenue, Minneapolis, MN 55415.

E. APPLICATION DEADLINE

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 December 1 for spring review and June 1 for fall review.

F. QUESTIONS

Contact UCNS with questions: UCNS, 201 Chicago Avenue, Minneapolis, MN 55415 Tel: 612-928-6399 Fax: 612-454-2750. E-mail: [email protected].

G. GLOSSARY OF TERMS

A 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/

mailto:[email protected]?subject=Accreditation%20Application%20Question

TABLE OF CONTENTS Section Page

1 Program Information 1.A Program Identification 1.B Program Director Information 2 Institutional Affiliates

2.A Sponsoring Institution 2.B Primary Institution

2.C-F Participating Institution 2.G Overseeing Department 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 Years 3.D Fellows Completing the Program in the Last Three Years 4 Faculty and Personnel

4.A Program Director 4.B Core Faculty 4.C Other Faculty 5 Facilities and Resources

5.A Facilities and Resources 6 Educational Program

6.A Curriculum 6.B Seminars and Conferences 6.C Educational Program 6.D Program Policies 7 Research and Scholarly Activity 8 Evaluation

8.A Fellow Evaluation 8.B Faculty Evaluation 8.C Program Evaluation 8.D Curriculum Development 8.E Curriculum Evaluation 9 Signatures

Appendices A Institution Letter(s) B Curriculum Vitae C Graphic Display of the Curriculum D Goals and Objectives E Formal Didactics F Clinical Components G Duty Hours Compliance H Fellow Meeting Attendance, Research Projects, Publications, and Scholarly Activity I Evaluation Form Samples


PROGRAM INFORMATION FORM (PIF)

SECTION 1. PROGRAM INFORMATION

A. Program Identification

Date: Name of primary institution: Title of program: Does your program currently have fellows? Yes NoIf yes, how many fellows do you have each year? How many years is the fellowship? UCNS program number (for office use only):

B. Program Director Information

Name: Credentials (MD, MPH, etc.): Title: Address: City State: Zip code: Telephone: FAX: Email: Date the program director was first appointed: Primary specialty board certification: Most recent certification/recertification date: Secondary specialty board certification: Most recent certification/recertification date: Is the program director ABMS or RCPSC (i.e., ABPN, ABIM) certified? YES NOIs the program director UCNS certified in Geriatric Neurology? YES NONumber of years spent teaching in GME in this subspecialty: Is the program director a full-time staff member of the sponsoring or primary institution? YES NODoes the program director hold a current license to practice medicine in the state of the sponsoring or primary institution? YES NO

Is the program director based at primary teaching institution? YES NOPercentage of hours per week the program director spends in:

Clinical (Time spent in patient care):

Administration (Time spent in program administrative duties):

Research (Time spent completing research activities):

Education (Time spent instructing fellows and preparing instruction materials):

Is the program director also the department chair? YES NOIf no, chair name and credentials:


SECTION 2. INSTITUTIONAL AFFILIATES (Program Requirements II.)Instructions: Complete the tables below for all institutions associated with the program. Institution definitions are listed in the program requirements. Using the template provided for Appendix A, submit an institutional letter for each sponsoring, primary, and participating institution listed below.

A. SPONSORING INSTITUTION: (Institution #1) (The university, hospital, or foundation that has ultimate responsibility for this program and must be accredited as a sponsoring institution by the ACGME.)

Name of sponsor: Address: City: State: Zip code: Type of institution: (e.g., teaching hospital, general hospital, medical school): Ownership type: (e.g., state, corporation, church): Is the institution ACGME accredited YES NO Duration of accreditation: Next review date: Name and credentials of the designated institutional official: Does the SPONSOR have an affiliation with a medical school (may be the sponsoring institution)? YES NOIf yes, name of medical school:

B. PRIMARY INSTITUTION (Institution #2) Same as the sponsoring institution

Name: Address: City: State: Zip code: Name and credentials of the individual responsible for oversight of training at this institution:

C. PARTICIPATING INSTITUTION (Institution #3) Not applicable

Name: Address: City: State: Zip code: Distance from primary institution Miles: Minutes:

Type of rotation (select one) Elective Required Both

Duration of fellow’s rotation (in months) Year 1: Year 2: Name and credentials of the individual responsible for oversight of training at this institution: Brief educational rationale for use of this institution:

D. PARTICIPATING INSTITUTION (Institution #4) Not applicable



Length of fellows rotation (in months) Year 1: Year 2: Name and credentials of the individual responsible for oversight of training at this institution:


Brief educational rationale for use of this institution:

E. PARTICIPATING INSTITUTION (Institution #5) Not applicable



Length of fellows rotation (in months) Year 1: Year 2: Name and credentials of the individual responsible for oversight of training at this institution: Brief educational rationale for use of this institution:

F. PARTICIPATING INSTITUTION (Institution #6) Not applicable



Length of fellows rotation (in months) Year 1: Year 2: Name and credentials of the individual responsible for oversight of training at this institution: Brief educational rationale for use of this institution:

G. OVERSEEING DEPARTMENT (Previously referred to as “Core Program”) Specialty: Name of institution or hospital: Address: City, State, Zip Code: State: Zip code: Website address: Date program approved for accreditation: Next review date: Name of program director:


SECTION 3. FELLOW INFORMATION

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

Positions Year 1 Year 2 Year 3 TotalNumber of requested positions Number of filled positions*

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

Note: The fellow complement is the number of fellows allowed to be enrolled in the program. There must be at least 1 core faculty member for every 2 fellows. The number of fellows enrolled in the program at any time must not exceed the fellow complement.

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

1. List all fellows actively enrolled in this program as of August 31 of the current academic year (see Section 3.A). List names alphabetically. Indicate fellows accepted as transfer with an asterisk (*). If no fellows are currently enrolled, please write “NA” in the table.

YEAR ONE

Name Medical school Prior GME training program

ABMS/RCPSC eligible or certified?

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

YEAR TWO Not applicable because the program does not offer a second year



YES NO YES NO YES NO YES NO YES NO

YEAR THREE Not applicable because the program does not offer a third year



YES NO YES NO


YES NO YES NO YES NO

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 fellow complement. What effect will this have on your faculty resources?

C. Aggregate Data on Fellows Completing or Leaving the Program for the Last Three Years Start with the most recent year in the first column.

Not applicable because the program has not graduated any fellows

Based in 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* *Please provide reason(s) for fellows who left the program in the last three years (e.g., withdrawn, transferred, leave of absence, or dismissed).

D. Fellows Completing Program in the Last Three Years Beginning with the most recent graduated cohort, list all fellows who have completed all training for this subspecialty based on the last academic year ending June 30, .


Name Start date Actual date of completion Practice position ABMS certified? UCNS certified?


List fellows who have completed all training for this subspecialty based on the academic year ending June 30, .


Name Start Date Actual Date of Completion

Practice Position ABMS Certified? UCNS Certified?


List fellows who have completed all training for this subspecialty based on the academic year ending June 30, .



Name Start date Actual date of completion Practice position ABMS certified? UCNS certified?



SECTION 4. FACULTY AND PERSONNEL

A. Program Director (Program Requirements IV.)

1. Describe the program director’s qualifications in Geriatric Neurology. Indicate appropriate qualifications, including clinical, educational, and administrative abilities, as well as experience in his/her field.

2. List the program director’s educational experience and abilities. Examples should be submitted documenting the program director’s prior and ongoing experience in teaching, lecturing, or writing on topics related to Geriatric Neurology, as well as experience in administration of educational programs.

3. List the program director’s CME activities related to Geriatric Neurology in the past three years

4. Briefly describe the program director’s overall responsibilities and activities ensuring that all responsibilities of the program director that are listed in the program requirements are addressed.

B. Core Faculty – Geriatric Neurology (Program Requirements IV.)

Core faculty are physicians who oversee clinical training in the subspecialty. The program director is considered a core faculty member for the purpose of determining the fellow complement. Beginning with the program director, list all members of the program responsible for training. Include all core faculty. See Section 2 for institution numbers.

Name Credentials (MD, MPH, etc.) Institutional privileges Geriatric Neurology Certification

UCNS Certified UCNS Eligible

Role in Curriculum: Program Director


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:



Role in Curriculum:


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:

Using the template provided for Appendix B, attach a curriculum vitae for each of the faculty listed above. CVs submitted in a format other than that of Appendix B will not be accepted. A CV must be submitted for each person included above.

If additional rows are needed to list more than 11 faculty, please e-mail [email protected].

C. Other Faculty

Other faculty are physicians and other professionals determined by the subspecialty to be necessary in order to deliver the program curriculum. See Section 2 for institution numbers.

Name Credentials (MD, MPH, etc.) Institutional privileges Geriatric Neurology certification


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:


mailto:[email protected]


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:


Role in Curriculum:

Using the template provided for Appendix B, attach a curriculum vitae for each of the faculty listed above. CVs submitted in a format other than that of Appendix B will not be accepted. A CV must be submitted for each person included above.

If additional rows are needed to list more than 11 faculty, please e-mail [email protected].


mailto:[email protected]

SECTION 5. FACILITIES AND RESOURCES (Program Requirements III.)

A. Facilities and Resources

1. Indicate in the table below the availability of the program’s facilities and resources. Facilities and Resources Presenta. Is there administrative support for the fellowship and program director? YES NOb. Fellow offices and resources

Do fellows have space to complete administrative responsibilities? YES NOIs there administrative support for fellows? YES NODoes the fellow have access to office equipment such as copiers, slide projectors, PowerPoint, video projector equipment, or technology services for slide presentations, illustration services?

YES NO

c. Do fellows and faculty have access to reference materials such as textbooks, journals, and online databases? YES NO

2. Briefly describe the facilities that will be used for conferences.


SECTION 6. EDUCATIONAL PROGRAM

A. Curriculum

1. Please provide a narrative overview of this training program. Include a discussion of strengths and challenges.

2. Using the template provided for Appendix C, describe in block form the typical curriculum for fellows by months (or four-week stints), not weeks, including the institution (#1, 2, 3, 4) as listed in Section 2.

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 appropriate block template, if applicable. Those clinical experiences offered longitudinally should be recorded separately in the longitudinal templates by year. Conferences, lectures, or other didactic experiences must not be included in the longitudinal template. If the program does not utilize block assignments you may submit a description applicable to your program; however, programs that do use the provided template may encounter delays in review if the reviewers require further clarification.

3. Using the template provided for Appendix D, identify and describe all rotations in which fellows participate.

For EACH rotation:1) name the rotation,2) describe the rotation (block vs. longitudinal, description of activities, etc.),3) list the specific learning objectives (see the Goals and Objectives Example, which is available on the UCNS

website), 4) link each specific learning objective to corresponding ACGME competency/global learning objective(s) using the

numbers from the global objectives table available on the UCNS website (e.g., A.1. for the first objective in the patient care core competency),

5) identify the objective type(s) (knowledge, skills, and attitudes and behaviors)*, 6) identify the assessment type(s) (formative or summative)*, and 7) identify the assessment method(s) (multiple choice questions, test, essay, oral exam, NEX, etc.)*.

THE ACGME COMPETENCY/GLOBAL LEARNING OBJECTIVES, A SAMPLE TABLE, AND ADDITIONAL REFERENCE MATERIALS are available on the UCNS website.

*For assistance in writing objectives and determining the objective type(s) and assessment type(s) and method(s), reference the Guide to Writing Goals & Learning Objectives Linked to Assessments: Curricular Alignment, which is available on the UCNS website.

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

B. Seminars and Conferences (Program Requirements VI.)

1. Using the template provided for Appendix E, list the schedule of all didactics in which fellows participate. Indicate which conferences are mandatory and who attends the courses. The curricular components listed must ensure that all required didactic components that are listed in the program requirements are included in the program’s instruction.

2. Is there a fellowship-specific 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. Clinical Components (Program Requirements VI.)Using the template provided for Appendix F, indicate which clinical experiences are included in the program.

3. Document how fellows are provided with direct experience in progressive responsibility for patient management. Indicate:

a. What performance criteria/milestones does your program use to determine how fellows are provided with progressive patient-care responsibility?

b. Who is involved in decision making (i.e., program director, core faculty, committee)?

D. Program Policies (Program Requirements VI.)

1. Describe the program director’s supervision of 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 (Appendix G).

3. Describe what policies are in place for responding to impaired fellows.

4. How does the program monitor fellow stress and provide counseling or support services to fellows?


http://www.acgme.org/

SECTION 7. RESEARCH AND SCHOLARLY ACTIVITY (Program Requirements VI.)

Fellow Meeting Attendance, Research Projects, Publications, and Scholarly Activity Appendix H

Using the template provided for Appendix H, list meeting attendance, research projects, publications, and scholarly activity by fellows for the past three years.

A. Meeting Attendance - comment on how many and how often fellows attend local, regional, and national subspecialty meetings, and list the meeting names.

B. Research Projects - list the research projects by fellows from the program.

C. List of Publications - list the publications by fellows from the program (not manuscripts submitted or in preparation).

D. Scholarly Activity - list any other scholarly activities of fellows.


SECTION 8. EVALUATION (Program Requirements VI. and VII.)

A. Fellow Evaluation

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

2. Describe 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. In Appendix I, please provide a copy of a final evaluation used for fellows who complete the program.

B. Faculty Evaluation

Describe how the program director evaluates faculty. How often does this evaluation occur? Are written evaluations by fellows incorporated into the process?

C. Program Evaluation

Describe the system by which the program is evaluated. Are written evaluations by the fellows used?

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 the process by which the training program goals and objectives are developed, who participates, and how often they are revised.

E. Curriculum Evaluation

1. Describe the criteria used in assessing the extent to which goals and objectives 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 Name:

Telephone Number: E-mail:

The signatures below attest to the completeness and accuracy of the information provided. Please use the appropriate electronic signature (see example below), or sign and fax only this signature page to UCNS at 612-454-2750.

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” must be as follows: /John Doe/.

Program Director

Name:

Signature: Date:

Department Chair

Name:

Signature: Date:

Designated Institution Official

Name:

Signature: Date:

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

Please note, program applications are not considered complete until all of the following are received by UCNS:1. Completed and signed Program Information Form (all signatures must be included)2. Application fee paid by check or money order (credit cards and electronic fund transfers are not accepted)3. Completed Appendices A-I (provided templates must be used)

Upon receipt of all components of the application, staff will review the documents for completeness and will contact the program director with information regarding the next step in the process.


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