RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY

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

SUBSPECIALTY PROGRAMS IN MUSCULOSKELETAL RADIOLOGY 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 maybe 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.

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

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 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.

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SUBSPECIALTY PROGRAMS IN MUSCULOSKELETAL RADIOLOGY PROGRAM INFORMATION FORM

Program Name:

TABLE OF CONTENTS

When you have the completed forms, sequentially number the bottom center of each page. 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

Related Specialists 6

Patient Data 7

Skill Objectives 8

Narrative Descriptions 9

Curriculum 10

Formal Teaching Exercise 11

Equipment 12

Facilities & Space 13

Evaluation 14

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PROGRAM INFORMATION FORM (Part 1)

FOR NEW APPLICATIONS ONLY – MUSCULOSKELETAL RADIOLOGY

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:

Core Program InformationTitle of Core Program:

Core Program Director:

10 Digit ACGME Program ID#:

Accreditation Status: Effective Date:

Next Review Date: Last Review 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 Core Program Director (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:

Is Program Director also Department Chair?

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

SECTION 2. PARTICIPATING SITES

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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 ( ) Participating ( ) Clinical ( )

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

Length of Fellow Rotation (in months) Year 1:

Joint Commission Approved: ( ) YES ( ) NO ( ) N/A

Content of Educational Experience:

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

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:





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Name:

Address:






Minutes:






Name:

Address:






Minutes:






Name:

Address:






Minutes:





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SECTION 3. FELLOW 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 fellows on duty.

B. Actively Enrolled Residents (if applicable)

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. Place an (*) asterisk next to the name of each fellow accepted as a transfer. Documentation of previous experience for transfer students should be available for review by the site visitor.

Name

Program Start Date

Expected Completion

DateYear in

Program

Years of Prior GME

Specialty of Most Recent Prior GME Medical School

Year 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.

Name (Position)Degre

e

Based Primarily at Site #*

Primary and Secondary Specialties / Field No. of Years

Teaching in This Specialt

y

Average Hours Per Week Spent On

Specialty / Field

Board Certificatio

n (Y/N)†

Most Recent

Certification Date

Clinical Supervisio

n Admin

Didactic Teachin

gResearc

h

(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

SpecialtyCertification

YearRe-Certification

YearState

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 – MUSCULOSKELETAL RADIOLOGY

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 citations were listed, indicate 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, fellow 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 fellows and faculty in the program are involved in the evaluation process.

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

4. Summarize how the institution complies with the ACGME Institutional Requirements regarding fellow support, benefits and conditions of employment to include the details of the fellow contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the fellow contract/agreement to the PIF but state when it is given to the fellows and applicants. Have a copy available for verification by the site visitor on the day of the survey with the various items required by the ACGME numbered according to the Institutional Requirements.)

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

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SECTION 6: RELATED SPECIALISTS WORKING WITH THE MUSCULOSKELETAL PROGRAM

Are the following specialists present in the participating sites?

SITE #1 SITE #2 SITE #3

YES

(Include Number) NO

YES(Include Number) NO

YES(Include Number) NO

1. Rheumatologist

2. Emergency room physician

3. Orthopaedic surgeon

4. Neurosurgeon

5. Bone pathologist

6 Oncologist

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SECTION 7: PATIENT DATA

Provide the following information for the most recent 12-month period.

Reporting Period: FROM: TO:

PATIENT EXAMINATION DATA SITE #1 SITE #2 SITE #3

Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient

1. Patient examined

TOTAL:a. Adult

b. Pediatric

Diagnostic examinations

TOTAL:

a. Adultb. Pediatric

3. Musculoskeletal exams

a. Adult

b. Pediatric

4. Number of emergency room radiology exams. (included above)

a. Adult

b. Pediatric

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SECTION 8: SKILL OBJECTIVES

Indicate whether or not the program provides experience in each of the following procedures. Use the same 12-month period as indicated on the previous pages. For procedures not performed at any of the participating sites, provide an explanation.

Inclusive Dates From: To:

Musculoskeletal Procedures

Site 1 Site 2 Site 3

# performed in site # performed in site # performed in site

MRI

1. Shoulder

2. Elbow

3. Wrist

4. Hip

5. Knee

6. Ankle

7. Extremities

8. Vertebral column

9. Soft tissues & muscles

10. Pelvis

Computed Tomography

1. Hip

2. Other joints

3. Vertebral column

4. Soft tissue & muscles

5. Pelvis

Arthrography

1. Shoulder

2. Hip

3. Knee

4. Ankle

5. Wrist

Biopsies and Drainage

Ultrasound

Bone Densitometry

Tomography

Nuclear Radiology

For procedures not performed at any of the participating sites, provide an explanation.

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SECTION 9: NARRATIVE DESCRIPTION OF THE MUSCULOSKELETAL RADIOLOGY SUBSPECIALTY TRAINING PROGRAM

Provide a narrative description of the musculoskeletal radiology training program. The points listed below should be covered in the narrative.

1. Provide a rotation schedule for the 12-month program.

2. Provide the program goals and objectives.

3. What is the impact of this program on the core program?

a. Describe the level of responsibility that the subspecialty resident has for patient assessment and follow-up and actual performance of procedures.

b. What measures are taken to insure that core residents are not adversely affected by the subspecialty residents?

4. If there are outside rotations, describe the reasons for each such rotation. Describe the supervision available and the duties and responsibilities of the subspecialty resident on each outside rotation.

5. How many hours does the subspecialty resident work per week?

6. How are emergency and weekend procedures staffed?

7. Are these residency programs available in the primary site?

a. Orthopaedic Surgery ............................................................................................................. ( ) YES ( ) NOb. Rheumatology....................................................................................................................... ( ) YES ( ) NOc. Pathology............................................................................................................................... ( ) YES ( ) NOd. Neurosurgery......................................................................................................................... ( ) YES ( ) NO

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SECTION 10: CURRICULUM

The points listed below should be covered in the narrative.

1. Describe resident responsibility for invasive procedures. How is graded responsibility assured? Does responsibility include pre- and post-procedural patient care for in- and out-patient settings? What is the extent of these responsibilities?

2. Describe the mechanism of documenting the invasive cases in which residents have had direct participation. How often does the program director review the logs with the residents?

3. Describe the clinical experience and didactic instruction in each of the following areas:

a. Plain Film Interpretation:b. Computed Tomography:c. Ultrasonography:d. Magnetic Resonance Imaging:e. Nuclear Radiology:f. Interventional Techniques:g. Bone Densitometry:

4. List the intra- and extra-departmental conferences that are attended by the musculoskeletal resident.

Conference FrequencyResponsible Individual

or Service

Is Attendance Required?

YES NO

5. Describe the availability and type of musculoskeletal teaching files.

6. Do residents attend at least one national meeting or postgraduate course dealing with musculoskeletal radiology during the year?............................................................................................................ ( ) YES ( ) NO

a. Is funding provided?.............................................................................................................. ( ) YES ( ) NO

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7. Do subspecialty residents have the following types of assistance available to them for research:

a. Secretarial............................................................................................................................. ( ) YES ( ) NOb. Electronic database searches................................................................................................ ( ) YES ( ) NOc. Editing.................................................................................................................................... ( ) YES ( ) NOd. Statistics................................................................................................................................ ( ) YES ( ) NOe. Photography.......................................................................................................................... ( ) YES ( ) NO

8. Explain how the program complies with the requirements for documented review of all mortality and morbidity related to the performance of interventional procedures.

9. Describe the opportunities for residents to participate in research. Include the plans for resident participation in the design, performance and interpretation of research studies and how the resident is given the opportunity to develop competence in critical assessment of investigative techniques.

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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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SECTION 12: EQUIPMENT

Site 1 Site 2 Site 3

1. Diagnostic radiology equipment

a. Radiography units

b. Body section units (tomography)

c. Mobile radiographic units

d. CT units (include dates installed)

2. Ultrasound equipment

3. MRI units (include dates installed)

4. Bone densitometry units

5. Nuclear radiology cameras

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SECTION 13: FACILITIES AND SPACE

Describe the following:

1. Department library (include total number of titles and journal subscriptions; indicate number of titles added during the last 12 months).

2. Conference facilities and space

3. Office space for faculty/subspecialty residents

4. Research space and laboratory facilities

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SECTION 14: EVALUATION

1. Describe the method of subspecialty resident evaluation, including who performs the evaluation and how often each subspecialty resident’s performance is reviewed and discussed with the subspecialty resident.

2. Is the written evaluation of performance and progress made available to the subspecialty resident following each evaluation?

3. How is the evaluation of the training program and faculty by the subspecialty resident(s) accomplished?

a. Does this occur at least annually?......................................................................................... ( ) YES ( ) NO

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RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY