RESIDENCY REVIEW COMMITTEE FOR PSYCHIATRY

RESIDENCY REVIEW COMMITTEE FOR PSYCHIATRY515 N State, Ste 2000, Chicago, IL 60654 www.acgme.org

GERIATRIC PSYCHIATRY 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.

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

Instructions: Instructions have been provided at the top of each section of the forms. Please read them carefully before providing information. Information submitted should be as complete and as concise as possible. Do not attach any unrequested materials such as curriculum vitae, reprints, brochures, annual reports, resident handbooks, minutes of meetings, etc.

For "LENGTH OF ASSIGNMENT," give the total number of months that each Geriatric Psychiatry resident spends in that site at each level of training. Time spent on each rotation should be expressed as full-time-equivalent months. The total amount of time in training should add up to at least 12 months. For "Local Program Director," list the person who supervises resident training in Geriatric Psychiatry at that site. Also note that "Year 1" refers to the first year of the Geriatric Psychiatry training program regardless of how many post-graduate years the resident had before entering the Geriatric Psychiatry program.

Attachments: Be sure to include the following attachments:

1) An explanation for any participating sites that is not JCAHO-accredited.

2) A letter of affiliation as Section 6.0 for all participating sites in which residents receive required training.

3) A copy of the written due process policy and procedure.

document.doc i

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

Approval Procedure

Residencies in Geriatric Psychiatry are evaluated by the Residency Review Committee for Psychiatry at each of its two meetings during the year. These meetings are usually in the spring and fall. The Committee closes its agenda ten weeks prior to each meeting. Review materials not received by that time may not be considered until the subsequent meeting. As a consequence, there may be a delay in excess of six months between the time of the site visit and the review of the program by the Committee.

document.doc ii


GERIATRIC PSYCHIATRY PROGRAM INFORMATION FORM

Program Name:

TABLE OF CONTENTS

When you have the completed forms, number each page sequentially in the bottom 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

Rotations 6

Scheduled Seminars & Conferences 7

Clinical Services 8

Affiliations 9

Other Professional Staff 10

Evaluation Methods 11

Due Process Procedures 12

Selection & Appointment Process 13

Clinical Training & Additional Issues 14

document.doc 1


PROGRAM INFORMATION FORM (Part 1)

FOR NEW APPLICATIONS ONLY – GERATRIC PSYCHIATRY

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:

document.doc 2

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 ( ) 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)

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:





document.doc 3


Name:

Address:











Name:

Address:











Name:

Address:










document.doc 4

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 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.

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

document.doc 5

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





document.doc 6

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:

document.doc 7

SECTION 4. FACULTY / TEACHING STAFF

A. Faculty Roster List alphabetically and by site all physician faculty who devote at least 10 hours a week to resident education. Supply a one page CV for each faculty listed.

Name (Position) Degree

Based Primarily at

Site #*

Primary and Secondary Specialties / Field No. of Years

Teaching in This

Specialty

Average Hours Per Week Spent On

Specialty / Field

Board Certificatio

n (Y/N)†

Most Recent

Certification Date

Clinical Supervisio

n AdminDidactic 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.

document.doc 8

B. Faculty Curriculum Vitae Provide a one page CV for each faculty member who devotes at least 10 hours to the program.

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:

document.doc 9


PROGRAM INFORMATION FORM (Part 2)

FOR NEW APPLICATIONS ONLY – GERATRIC PSYCHIATRY

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. Psychiatry), 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.

document.doc 10

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 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.

document.doc 11

SECTION 6: ROTATIONS

Instructions: Create a block diagram of the clinical rotations to which residents are assigned in each year of the program. Show any percentage of time less than 100 percent for each block of time. If there are alternative pathways, indicate them as shown in the example below, but do not show diagrams for individual residents. Identify the sites in which each rotation occurs. Do not include this example page in the final submission of the document.

Example:*

4 months

Geriatric InpatientHospital A

50%

Outpatient50%

4 months

Nursing Home75%

Adult Day Health Care25%

4 months

Hospice Facility60%

Respite Care 40%

Or

6 months

Geriatric InpatientHospital B

75%

Outpatient25%

6 months

Adult Day Health Care Treatment40%

Geriatric Nursing Home40%

Hospice Facility20%

*The examples in no way imply an ideal program.

document.doc 12

SECTION 7: SCHEDULED SEMINARS AND CONFERENCES

Instructions: List all scheduled seminars and didactic courses attended by residents using the format below. Provide a full description. Number seminars consecutively so that they may be more easily referenced in later narratives. Be brief!

Format:

No.: Title

a. Required or elective;b. Principle instructor(s) with professional degreec. Brief descriptiond. Additional attendeese. Length of session, frequency and total number of sessions

Example:

1. Seminar in Psychosocial Aspects of Geriatric Psychiatry

a. Required for geriatric residentsb. R. Jones, M.D. and W. Green, Ph.D.c. This is a reading seminar in which residents review classical and current literature on developmental

and psychological theories of aging. The topics discussed include ageism; retirement; effect of institutionalization; public policy on long-term care; economics; epidemiology of aging populations; changes in family structure; education and care for the caregiver; care settings for the elderly; ethics, quality of life, and brain death; and death and dying.

d. Psychology interns and social work studentse. 1 hour weekly for 26 weeks

2. Biologic Aspects of Geriatric Psychiatry

a. Required for geriatric residentsb. R. Black, M.D.c. Dr. Black leads discussions regarding the aging central nervous system including relevant

neuropathology, neuroanatomy, neurochemistry, and neurophysiology. Additional readings and discussion include changes in other major organ systems with aging, with special emphasis on sensory receptor changes and psychopharmacology.

d. All members of the Geriatric Unit Treatment Team and all trainees assigned to the Unit.e. 1 hour weekly for 26 weeks.

3. Psychiatric Aspects Specific to Geriatrics

a. Required for geriatric residentsb. T. Smith, M.D.c. Dr. Smith leads a discussion of a resident's treatment of geriatric patients focusing on the following

issues: bereavement and loss in the aged; psychologic and neuropsychologic testing; clinical psychiatric syndromes in the elderly (e.g. depression and mania and their differing manifestation in old age, paranoid disorders, hypochondriasis, acute and chronic anxiety states, and schizophrenia); transient situational disturbances; sleep disturbances peculiar to old age and the relation of other disorders to normal sleep patterns; grief reactions and issues related to chronic illness, death, and dying; delirium and dementias; syndromes of substance abuse in the elderly; and behavioral and diagnostic skills used in the aging population.

d. Attended by geriatric residents only.e. 1 hour every other week throughout the year.

document.doc 13

SECTION 8: CLINICAL SERVICES

Instructions: Provide a brief narrative description of EACH clinical service indicated in the block diagram to include the following information. Do not include this example page in the final submission of the document.

Format:

Type of Service

A. The name of institution(s), whether required or elective, and duration of training, full- or part-time.B. Description of faculty staffing.C. Description of educational activities on this service.D. Breadth of clinical population and experience, including sex, age, ethnic/cultural and socioeconomic mix,

diagnoses of patients cared for by this service during a year, and types of treatment provided.E. Average case loads for residents and description of residents' clinical activities, including level of

responsibility.F. Scheduled supervision: frequency; whether group or individualG. The presence of rotators from other services/programs sharing the same patient population.H. Other (include any other important information relevant to clinical or educational experience).

Example:

Geriatric Psychiatry Outpatient Clinic

A. Required 4 month rotation at Hospital A

B. Faculty consists of 2 full-time psychiatrists with added qualification in geriatrics, 1 full-time neurologist, 1 family practitioner with added qualifications in geriatrics, 1 internist with added qualifications in geriatrics, 1 psychologist and 2 half-time social workers; 4 voluntary clinical faculty also spend 1-2 hours weekly at the Clinic.

C. Residents spend 2-4 hours weekly in seminars and case conferences; faculty are always available for consultation; Residents are supervised in the medical and neurologic evaluation and management of the geriatric population; and case loads are carefully monitored and controlled for both breadth and variety of experience.

D. The Clinic population is about 60% males and 40% females; 60% white, 30% black and 10% Hispanic; all over the age of 65. There are approximately 12 active cases at any time. There were 150 new cases seen during that year. Diagnoses of patients include latent onset schizophrenia, severe depression mood disorders, dementia of the alzheimer type, and other organic brain disorders. The nonpsychotic patients include a variety of conditions such as nonpsychotic depression neurotic conditions and concomitance of other medical diseases. Residents spend their time becoming proficient in the following evaluation and therapeutic modalities: individual psychotherapy, family intervention, group psychotherapy, milieu therapy, behavior modification techniques, psychopharmacology, consultation-liaison, and somatic therapies.

E. An average case load for a resident would consist of 10-12 patients in individual psychotherapy, 1 group, 2 families, 2 evaluation cases and 4 long-term management cases.

F. All residents have one hour of individual supervision twice weekly, group supervision of group and family work every other week. Additional supervision may be provided on an individual basis.

G. Geriatric family practice and internal medicine residents.

H. Eclectic faculty experienced in assessment, psychoanalysis, behavior modification and family therapy.

document.doc 14

SECTION 9: AFFILIATIONS

Instructions: Complete for every affiliation identified on pages 1-3. For any affiliation in which residents receive required and selective training, a copy of the letter of affiliation must be attached. Complete, current affiliation agreements that fulfill the Institutional Requirements must be submitted for applications for new programs and for sites that have been added to the program since the last review for existing programs. Affiliation agreements for previously approved sites need not be submitted but must be available for inspection by the site visitor. Briefly, in narrative form, describe the facility, distance from primary site of training, the breadth of clinical experience, the faculty, educational activities, and supervision. Indicate the duration of time the residents spend at the facility, whether full- or part-time, and whether required or optional. Do not include this example page in the final submission of the document.

Example:

Johnson Hospital (agreement attached)

Residents have a required full-time rotation of 4 months duration to this facility. Johnson Hospital is a 600 bed general medical facility with 50 inpatient beds and outpatient services for ages 65 and older, and a 15-bed geriatric psychiatric unit (ages 65 and older) and an outpatient psychiatric clinic. It is located 5 miles from the primary site of training. Fifty percent of inpatients are psychotic with latent onset schizophrenia, severe depressive mood disorders, dementia of the alzheimer type and other organic brain disorders. The nonpsychotic patients include a variety of conditions such as nonpsychotic depression, neurotic conditions and concomitance of other medical diseases. Treatment approaches include individual and group psychotherapy, behavior modification, therapeutic community, psychopharmacology, and family therapy. Residents have primary responsibility for 3-5 inpatients and 3-4 outpatients, and have 3 hours per week of individual supervision. The seminars and conferences and described in Section 4.0. Residents return to the primary clinical site for 1/2 day per week for conferences. The psychiatric faculty consists of 2 full-time geriatric psychiatrists, both certified in general and geriatric psychiatry, 2 psychologists, and 6 psychiatric social workers.

document.doc 15

SECTION 10: OTHER PROFESSIONAL TEACHING STAFF

Instructions: Other Professional Staff: List psychologists, anthropologists, sociologists, psychiatric nurses, social workers, physiologists, research personnel, etc., who are directly involved in this training program on a regular basis. Do not list occasional lecturers and consultants. Reproduce this page as necessary.

Name, Degree and TitlePrimarily based at Site 1.2,1.3, 1.4, 1.5

Time devoted to teachingScientific or Professional

DisciplineMonths per

yearHours per

month

document.doc 16

SECTION 11: EVALUATION METHODS

Instructions: The following items require a YES (Y) or NO (N) response. Attach a brief description or explanation where indicated. Be brief! In some cases, written materials, i.e., forms, activity records, patient logs, etc., may be used as documentation. Do not attach these, but have them available on request.

A. Evaluations of Residents

1. Does the program director maintain a file that documents the qualifications and progress of each resident? ...........................................................................................................................YES ( ) NO ( )

2. Does the program provide at least two hours of individual supervision on a weekly basis for each resident, in addition to teaching conferences, rounds or clinical discussions? .................................YES ( ) NO ( )

3. Are supervisory and other faculty written evaluations of the performance of residents obtained regularly and are they available in a resident's file? .........................................................................YES ( ) NO ( )

4. Are there regularly scheduled evaluative meetings with individual residents to discuss their evaluations and progress in the program? How often? ..............................................YES ( ) NO ( ) How Often ( )

5. Is a written summary of these meetings entered in the resident's training file? .................YES ( ) NO ( )

6. Does the resident's file include copies of all evaluations of performance made in the course of training?........................................................................................................................................... YES ( ) NO ( )

7. Do residents receive copies of these evaluations? ............................................................YES ( ) NO ( )

8. Is the resident's entire file accessible to the resident and other authorized personnel? If not, please explain and specifically identify the types of information withheld. ....................................YES ( ) NO ( )

9. Are there methods by which the resident's performance in regard to issues involving clinical responsibilities, ethical behavior, and interpersonal relationships with staff and other trainees evaluated?........................................................................................................................................... YES ( ) NO ( )

Describe briefly:

10. Is there a final evaluation of the resident upon the conclusion of training that verifies that the resident has successfully completed all required components of the program and is deemed competent to practice independently?...................................................................................................................YES ( ) NO ( )

B. Evaluation of Faculty

1. Is there a systematic method for the evaluation of faculty performance by residents?.......YES ( ) NO ( )

Describe briefly, including how this information is made available to the faculty.

2. Is there a systematic method by which the program leadership regularly evaluates the faculty's contributions to the educational program? .........................................................................YES ( ) NO ( )

3. Are the results of this evaluation formally shared with the faculty and used to improve the program? ........................................................................................................................................... YES ( ) NO ( )

Describe briefly

document.doc 17

C. Evaluation of Program

1. Does the program director meet regularly with residents as a group to discuss the program and to resolve problems? If so, how often? ....................................................................YES ( ) NO ( ) How Often ( )

2. Are there other systematic methods by which the clinical experiences and didactic programs are evaluated? ........................................................................................................................YES ( ) NO ( )

Describe briefly.

D. Goals and Objectives

1. Is there a written statement of the goals and objectives of the program that is made available to the residents?YES ( ) NO ( )

a. If "Yes", then attach and number as 16a, 16b, 16c, etc.

b. If "no", briefly describe how residents are informed about these matters.

2. Are the goals and objectives provided to faculty? ....................................................................YES ( ) NO ( )

3. Is there a written due process procedure? (Attach a copy.) ....................................................YES ( ) NO ( )

4. Do residents receive a copy at the beginning of their training? ................................................YES ( ) NO ( )

document.doc 18

SECTION 12: DUE PROCESS PROCEDURES

Instructions: Provide a brief narrative description of each incident since the previous accreditation survey in which the due process procedures have been formally instituted, including outcome, since the previous accreditation survey. DO NOT include the resident's name, but identify as Resident 1, 2, 3, etc. See the example below. Do not include this example page with the final submission of the document.

Example:There has been only one incident. A resident was placed on probation by the Training Committee after the first six months of training. Evaluations by supervisors indicated failure to maintain appointments, delays in medical record entries, and lack of attendance at conferences and rounds. The resident requested reconsideration and presented his rebuttal to the Training Committee. The Committee maintained its original decision. The resident filed a formal grievance. As specified in the procedures, a Grievance Panel was established. The resident contended he had been treated unfairly, that he had not been warned and that the expectations were not clear to him. The grievance was withdrawn, prior to hearing. The resident has continued in the program without further difficulty.

document.doc 19

SECTION 13: SELECTION AND APPOINTMENT PROCESS

1. Do you accept only applicants whose language facility in English is sufficient to facilitate accurate and unhampered communication with patients and teachers? ........................................................( )YES ( ) NO

2. Is there a Selection Committee to assist the Program Director in the appointment of residents? .................................................................................................................................................. ( ) YES ( ) NO

Briefly describe its composition:

3. Is there a procedure for written documentation of the credentials of applicants, including medical school graduation, completion of accredited residency, state licensure, past performance, professional integrity?

( )YES ( ) NO

Briefly describe

4. Is this documentation always made a part of the resident's permanent training record? .........( ) YES ( ) NO

5. Is there a procedure for evaluating and selecting applicants? ................................................( ) YES ( ) NO

Describe briefly:

6. Prior to entering the program, are all applicants provided with a written description of:

a) Clinical rotations and the educational program? .................................................................( ) YES ( ) NO

b) Financial compensation and policies regarding vacations and leaves (i.e., sickness, disability, maternity/paternity, etc.)? ................................................................................................... ( ) YES ( ) NO

c) Liability, medical, and disability coverage, including any important exceptions to coverage? ............................................................................................................................................ ( ) YES ( ) NO

d) Requirements for duty hours and call? ...............................................................................( ) YES ( ) NO

document.doc 20

SECTION 14: ADMINISTRATION AND DIRECTION OF PROGRAM

A. Residency Training Committee

1. Is there a Residency Training Committee? .........................................................................( ) YES ( ) NO

2. Is there a resident on the Committee? ................................................................................ ( ) YES ( ) NO

3. Does the Committee participate in program development? ................................................( ) YES ( ) NO

4. Does the Committee participate in program evaluation? ....................................................( ) YES ( ) NO

5. Does the Committee participate in resident evaluation and/or advancement? ...................( ) YES ( ) NO

6. Is the Committee responsible for teacher and course evaluation and monitoring? .............( ) YES ( ) NO

7. Is there a written description of the Committee and its responsibilities? (Do not attach, but have available upon request.) .................................................................................................................... ( ) YES ( ) NO

8. Are formal minutes kept of the Committee’s deliberations? ................................................( ) YES ( ) NO

B. Residency Training Records

1. Does the program director maintain files on each resident in training which contain the following:

a) Application materials and credentials? .........................................................................( ) YES ( ) NO

b) A record of all rotations and clinical assignments? .......................................................( ) YES ( ) NO

c) A record of all evaluations? .......................................................................................... ( ) YES ( ) NO

d) Documentation that all required clinical experiences have been satisfactorily completed? ...................................................................................................................................... ( ) YES ( ) NO

e) A record of all due process actions? ............................................................................( ) YES ( ) NO

f) A statement by the program director, upon graduation, that there is no documented evidence of unethical behavior, unprofessional behavior, or serious question of clinical competence? ...................................................................................................................................... ( ) YES ( ) NO

C. Accreditation Responsibilities

1. Since the last accreditation review, has there been a change in program directorship? . .......................................................................................................................................... ( ) YES ( ) NO

If yes, describe briefly

2. Has this change been reported to the Residency Review Committee? ..............................( ) YES ( ) NO

document.doc 21

SECTION 15: CLINICAL TRAINING AND ADDITIONAL ISSUES

Instructions: When a narrative description is requested, include a description of clinical experience, duration, whether required, selective or elective, full or part time, and when the rotation occurs in the training program. Reference the associated seminars from Section 4.0 by number (e.g., Seminars 01, 03). Be brief!

A. Clinical Case Conferences

1. Are there clinical case conferences, attended by both faculty and residents, which address both theoretical and practical matters relating to diagnosis, management and treatment?.........( ) YES ( ) NO

Briefly describe:

2. Are there interdisciplinary conferences with attendance by nonpsychiatrists and other medical specialists?.......................................................................................................................... ( ) YES ( ) NO

Briefly describe:

B. Neurology

1. Is there teaching in neurology specific to geriatrics? ......................................................( ) YES ( ) NO

Briefly describe the nature of this training:

2. Is there experience with the handicapped elderly? ............................................................( ) YES ( ) NO

Briefly describe:

C. Consultation and Liaison Geriatric Psychiatry

1. Is there supervised consultation/liaison psychiatry experience involving patients on geriatric, medical and/or surgical services? ................................................................................................... ( ) YES ( ) NO

Briefly describe:

D. Social/Cultural/Community Psychiatry:

1. Is there education regarding culture and the subcultural influences in the patient populations to which residents are exposed? ..................................................................................................... ( ) YES ( ) NO

Briefly describe:

2. Briefly describe any clinical experience offered in social and community work among the aged.

document.doc 22

E. Continuous Care Experience: Inpatient

1. Do residents have an opportunity to follow patients after discharge from the hospital? ......( ) YES ( ) NO

Briefly describe, including the diagnostic categories, duration of treatment and the minimum numbers of patients, so followed:

F. Continuous Care Experience: Outpatient

1. Do residents have an opportunity to treat outpatients longitudinally with supervision? .......( ) YES ( ) NO

2. Do such experiences include patients representing a variety diagnostic categories, utilizing a variety of therapeutic approaches to treatment? ................................................................................ ( ) YES ( ) NO

3. Do clinical experiences, under supervision, include both psychological and biological approaches to treatment? .......................................................................................................................... ( ) YES ( ) NO

G. Scholarly Activity

1. Does the training program include opportunities to learn appreciation of research methods and the critical appraisal of professional/scientific literature pertinent to geriatric psychiatry? ....................( ) YES ( ) NO

2. Do residents participate in clinical or basic research?.........................................................( ) YES ( ) NO

a) If yes, how many residents have participated the past residency year?

b) List projects in which residents have participated in the past five years.

3. Does the program provide residents with opportunities to attend relevant symposia and conferences in geriatric psychiatry? ............................................................................................................ ( ) YES ( ) NO

4. Do they have other scholarly activities? . ............................................................................( ) YES ( ) NO

Please describe

H. Administrative Psychiatry

1. Do residents obtain knowledge and experience in the administrative aspects of geriatric psychiatric practice? ............................................................................................................................ ( ) YES ( ) NO

Briefly describe and reference seminar numbers from Section 4.0:

I. Collaborative Learning

1. Are there clinical experiences in which residents actively collaborate with other mental health professionals in the treatment of patients? ........................................................................( ) YES ( ) NO

Briefly describe:

2. Are there opportunities for the residents to learn leadership and management skills with a team of mental health care professionals? .................................................................................................. ( ) YES ( ) NO

document.doc 23

J. Ethics

1. Do residents receive education in ethics relevant to the care of the aged? .......................( ) YES ( ) NO

Briefly describe:

K. Psychiatric Law

1. Do residents receive training in legal aspects of treating the geriatric patient? .................( ) YES ( ) NO

Briefly describe and reference seminar numbers from Section 4.0:

L. Teaching

1. Do the residents participate in teaching of other health professionals? .............................( ) YES ( ) NO

Briefly describe:

M. Clinical Experience with Multiple Treatment Modalities Relevant to the Care of the Aged

Briefly describe whether there is BOTH didactic and clinical experience, where it occurs, the extent of the experience, and the nature and amount of supervision. Reference the relevant numbers in Section 4.0 for seminars and conferences related to the training experience.

1. Individual psychotherapy

a) Psychodynamic............................................................................................................. ( ) YES ( ) NO

b) Behavioral .................................................................................................................... ( ) YES ( ) NO

c) Supportive..................................................................................................................... ( ) YES ( ) NO

d) Other (describe)............................................................................................................ ( ) YES ( ) NO

2. Other modalities

a) Family intervention ....................................................................................................... ( ) YES ( ) NO

b) Group therapy .............................................................................................................. ( ) YES ( ) NO

document.doc 24

c) Crisis intervention/suicide prevention ...........................................................................( ) YES ( ) NO

d) Pharmacologic therapies .............................................................................................. ( ) YES ( ) NO

e) Milieu therapy............................................................................................................... ( ) YES ( ) NO

f) Somatic therapy ........................................................................................................... ( ) YES ( ) NO

g) Other (i.e., hypnosis, biofeedback, etc.)........................................................................( ) YES ( ) NO

N. Library Facilities

1. Is there a psychiatric library readily available to the residents?...........................................( ) YES ( ) NO

2. Is this library available to the residents after hours and on weekends, if needed?..............( ) YES ( ) NO

3. Location:

4. Number of psychiatry/behavioral science journals regularly received:

5. Number of medical journals regularly received:

6. Are the following available:

a) MEDLINE ..................................................................................................................... ( ) YES ( ) NOb) MEDLAR ...................................................................................................................... ( ) YES ( ) NOc) INDEX MEDICUS ......................................................................................................... ( ) YES ( ) NOd) Other ............................................................................................................................ ( ) YES ( ) NO

O. Laboratory and Special Facilities

1. Are the following available:

a) Clinical laboratories ...................................................................................................... ( ) YES ( ) NOb) Sleep laboratories ........................................................................................................ ( ) YES ( ) NOc) Electroencephalography ............................................................................................... ( ) YES ( ) NOd) Imaging......................................................................................................................... ( ) YES ( ) NOe) Psychological ............................................................................................................... ( ) YES ( ) NOf) Neuropsychological ...................................................................................................... ( ) YES ( ) NO

document.doc 25

P. Night Call

1. Frequency in year of residency training:

Minimum Per Month Maximum Per Month

2. Check in which area(s) call takes place: ( ) Inpatient ( ) Outpatient ( ) ED

3. Is a faculty supervisor always available for consultation and assistance if needed?............................................................................................................................................... ( ) YES ( ) NOa) Inpatient.......................................................................................................................... ( ) YES ( ) NOb) Outpatient........................................................................................................................ ( ) YES ( ) NOc) ED................................................................................................................................... ( ) YES ( ) NO

4. Is call taken in-house or from home for:

a) Inpatient:............................................................................................................. ( ) In-house ( ) Home b) Outpatient:............................................................................................................ ( ) In-house ( ) Homec) ED:....................................................................................................................... ( ) In-house ( ) Home

Q. Relationship of Geriatric Psychiatry Residents to General Psychiatry Residents:

1. Are geriatric psychiatry residents involved in the didactic teaching of general psychiatry residents?............................................................................................................................................... ( ) YES ( ) NO

If yes, briefly describe

2. Do geriatric psychiatry residents have supervisory and/or bedside teaching responsibilities for general psychiatry residents?............................................................................................................. ( ) YES ( ) NO

If yes, briefly describe

R. Liability Coverage

1. Are residents provided with professional liability coverage related to their clinical activities in the program?............................................................................................................................................... ( ) YES ( ) NO

2. Does this professional liability insurance include "tail" coverage for legal actions filed after the resident has left the program?............................................................................................................. ( ) YES ( ) NO

3. Are residents provided with a written statement regarding the nature, extent and limitations of their liability coverage?.............................................................................................................................. ( ) YES ( ) NO

S. Outside Activity

1. How does the program monitor clinical activity outside the residency?

document.doc 26

VERIFICATION OF INFORMATION

Information Furnished By:Name: Title:

Signature: Date:

If information is furnished by someone other than the Program Director, the latter must verify the accuracy of the information submitted.Verified By program Director:

Name: Title:

Signature: Date:

If Program Director is not the Chairman of the Department of Psychiatry or Institutional Director, the Chairman or Institutional Director must verify the accuracy of the information submitted.Verified By Chairman of Department of Psychiatry Or Site Director:

Name: Title:

Signature: Date:

document.doc 27

Documents

RESIDENCY REVIEW COMMITTEE FOR PSYCHIATRY