the residency review committee for dermatology

THE RESIDENCY REVIEW COMMITTEE FOR DERMATOLOGY515 N State, Ste 2000, Chicago, IL 60654 312-755-5025 www.acgme.org

PROGRAM INFORMATION FORM - PROCEDURAL DERMATOLOGY

FOR NEW APPLICATIONS ONLY

GENERAL INSTRUCTIONS

This form is for use by programs making Initial Application Only (for re-accreditation, use the Continued Accreditation PIF and the Web 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: 312-755-5026).

For word processing questions/problems, contact the ACGME Help Desk (Phone: 312-755-7464).

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

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

THE RESIDENCY REVIEW COMMITTEE FOR DERMATOLOGY515 North State Street, Suite 2000 Chicago, Illinois 60654 Phone: 312-755-5025

PROGRAM INFORMATION FORM - PROCEDURAL DERMATOLOGY

TABLE OF CONTENTS

When you have the completed forms, number each page sequentially in the upper right hand corner. 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.

Section Page(s)

General Program Information 1

Participating Institutions 2

Resident Complement 3

Faculty / Teaching Staff 4

Background Information 5

Procedures Performed at Program Sites 6

Outline of Fellow Assignments 7

Narrative Description of the Program 8

Goals and Objectives SuppI

Evaluation Forms SuppII

Institutional Statement (For Single/Limited Site Sponsors Only) SuppII

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PROGRAM INFORMATION FORM - PROCEDURAL DERMATOLOGY(Part 1)


SECTION 1. GENERAL PROGRAM INFORMATION

A. Accreditation Information

Date:

Title of Program:

B. Program Director Information

Name:

Title:

Address:

City, State, Zip code:

Telephone: FAX: Email:

Date First Appointed:

Principal Activity Devoted to Resident Education:

Term of PD Appointment:

Primary Specialty Board Certification: Most Recent Date:

Secondary Specialty Board Certification: Most Recent Date:

Number of years spent teaching in GME in this specialty:

Director based at primary teaching institution? ( ) YES ( ) NO

Number of hours per week Director Spends in:

Clinical Supervision: Administration: Research: Didactics/Teaching:

Is Program Director also Department Chair? ( ) YES ( ) NO

If No, Chair Name:

The signatures of the director of the program, the chief of the department and the designated institutional official attest to the completeness and accuracy of the information provided on these forms.

Signature of Program Director (and date):

Signature of Chief/Department Chair if different from Program Director (and date):

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

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SECTION 2. PARTICIPATING INSTITUTIONS

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 INSTITUTION (Institution #1)

Name:

Address:

City, State, Zip Code:

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

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

Length of Resident Rotation (in months) Year 1:

CEO/Director/President’s Name: JCAHO Approved? ( ) YES ( ) NO ( ) NA


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

Brief Educational Rationale:

PARTICIPATING INSTITUTION (Institution #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:







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Name:

Address:













Name:

Address:













Name:

Address:












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SECTION 3. RESIDENTS

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

Positions Year 1 Total

Number of Requested Positions

Number of Filled Positions*

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

B. Actively Enrolled Residents (if applicable)

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

NameProgram

Start Date

Expected Completion

Date

Year in Program

Years of Prior GME

Specialty of Most Recent Prior GME

Medical SchoolYear of Med

School Graduation

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SECTION 4. FACULTY / TEACHING STAFF

A. Faculty Roster

List those key members of the teaching staff who currently devote 8 plus hours per week to fellow education. Include members of other departments if applicable. Indicate whether "Chief", "Attending", etc. in the position field. If a "Consultant" in a related field, note the field, e.g., "Radiology" "Pathology."

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

Name (Position) Degree

Based Primarily at Institution

#*

Specialty / FieldBoard

Certification (Y/N)†

Most Recent

Certification Date

Years as Faculty in Specialty

Clinical Supervisio

n Admin

Didactic Teaching

Research

(PD)

*as listed in Part 1, Section 2.† Certification for the primary specialty refers to ABMS Board Certification. Certification for the secondary specialty refers to sub-Board certification in a subspecialty or another specialty area

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B. Key Faculty Curriculum Vitae - Complete for each faculty member. One page only.

First Name: MI: Last Name:

Present Position:

Medical School Name:

Degree Awarded: Year Completed:

Graduate Medical Education Program Name(s); include all residency and fellowships:

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):

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 5):

Participation in Local, Regional, and National Activities / Presentations (Limit of 5):

If not Board certified, explain equivalent qualifications:

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PROGRAM INFORMATION FORM - PROCEDURAL DERMATOLOGY(Part 2)


SECTION 5. BACKGROUND INFORMATION

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

For those institutions which are either a single-program institution (e.g., dermatology only), 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 (Supplement III).

2. Describe the formal method by which a periodic evaluation of the program’s educational quality and compliance with the program requirements occurs. Explain how residents and faculty in the program are involved in the evaluation process.

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

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

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

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SECTION 6. PROCEDURES PERFORMED AT PROGRAM SITES

Provide number of dermatologic procedures performed in a recent 12 month period in each program institution identified in Part 1, Section 2. If more than four institutions are involved in the program, duplicate the form as needed.

12-Month Period Covered by Statistics From: To:

Operative Procedures #1 #2 #3 #4 Row Total

Excision - Benign Lesion

Excision - Malignant Lesion

Nail procedures

Repair (closure) simple / intermediate / complex

Grafts (split or full)

Flaps

Ambulatory phlebectomy / vein surgery

Dermabrasion

Chemical Peel: superficial-epi

Chemical Peel: deep dermal

Tumescent liposuction

Hair removal laser

Vascular lesion laser

Pigmented lesion laser

Laser (ablation, resurfacing)

Non-ablative rejuvenation

Intense pulsed light

Mohs micrographic surgery

Mohs micrographic surgery (complex / large)

Sclerotherapy

Hair transplantation

Soft Tissue Augmentation / Skin Fillers

Rhinophyma correction

Lip excision / wedge / vermilionectomy

Scar revision (acne scar or procedure not otherwise listed)

Botulinum toxin chemodeinnervation

Other

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SECTION 7. OUTLINE OF FELLOW ASSIGNMENTS

Provide a typical weekly schedule for a program fellow resident using the chart below.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

AM

PM

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SECTION 8. NARRATIVE DESCRIPTION OF THE PROGRAM

The questions which follow provide programs with an opportunity to systematically describe the manner in which they comply with accreditation requirements (PR.). Responses should be concise and focused. During the site visit, residents, faculty, and others will be asked for comment on the information provided. As a result, those who will be interviewed should read the PIF prior to their meeting with the site visitor.

Institutional Support

1. Program Sponsorship and Affiliation

A. If the program is sponsored by an institution that also sponsors a Dermatology residency, how do the two program directors monitor the interaction of residents and fellow to ensure appropriate educational experiences for both?

B. If the program is not affiliated with an accredited Dermatology residency, explain why. Note: Programs that are not sponsored by institutions that also sponsor other programs must document compliance with the ACGME's institutional requirements.

2. Describe the space dedicated to the performance of dermatologic surgery, including Mohs micrographic frozen section laboratories and patient examination areas. Are program's laboratory facilities accredited? If so, identify the accreditation agency(ies).

3. Summarize fellow access to (a) a major medical library, (b) electronic retrieval of information and medical databases, and (c) on-site collection of texts and journals at each program institution.

Responsibilities of the Program Director

4. Where and when did the program director receive residency training in dermatology? Where and when did the program director receive fellowship training in dermatologic surgery?

5. How does the program director select, supervise, and evaluate the teaching staff and other program personnel at each institution participating in the program? Has a local site director been identified in each program institution? How does the director monitor resident supervision at each institution?

6. Has the program implemented procedures regarding fellow grievances during the last five years? If yes, provide a concise summary.

7. How does the program monitor fellow stress, including mental or emotional conditions inhibiting performance or learning? What arrangements does the program have for the provision of counseling and psychological support services for fellow?

8. Identify changes specified in IV.B.6. of the Program Requirements that have been made since the last accreditation site visit? Note: Documentation of the Residency Review Committees approval of each change must be available for the site visitor’s review.

9. If the program has a Co-director, identify the individual and provide a brief description of his/her responsibilities for the fellowship.

Other Specialties and Program Personnel

10. Concisely describe the opportunities fellows have to work with personnel from other specialties.

11. Concisely summarize the technical, clerical, and other non-physician personnel who provide support for the administrative and educational conduct of the program. Is the support of the program in this area satisfactory at all program institutions?

The Educational Program

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12. Describe the didactic component of the program. Include a list of the conferences that were held during the last year, including those that were devoted to each of the three components of the body of knowledge which serve as the basis for procedural dermatology: cutaneous oncologic surgery, cutaneous reconstructive surgery, and cutaneous cosmetic surgery. Provide the date, location, audience and specific topic of each session.

13. Concisely describe fellow education in related disciplines such as surgical anatomy, sterilization of equipment, aseptic technique, anesthesia, closure materials, instrumentation, cardiopulmonary resuscitation, and wound healing. PR V.B.2.

14. How does the program ensure that fellows have opportunity to develop competence in pre-operative evaluation of patients? Include comment on the manner in which fellows gain experience in the identification of a) patients whose conditions should be treated by dermatologic surgical techniques and b) those who should be referred to other specialists.

15. How does the program ensure that fellows have opportunity to gain experience in the post-operative follow up care of patients?

16. Describe the manner in which faculty instruct and supervise fellows during the performance of dermatologic surgical procedures. How are fellows given the opportunity to assume increasing responsibility as they gain experience and develop more advanced skills.

17. Summarize fellow education and experience in laboratory management and slide review.

18. Summarize fellow education and experience in the area of quality improvement activities.

Scholarly Activity

19. Summarize program research activity, including comment on each of the following:

A. List the staff who provide stimulation and supervision of clinical or laboratory research activity by residents and identify their particular area(s) of expertise.

B. List the publications in refereed journals (during the last 3 years) by program residents. Provide titles, co-authors, dates with resident name in bold font.

C. List the research presentations (during the last three years) that resulted from resident research activity during the program.

D. Describe the time free of clinical duties that is provided for resident participation in clinical or laboratory research.

Fellow Duty Hours & Working Environment

20. Has the program been granted an exception to the program requirement regarding the 80 hour per week duty limit for fellows? Note: Documentation of Residency Review Committee approval must be provided for site visitor review.

21. How does the program ensure that all fellows have (a) at least 1 day in 7 free from all educational and clinical responsibilities and (b) a 10-hour time period between daily duty periods and after in-house call?

22. Describe the manner in which the program ensures the fellows' call schedule is in compliance with V.F.3. of the program requirements.

23. Summarize the program's policies regarding fellow moonlighting.

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Evaluation

24. Describe the manner in which the program director and other members of the teaching staff participate in a quality improvement review of the frozen section slides.

25. Concisely summarize the manner in which fellows are evaluated (including comment on how feedback is provided to promote improvement in fellow performance.

26. Concisely summarize the manner in which faculty are evaluated, including comment on the manner in which written fellow evaluations are utilized.

27. Describe the manner in which program personnel (including at least one fellow) review, at least once each year, program effectiveness. How are evaluations of fellow performance utilized in this process?

28. Provide a frank assessment of (a) program strengths, (b) program needs, and (c) plans to address those needs in the future.

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SUPPLEMENT I: GOALS AND OBJECTIVES

Attach a copy of the educational goals and objectives for each required rotation or major assignment.

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SUPPLEMENT II. SAMPLE EVALUATION FORMS

Attach samples of any forms used to evaluate the fellows, the faculty, and the program.

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SUPPLEMENT III. INSTITUTIONAL STATEMENT

For those institutions which are either a single-program institution (e.g., dermatology only), or an institution with multiple residencies accredited by the same Residency Review Committee:

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

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the residency review committee for dermatology

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