New Application Only

THE RESIDENCY REVIEW COMMITTEE FOR NUCLEAR MEDICINE515 N State, Ste 2000, Chicago, IL 60654 (312) 755-5000 www.acgme.org

FOR NEW APPLICATIONS ONLY

GENERAL INSTRUCTIONS

APPLICATIONS FOR A NEW PROGRAM: This Program Information Form (PIF) is for programs applying for INITIAL ACCREDITATION ONLY (for Continued Accreditation or re-accreditation, use the CONTINUED ACCREDITATION PIF in conjunction with 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. Where patient numbers are requested, estimate what you expect will occur. 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.

Once the forms are complete, number the pages sequentially in the bottom center. Send four complete copies to the executive director of the Residency Review Committee for Nuclear Medicine at the address above. They must be identical and final. Draft copies are not acceptable. The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two or three ring binders, spiral bound notebooks, or any other form of binding.

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 designated institutional official of the sponsoring institution.

Review the Program Requirements for Residency Education in Nuclear Medicine. The Program Requirements and the Institutional Requirements may be downloaded from the ACGME website (www.acgme.org):

For questions regarding:

-the completion of the form (content), contact the Accreditation Administrator.

-the Accreditation Data System, email [email protected].

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

Note that the process takes approximately one year from the time the application is received until it is evaluated by the Residency Review Committee. A site visit will be scheduled during that year.

Nuclear Medicine New Application PIF i

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

Attach the following documents to the application:

References to Common Program and Institutional Requirements are in parenthesis

1. Policy for supervision of residents (addresses residents’ responsibilities for patient care and progressive responsibility for patient management and faculty responsibilities for supervision) (CPR IV.A.4.; IR III.B.4.)

2. Program policies and procedures for residents’ duty hours and work environment (CPR II.A.j.4.; CPR VI.C.; IR II.D.4.i.; IR III.B. 3.)

3. Moonlighting policy (CPR VI.F.1-2; CPR II.A.4.j.; IR II.D.4.j.)

4. Overall educational goals for the program (CPR IV.A.1.)

5. A sample of competency-based goals and objectives for one assignment at each educational level (CPR IV. A. 2.)

6. All Program Letters of Agreement (PLAs) (CPR I.B.1.)

7. A blank copy of the forms that will be used to evaluate residents at the completion of each assignment (CPR V.A.1.a.)

8. Copies of tools the program will use to provide objective assessments of competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (CPR V.A.1.b.(1))

9. A blank copy of the form that will be used to document the semiannual evaluation of the residents with feedback (CPR V.A.1.b.(2) & (4))

10. A blank copy of the final (summative) evaluation of residents, documenting performance during the final period of education and verifying that the resident has demonstrated sufficient competence to enter practice without direct supervision (CPR V.A.2.)

11. A blank copy of the form that residents will use to evaluate the faculty (CPR V.B. 3.)

12. A blank copy of the form that residents will use to evaluate the program (CPR V.C.1.d.(1))

Single Program Sponsors only:

1. A copy of the resident contract with the pertinent items from the institutional requirements and Master Affiliation Agreements

2. Institutional policy for recruitment, appointment, eligibility, and selection of residents (IR II.A.)

3. Institutional policy for discipline and dismissal of residents, including due process (IR II.D.4.e.; IR III.B.7.)

Nuclear Medicine New Application PIF ii


Program Name:

TABLE OF CONTENTS

When you have the completed forms, number each page sequentially in the bottom center. Record this pagination in the Table of Contents and submit this cover page with the completed PIF.

Common PIF Page(s)Accreditation Information

Response to Previous CitationsParticipating Sites

Single Program Sponsoring Institutions (If applicable)Program Personnel and Resources

Program Director InformationPhysician Faculty RosterFaculty Curriculum VitaeNon Physician Faculty RosterNon Physician Faculty Curriculum VitaeProgram Resources

Resident AppointmentsEvaluation (Residents, Faculty, Program)Resident Duty HoursResident Scholarly Activities

Specialty Specific PIF Page(s)Patient Care

Adult Diagnostic Nuclear Imaging StudiesAdult Radionuclide TherapyPediatric Diagnostic Nuclear Imaging StudiesPediatric Radionuclide TherapyDiagnostic Nuclear Nonimaging Studies (Pediatric and Adult)

Medical KnowledgeBasic ScienceClinicalDidactic: OtherOrganizationIn Vivo (Imaging) TrainingTherapy TrainingNon Imaging TrainingPediatric Nuclear MedicineQuality Control and AssuranceResearchResident Duty Hours and the Working Environment

Practice-Based Learning & ImprovementInterpersonal & Communication Skills

Nuclear Medicine New Application PIF iii

Specialty Specific PIF Page(s)ProfessionalismSystems-Based PracticeTraining Other LearnersFacilitiesAppendix A - BibliographySample Monthly Clinical Conferences

Nuclear Medicine New Application PIF iv


PROGRAM INFORMATION FORM

A. ACCREDITATION INFORMATION

Date:

Title of Program:

Requested Effective Date of Accreditation:

Status of core program, if applicable:

Length of program:

Number of requested resident positions:

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.

Name of Program Director:

Signature of Program Director (and date):

Name of Designated Institutional Official (DIO):

Signature of DIO (and date):

1. Respond to Previous Citation(s)

If the program reapplies for accreditation within two years after accreditation has previously been withdrawn or proposed withdrawn, the accreditation history of the last accreditation action of that program shall be included as part of the file.

a) In the case of application after proposed withdrawal, provide a statement rebutting each citation and documenting compliance with ACGME Requirements or provide a response to b) below.

b) In case of application after either proposed withdrawal or withdrawal, provide a statement of the measures the program has taken to comply with ACGME Requirements relating to each citation in the last letter of accreditation.

Nuclear Medicine New Application PIF 1

B. PARTICIPATING SITES

SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.) Name of Sponsor: Address: Single Program Sponsor? ( ) YES ( ) NOCity, 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 ( ) NO

If 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:Clinical Site? ( ) YES ( ) NOType of Rotation (select one)

Elective ( ) Required ( ) Both ( )

Length of Resident/Fellow Rotations (in months) Year 1: Year 2: Year 3:CEO/Director/President’s Name: Joint Commission Approved? ( ) YES ( ) NO If no, explain:

The Program Director must submit any participating sites routinely providing a required educational experience. Duplicate as necessary. PARTICIPATING SITE (Site #2) Name:Address:City, State, Zip Code:Integrated: ( ) YES ( ) NODoes this site also sponsor its own program in this specialty? ( ) YES ( ) NODoes it participate in any other ACGME-accredited programs in this specialty? ( ) YES ( ) NODistance between #2 & #1:

Miles: Minutes:

Type of Rotation (select one)

( ) Elective ( ) Required ( ) Both

Length of Resident/Fellow Rotations (in months) Year 1: Year 2: Year 3:CEO/Director/President’s Name:Brief Educational Rationale:


1. SINGLE PROGRAM SPONSORING INSTITUTIONS (if applicable)

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

a) 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. (IR I.B.2)

b) 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. (CPR V.C; IR IV)

c) 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. (IR II.A-B)

d) 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.) (IR II.C-D)

e) 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. (IR II.D.4.c-d)


C. PROGRAM PERSONNEL AND RESOURCES

1. Program Director Information

Name: Title: Address: City, State, Zip code:Telephone: FAX: Email:Date First Appointed as Program Director: Will Your Principal Activity Be Devoted to Resident Education? ( ) YES ( ) NOTerm of Program Director Appointment: Date first appointed as faculty member in the program:Percentage of time the program director devotes to the program in the following activities:Clinical Supervision:

Administration: Research: Didactics/Teaching:

Primary Specialty Board Certification: Most Recent Year:Secondary Specialty Board Certification: Most Recent Year: Number of years spent teaching in GME in this specialty:

a) Does the program director approve the selection of program faculty as appropriate?..............................................................................................................................( ) YES ( ) NO

b) Will the program director evaluate the faculty and approve the continued participation of program faculty based on evaluation?.................................................................................( ) YES ( ) NO

c) Will the program director comply with the sponsoring institution’s written policies and procedures, including those specified in the Institutional Requirements, for selection, evaluation and promotion of residents, disciplinary action, and supervision of residents?................................( ) YES ( ) NO

d) Is the program director familiar with and does he/she comply with ACGME and RC policies and procedures as outlined in the ACGME Manual of Policies and Procedures? ......( ) YES ( ) NO


2. Physician Faculty Roster

List alphabetically and by site all physician faculty who devote at least 10 hours a week to resident education. Using the form provided below, supply a one page CV for each faculty listed.

Name (Position)Degre

e

Based Primarily at Site #

Primary and Secondary Specialties / Field

Years as Faculty

in Specialt

y

Average Hours Per

Week Devoted

to Resident

EducationSpecialty /

Field

Board Certificatio

n (Y/N)†

Most Recent

Certification Date

(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), the certification question refers to ABMS Board Certification.


3. Faculty Curriculum Vitae

First Name:

MI:Last Name:

Present Position:Medical School Name:Degree Awarded:

Year Completed:

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

Specialty/FieldDate From:

To:

Certification and Re-Certification Information Current Licensure Data

SpecialtyCertification 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:

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 (Limit of 10 in the last 5 years):

If not ABMS board certified, explain equivalent qualifications:


4. Non Physician Faculty Roster

List alphabetically the non-physician faculty who provide required instruction or supervision of residents in the program. In addition, provide a one page CV for each non-physician faculty listed using the form provided below.

Name (Position) Degree

Based Primarily at

Site # Specialty / Field Role In Program

Years as Faculty in Specialty

5. Non-Physician Faculty Curriculum Vitae

First Name:

MI:Last Name:

Present Position:Degree Awarded:

Year Completed:

Specialty/Field

Current Licensure Data Type of License State Date of Expiration

Academic Appointments - List the past 10 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:

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 (Limit of 10 in the last 5 years):


6. Program Resources

a) How will the program ensure that faculty (physician and nonphysician) have sufficient time to supervise and teach residents? Mention time spent in activities such as conferences, rounds, journal clubs, etc. if relevant.

b) Briefly describe the educational and clinical resources available for resident education.[The answer must include how specialty specific reference materials are accessible. It should also include resources provided by the program and the institution.]


D. RESIDENT APPOINTMENTS

Total Number of Requested Positions

1. Describe how residents will be informed about their assignments and duties during residency. [The answer must confirm that there are goals and objectives for each assignment and for each year, and that these will be readily available (hard copy, electronically, listserv, etc.) to all residents.]

2. Will there be other learners (such as residents from other specialties, subspecialty fellows, nurse practitioners, PhD or MD students) in the program, sharing educational or clinical experiences with the residents? If yes, describe the impact those other learners will have on the program’s residents.

3. Describe how the program will handle complaints or concerns the residents raise. (The answer must describe the mechanism by which individual residents can address concerns in a confidential and protected manner as well as steps taken to minimize fear of intimidation or retaliation.)


E. EVALUATION (RESIDENTS, FACULTY, PROGRAM)

1. Will residents be evaluated on their performance following each learning experience?..............................................................................................................................( ) YES ( ) NO

If no, explain

2. Will these evaluations be documented (in written or electronic format)?..............( ) YES ( ) NO

If no, explain

3. Using the table below (add rows as needed):

a) provide the methods of evaluation used for assessing resident competence in each of the six required ACGME competencies and,

b) identify the evaluators for each method (e.g., “performance in patient care is evaluated by global forms completed by faculty and senior residents, observed histories and physicals by the ward attending and the continuity preceptor; medical knowledge is assessed through the In-Training Examination and an evidence-based journal club evaluated by the PD, etc.”)

Examples of assessment methods: direct observation, videotaped/recorded assessment, global assessment, simulations/models, record/chart review, standardized patient examination, multisource assessment, project assessment, patient survey, in-house written examination, in-training examination, oral exam, objective structured clinical examination, structured case discussions, anatomic or animal models, role-play or simulations, formal oral exam, practice/billing audit, review of case or procedure log, review of patient outcomes, review of drug prescribing, resident experience narrative and any other applicable assessment method

Examples of types of evaluators: self, program director, nurse, faculty supervisor, medical student, faculty member, allied health professional, resident supervisor, patient, other residents, technicians, clerical staff, evaluation committee, consultants

Competency Assessment Method(s) Evaluator(s)

Patient Care

Medical Knowledge

Practice-based learning & Improvement

Interpersonal & Communication Skills

Professionalism


Competency Assessment Method(s) Evaluator(s)

Systems-based Practice

4. Describe how evaluators will be educated to use the assessment methods listed above so that residents are evaluated fairly and consistently.

Limit your response to 400 words.

5. Describe how residents will be informed of the performance criteria on which they will be evaluated.


6. Describe the system that ensures that faculty will complete written evaluations of residents in a timely manner following each rotation or educational experience.


7. Describe the process that will be used to complete and document written semiannual resident evaluations, including the mechanism for reviewing results of the evaluation (e.g., who meets with the residents and how the results are documented in resident files).


8. Describe the system that residents will use to provide annual confidential written evaluations of the teaching faculty. [The answer must include evaluations at least once per year, the steps taken to maintain confidentiality, and the process by which evaluations are sought.]


9. Describe the system that the program (or department, if applicable) will use to provide evaluation and feedback to the teaching faculty.


10. Describe the approach that will be used for program evaluation, including how the program will ensure that residents provide confidential written evaluation of the program at least annually.



F. RESIDENT DUTY HOURS

1. Excluding call from home, what is the projected average number of hours on duty per week per resident?

2. What is the projected average number of days per week of in-house call (excluding home call and night float) which residents will be assigned?

3. How will the faculty provide appropriate supervision of residents in patient care activities?

4. How will the program ensure that residents comply with the ACGME duty hour standards? Be specific as regards the duty hour weekly limit, time spent on-call, days free each week, length of duty shifts, periods of rest between duty shifts, and moonlighting policies, as applicable.

5. How will the program ensure that residents recognize the signs of fatigue and sleep deprivation?

6. How will the program ensure that resident education is not adversely affected by heavy service obligations?


G. RESIDENTS’ SCHOLARLY ACTIVITIES

Will the program offer residents the opportunity to participate in scholarly activities? If yes, briefly describe the opportunity and the expectations about residents’ participation. [The answer must include which research skills are taught in the curriculum.]


RESIDENCY REVIEW COMMITTEE FOR NUCLEAR MEDICINE515 N State, Ste 2000, Chicago, IL 60654 (312) 755-5000 www.acgme.org

SPECIALTY SPECIFIC PROGRAM INFORMATION FORM

I. PATIENT CARE

A. Adult Diagnostic Nuclear Imaging Studies

CPT Codes Site #1 Site #2 Site #3 Site #4THYROID AND ENDOCRINE1. Thyroid Uptake and Thyroid Imaging 78000-780112. Thyroid Carcinoma Metastases

Imaging 78015-78018

3. Parathyroid Imaging 780704. Adrenal Imaging 780755. Other Endocrine 78099TOTALS:HEMATOLOGIC1. Bone Marrow Imaging 78102-781042. Spleen Imaging, Platelet Survival 78185-781913. WBC Localization Imaging 78192-781934. Lymphatic System Imaging and

Sentinel Node Imaging78195

TOTALS:GASTROINTESTINAL1. Liver and Spleen Imaging 78201-782202. Hepatobiliary Imaging 78220-782233. Salivary Gland Imaging, GE Reflux,

Esophageal Motility Gastric Mucosa Imaging, Gastric Emptying

78230-78264

4. GI Blood Loss Imaging 782785. Bowel Imaging, Peritoneal-Venous

shunt Patency78290-78291

TOTALS:BONE IMAGING1. Bone and Joint Imaging (planar) 78300-783102. Bone, Triple Phase Imaging 783153. Bone and Joint Imaging

(Tomographic)78320

4. Bone Density Measurements 78350-78351TOTALS:CARDIOVASCULAR (Excluding PET)1. Cardiac Shunt Detention 784282. Vascular Flow Imaging, Venography 78445-784583. Myocardial Perfusion Imaging (planar) 78460-784614. Myocardial Perfusion Imaging

(Tomographic)78464-78465

5. Myocardial Infarct Avid Imaging 78466-784696. Cardiac Blood Pool Imaging 78472-784737. ECG-Gated Myocardial Perfusion 78478-78480


CPT Codes Site #1 Site #2 Site #3 Site #4Imaging (tomo)

8. Cardiac Blood Pool First Pass Study 78481-78483TOTALS:PULMONARY1. Pulmonary Perfusion 785802. Pulmonary Ventilation 78587-785943. Pulmonary Quantitative Differential

Function78596

TOTALS:CENTRAL NERVOUS SYSTEM (Excluding PET)1. Brain Imaging (Planar and

Tomographic)78600-78615

2. Cisternography, CSF Dynamics Shunt, CSF leak

78630-78652

3. Isotope Dacrocystograpy 78660TOTALS:GENITOURINARY1. Kidney Imaging/Function 78700-787252. Kidney Imaging/Function with Pharm.

Intervention78726

3. Kidney Transplant Evaluation 787274. Urinary Bladder Residual/Reflux 78730-787405. Testicular Imaging 78760-78761TOTALS:ONCOLOGY/INFECTION (Excluding PET)1. Localization of Tumor 78800-788032. Localization of Abscess 78805-78806TOTALS:PET IMAGING1. Tumor 788102. Cardiac 784593. Neurologic 786084. OtherTOTALS:


B. Adult Radionuclide Therapy

Procedure Description CPT Codes Site #1 Site #2 Site #3 Site #41. Therapy for Hyperthyroidism 790052. Therapy for Thyroid Carcinoma 79030, 790353. Therapy with Radiolabeled antibodies 794034. Therapy for Painful Bone Disease 79101-777505. Therapy for Polycythemia, Chronic

Leukemia79100

6. Intracavitary or Interstitial Radioactive Colloid Therapy

79200-79300

7. Other Non-Thyroid, Non-Hematologic Cancer Therapy (Specify)

79400-79999

6. Intraarticular Therapy 79440TOTALS:

C. Pediatric Diagnostic Nuclear Imaging Studies

Procedure Description CPT Codes Site #1 Site #2 Site #3 Site #4THYROID AND ENDOCRINE1. Thyroid Uptake and Thyroid Imaging 78000-78112. Thyroid Carcinoma Metastases

Imaging78015-78018

3. Parathyroid Imaging 780704. Adrenal Imaging 780755. Other Endocrine 78099TOTALS:HEMATOLOGIC1. Bone Marrow Imaging 78102-781042. Spleen Imaging, Platelet Survival 78185-781913. WBC Localization Imaging 78192-781934. Lymphatic System Imaging 78195TOTALS:GASTROINTESTINAL1. Liver and Spleen Imaging 78201-782202. Hepatobiliary Imaging 78220-782233. Salivary Gland Imaging, GE Reflux,

Esophageal Moltility Gastric Mucosa Imaging, Gastric Emptying

78230-78264

4. GI Blood Loss Imaging 782785. Bowel Imaging, Peritoneal-Venous

shunt Patency78290-78291

TOTALS:BONE IMAGING1. Bone and Joint Imaging 78300-783102. Bone, Triple Phase Imaging 783153. Bone and Joint Imaging

(Tomographic)78320

4. Bone Density Measurements 78350-78351TOTALS:


Procedure Description CPT Codes Site #1 Site #2 Site #3 Site #4CARDIOVASCULAR (Excluding PET)1. Cardiac Shunt Detention 784282. Vascular Flow Imaging, Venography 78445-784583. Myocardial Perfusion Imaging 78460-784614. Myocardial Perfusion Imaging

(Tomographic)78464-78465

5. Myocardial Infarct Avid Imaging 78466-784696. Cardiac Blood Pool Imaging 78472-784737. ECG-Gated Myocardial Perfusion

Imaging78478-78480

8. Cardiac Blood Pool First Pass Study 78481-78483TOTALS:PULMONARY1. Pulmonary Perfusion 785802. Pulmonary Ventilation 78587-785943. Pulmonary Quantitative Differential

Function78596

TOTALS:CENTRAL NERVOUS SYSTEM (Excluding PET)1. Brain Imaging (Planar and

Tomographic)78600-78615

2. Cisternography, CSF Dynamics 78630-78652TOTALS:GENITOURINARY1. Kidney Imaging/Function 78700-787252. Kidney Imaging/Function with Pharm.

Intervention78726

3. Kidney Transplant Evaluation 787274. Urinary Bladder Residual/Reflux 78730-787405. Testicular Imaging 78760-78761TOTALS:ONCOLOGY/INFECTION (Excluding PET)1. Localization of Tumor 78800-788032. Localization of Abscess 78805-78806TOTALS:


D. Pediatric Radionuclide Therapy

Procedure Description CPT Codes Site #1 Site #2 Site #3 Site #4Therapy of Hyperthyroidism 79000-79020Therapy for Thyroid Carcinoma 79030-79035Therapy for Polycythemia, Chronic Leukemia

79100

Intracavitary/Interstitial Therapy 79200-79300Other Non-Thyroid, Non-Hematologic Cancer Therapy

79400

Intravascular Particulate Therapy 79420Intraarticular Therapy 79440TOTALS:

E. Diagnostic Nuclear Nonimaging Studies (Pediatric and Adult)

List the number of each type of Nuclear Medicine procedures performed in those departments which participate in the nuclear medicine residency.

Test: CPT Codes Site #1 Site #2 Site #3 Site #4Glomerular Filtration Rate 78725Effective Renal Plasma Flow 78725Schilling Test 78270Red Cell and Plasma Volume 78120-78122Other (Specify)TOTALS:


II. MEDICAL KNOWLEDGE

A. Basic Science

1. Instruction that focuses on physical principles, computer applications instrumentation, or techniques of measurement and quantification should be listed under the subheading of BASIC SCIENCE

Basic Science Lecture Hrs Lab. HrsTotal Hours per Academic Year

Physical Science and InstrumentationRadiation Biology & Radiation ProtectionComputer ScienceMathematics and StatisticsComputer Processing of Clinical ImagesRadionuclide Chemistry and RadiopharmacyTotal Basic Science Hours

2. Provide a complete Basic Science didactic schedule (conferences and lectures) for the most recent academic year. The schedule must be complete and accurate, and must provide the title/topic of each session, date, presenter name.

Title/Topic Date Presenter Name

3. Provide a description of the Basic Science didactic schedule by diagramming a typical weekly schedule of these conferences with a brief textual explanation.

Time Monday Tuesday Wednesday Thursday Friday7:00 a.m.8:00 a.m.9:00 a.m.10:00 a.m.11:00 a.m.12:00 p.m.1:00 p.m.2:00 p.m.3:00 p.m.4:00 p.m.5:00 p.m.


B. Didactic and Clinical

Time in supervised clinical training or clinical conferences should not be included in this tabulation. Instruction that deals with biologic principles, in vivo tracer kinetics and clinical applications should be tabulated under the CLINICAL subheading.

Clinical Lecture Hours Lab. HoursTotal Hours per Academic Year

Nuclear ImagingCNSCardiacPulmonaryGIInfectionEndocrineMusculoskeletalHematology/OncologyRenalPET: Technical aspects & instrumentationTherapy of HyperthyroidsmTherapy of thyroid cancerTherapy with radiolabeled antibodiesOther radionuclide therapy (specify)In Vitro Assays (Methodology and application) GFR, Schilling Test, etc.In Vivo Measurement (Methodology and application) thyroid uptake, bone density, etc.Pediatric Nuclear MedicineQuality Management & ImprovementOther (Specify)

1. Provide a complete clinical didactic schedule (conferences and lectures) for the most recent academic year. The schedule must be complete and accurate, and must provide the title/topic of each session, date, presenter name, and number of hours.

Title/Topic Date Presenter Name Number of Hours


2. Provide a description of the clinical didactic lectures and clinical case conferences listed above, by diagramming a typical monthly schedule of these conferences (a sample schedule is provided at the end of this document) with a brief textual explanation.

Time Monday Tuesday Wednesday Thursday Friday7:00 a.m.8:00 a.m.9:00 a.m.10:00 a.m.11:00 a.m.12:00 p.m.1:00 p.m.2:00 p.m.3:00 p.m.4:00 p.m.5:00 p.m.7:00 a.m.8:00 a.m.9:00 a.m.10:00 a.m.11:00 a.m.12:00 p.m.1:00 p.m.2:00 p.m.3:00 p.m.4:00 p.m.5:00 p.m.7:00 a.m.8:00 a.m.9:00 a.m.10:00 a.m.11:00 a.m.12:00 p.m.1:00 p.m.2:00 p.m.3:00 p.m.4:00 p.m.5:00 p.m.7:00 a.m.8:00 a.m.9:00 a.m.10:00 a.m.11:00 a.m.12:00 p.m.1:00 p.m.2:00 p.m.3:00 p.m.4:00 p.m.5:00 p.m.


3. Describe how residents participate in the conferences listed above. How much responsibility do they have for their preparation and presentation?

C. Other

Total Hours per Academic YearJournal ClubLectures Presented by ResidentsAdministrative Conferences (i.e., QA)Other (specify):

D. Organization

1. Goals and Objectives

a) Attach the program’s overall educational goals and the competency-based goals and objectives for each assignment, at each educational level as Appendix A.

b) When are the goals and objectives distributed to faculty?.......................................................................( ) Prior to each rotation ( ) Annually ( ) Other

2. Describe the organization of the educational program.

3. Explain the provision for graduated resident responsibility and resident supervision.

E. In Vivo (Imaging) Training

1. Describe the provisions made in your program for didactic instruction and for practical experience and training in the full spectrum of in vivo imaging studies, including positron tomography.

2. Describe the arrangement for interdepartmental collaboration regarding in vivo imaging studies when applicable. The description should include, for example, the role of the Nuclear Medicine resident in the performance of cardiac studies and the relationship between Cardiology and Nuclear Medicine in the performance and interpretation of cardiac studies. If collaborative arrangements exist for other organ systems, these should be described as well.


F. Therapy Training

1. Describe the formal instruction devoted specifically to radionuclide therapy applications including dosimetry, physics, radiobiology and radiation safety.

2. Describe the clinical participation in the therapeutic applications of radionuclides.

3. Describe the provision for resident participation on the follow-up of therapy patients.

4. If the Nuclear Medicine division or department shares the responsibilities for radionuclide therapy with other divisions, describe the roles of each division and/or each participating site.

G. Non Imaging Training

(Non imaging training includes instruction in the principles of immunology; preparation of radiopharmaceuticals including radiolabeled antibodies; radiopharmaceutical absorption, excretion and dilution studies).

1. Describe the provisions made in your program for didactic instruction and for practical experience and training in the full spectrum of non imaging procedures.

2. If the Nuclear Medicine Department or Division shares the responsibility for non-imaging procedures with other divisions and/or participating sites, describe the roles of each division and/or participating site by identifying who is responsible for performing and interpreting the results of non-imaging studies.

H. Pediatric Nuclear Medicine

Describe the arrangements for training in pediatric nuclear medicine.

I. Quality Control and Assurance

Describe briefly the quality management and improvement for nuclear medicine and the role of the resident in these plans. The quality control plan should include quality control of instrument performance and of radiopharmaceutical preparation. The quality assurance plan should include efficacy assessment and compliance with NRC and JCAHO regulations. Describe how residents participate in quality management and improvement activities.


J. Research

Describe briefly the space and special facilities for Nuclear Medicine research.

K. Resident Duty Hours and the Working Environment

1. Describe nuclear medicine residents' work hours including night and weekend call. Indicate the frequency of call and availability of faculty supervision.

2. Explain how the program deals with impaired residents.



Describe the planned program learning activities which will provide experience in the general competencies for residents. Examples of learning activities include: didactic lecture, assigned reading, seminar, self-directed learning module, conference, small group discussion, workshop, online module, journal club, project, case discussion, one-on-one mentoring.

III. PRACTICE-BASED LEARNING AND IMPROVEMENT (PR IV.A.5.c))

1. Describe one learning activity in which residents will engage to identify strengths, deficiencies, and limits in their knowledge and expertise (self-reflection and self-assessment); set learning and improvement goals; identify and perform appropriate learning activities to achieve self-identified goals (life-long learning).


2. Describe one learning activity in which residents will engage to develop the skills needed to use information technology to locate, appraise, and assimilate evidence from scientific studies and apply it to their patients’ health problems. The description should include:

a) locating informationb) using information technologyc) appraising informationd) assimilating evidence information (from scientific studies)e) applying information to patient care


3. Describe one planned quality improvement activity or project in which at least one resident will participate that will require the resident to demonstrate an ability to analyze, improve and change practice or patient care. Describe planning, implementation, evaluation and provisions of faculty support and supervision that will guide this process.


4. Describe how residents will:

a) develop teaching skills necessary to educate patients, families, students, and other residents;b) teach patients, families, and others; and, c) receive and incorporate formative evaluation feedback into daily practice. (If a specific tool is

used to evaluate these skills have it available for review by the site visitor.)



IV. INTERPERSONAL AND COMMUNICATION SKILLS (PR IV.A.5.d))

1. Describe one learning activity in which residents will develop competence in communicating effectively with patients and families across a broad range of socioeconomic and cultural backgrounds, and with other physicians, other health professionals, and health related agencies.


2. Describe one learning activity in which residents will develop their skills and habits to work effectively as a member or leader of a health care team or other professional group. In the example, identify the members of the team, responsibilities of the team members, and how team members communicate to accomplish responsibilities.


3. Explain (a) how the completion of comprehensive, timely and legible medical records will be monitored and evaluated, and (b) the mechanism that will be used for providing residents feedback on their ability to maintain medical records.



V. PROFESSIONALISM (PR IV.A.5.e))

1. Describe one learning activity, other than lecture, by which residents will develop a commitment to carrying out professional responsibilities and an adherence to ethical principles.


2. How will the program promote professional behavior by the residents and faculty?


3. How will lapses in these behaviors be addressed?



VI. SYSTEMS-BASED PRACTICE (PR IV.A.5.f))

1. Describe the learning activities through which residents will achieve competence in the elements of systems-based practice. Examples of such activities would include: work effectively in various health care delivery settings and systems, coordinate patient care within the health care system; incorporate considerations of cost-containment and risk-benefit analysis in patient care; advocate for quality patient care and optimal patient care systems; and work in interprofessional teams to enhance patient safety and care quality.


2. Describe an activity that will provide experiential learning in identifying system errors.



VII. TRAINING OTHER LEARNERS

If the program provides rotations for residents or fellows from other specialties either within or from outside the site provide the number of trainees, trainee specialty, whether the rotation is observation or full participation, and length of time spent in your department.

Trainee Specialty

# of trainees per year at any

given timeFull

Participation ObservationalLength of Rotation


VIII. FACILITIES

1. Nuclear Medicine Equipment: List number of units in use in each site. Use institution numbers from. If more than four sites participate in the program, duplicate this table as needed.

Site #1 Site #2 Site #3 Site #4In Vitro Laboratory

Gamma Well SystemLiquid Scintillation SystemDose CalibratorChromotography

In Vivo Imaging/CountingProbe Counting SystemsCamerasPlanarMobileSPECT (not SPECT/CT)SPECT/CTPET (not PET/CT)PET/CT

Computer Access (yes/no)Nuclear Medicine PACSRadiology PACSRadiology Information SystemHospital Information SystemDesignated Resident Computers (How many?)

Radiopharmaceutical ChemistryCyclotronOther (Specify)

2. Institutional Patient Data: supply the following data for the most recent 12 month period available. Use institution numbers from. If more than four sites participate in the program, duplicate this table as needed.

From To

Site #1 Site #2 Site #3 Site #4Total Number of Active BedsHospital Admissions:

PediatricAdultTotal

Outpatient Visits: PediatricAdultTotal

3. Accreditation and Licensure for Nuclear Medicine: Indicate by Yes/No and date.If more than four sites participate in the program, duplicate this table as needed.


Accreditation and/or Licensure(Indicate by Yes/No and date) Site #1 Site #2 Site #3 Site #4Quality Assurance Programs

Society of Nuclear Medicine/ICANL (Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories)American College of RadiologistsCLIA (Clinical Laboratory Improvement Amendments)

Other (Specify)


APPENDIX A - BIBLIOGRAPHY

List no more than 10 representative publications from the past three years by members of the nuclear medicine teaching staff and residents. Underline the names of resident participants.


SAMPLE MONTHLY CLINICAL CONFERENCES

Time Monday Tuesday Wednesday Thursday Friday7:00 a.m.8:00 a.m. 8-9 NM Conf. (1)* 8-9 NM Conf. (1)9:00 a.m.10:00 a.m.11:00 a.m.12:00 p.m. 12-1 Rad Onc

Conf. (2)12-1 Endo Conf.

(3)1:00 p.m.2:00 p.m.3:00 p.m. 3-4 PET Conf. (1)4:00 p.m.5:00 p.m.7:00 a.m.8:00 a.m. 8-9 NM Conf. (1)* 8-9 NM Conf. (1)9:00 a.m.10:00 a.m.11:00 a.m.12:00 p.m.1:00 p.m.2:00 p.m.3:00 p.m.4:00 p.m.5:00 p.m.7:00 a.m.8:00 a.m. 8-9 NM Conf. (1)* 8-9 NM Conf. (1)9:00 a.m.10:00 a.m.11:00 a.m.12:00 p.m. 12-1 Endo Conf.

(3)12-1 Neuro Sci

Conf. (3)1:00 p.m.2:00 p.m.3:00 p.m.4:00 p.m.5:00 p.m.7:00 a.m.8:00 a.m. 8-9 NM Conf. (1)* 8-9 NM Conf. (1)9:00 a.m.10:00 a.m.11:00 a.m.12:00 p.m.1:00 p.m.2:00 p.m.3:00 p.m.4:00 p.m.5:00 p.m.

* Site Code: 1 – Site #1 A; 2 – Site #2; 3 – Site #3


Health & Medicine

New Application Only