THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY

THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY515 N State, Ste 2000, Chicago, IL 60654 (312) 755-5000 www.acgme.org

FOR CONTINUED ACCREDITATION

GENERAL INSTRUCTIONS

REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the Program Information Form (PIF) is being completed for a currently accredited program, follow the provided instructions to create the correct form. Go to the Accreditation Data System found on the ACGME home page (www.acgme.org) under Data Collection Systems. Using your previously assigned User ID and password, proceed to the PIF Preparation section on the left hand menu and update the Common PIF data. Most data are updated through annual updates, but some information is required at the time of site visit only. Once the data entry is complete, select Generate PIF to review and print the Common PIF (PDF). Pages will be numbered consecutively in the bottom center of each page.

Once the Common PIF is complete, proceed to the appropriate Residency Review Committee webpage to retrieve the Specialty Specific PIF for CONTINUED ACCREDITATION. Once the forms are complete, enter page numbers for the Continued PIF in the bottom center for each page that consecutively follows the Common PIF numbering, combine the Common PIF and the Continued Accreditation PIF and complete the Table of Contents (found with the Specialty Specific PIF instructions). After completing the PIF/documents, make four copies. 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. Mail one set of the completed forms to the site visitor at least 14 days before the site visit. The remaining three sets should be provided to the site visitor on the day of the visit.

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 Diagnostic Radiology. 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

Diagnostic Radiology Continued Accreditation PIF i

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

http://www.acgme.org/

Please have the following documents available for the site visitor:

References to Common Program and Institutional Requirements are in parentheses.

1. Policy for supervision of residents (addressing resident responsibilities for patient care, progressive responsibilities for patient management, and faculty responsibility for supervision) (CPR IV.A.4)

2. Program policies and procedures for residents’ duty hours and work environment (CPR II.A.4.j)

3. Moonlighting policy (CPR II.A.4.j; CPR VI.F)

4. Documentation of internal review (date, participants’ titles, type of data collected, and date of review by the GMEC)

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

6. Competency-based goals and objectives for each assignment at each educational level (CPR IV.A.2)

7. Current Program Letters of Agreement (PLAs) (CPR I.B.1)

8. Files of current residents who have transferred into the program, if applicable (including documentation of previous experiences and summative competency-based performance evaluations) (CPR III.C.1)

9. Evaluations of residents at the completion of each assignment (CPR V.A.1.a)

10. Evaluations showing use of multiple evaluators (faculty, peers, patients, self, and other professional staff) (CPR V.A.1.b.(2))

11. Documentation of residents’ semiannual evaluations of performance with feedback (CPR II.A.4.g; V.A.1.b.(4))

12. 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)

13. Completed annual written confidential evaluations of faculty by the residents (CPR V.B. 3)

14. Completed annual written confidential evaluations of the program by the residents (CPR V.C.1.d.(1))

15. Completed annual written confidential evaluations of the program by the faculty (CPR V.C.1.d.(1))

16. Documentation of program evaluation and written improvement plan (CPR V.C)

17. Documentation of resident duty hours (CPR II.A.4.j; VI.D.1-3)

18. Files of current residents and most recent program graduates

Added documents for some programs:

1. Documentation of conference attendance

2. Single RRC Sponsors only:

a) Copy of the resident contract with the pertinent items from the Institutional Requirements and Master Affiliation Agreements (IR II.D.4)

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

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

Diagnostic Radiology Continued Accreditation PIF ii

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

THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY515 N State, Ste 2000, Chicago, IL 60654 (312) 755-5000 www.acgme.org

10 Digit ACGME Program I.D. #:Program Name:

TABLE OF CONTENTS

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

Common PIF Page(s)Accreditation InformationParticipating Sites

Sponsoring Institution/Single or Limited Residency Institution (If applicable)Faculty/Teaching Staff

Program Director InformationPhysician Faculty RosterFaculty Curriculum VitaeNon Physician Faculty Roster

Resident AppointmentsNumber of PositionsActively Enrolled Residents (if applicable)Aggregated Data on Residents Completing or Leaving the Program for the last 3 years (if applicable)Residents Completing Program in the Last 3 years (if applicable)Transferred, Withdrawn, and Dismissed Residents (if applicable)

EvaluationResident Duty Hours

Specialty Specific PIF Page(s)Patient CareMedical Knowledge

Summary of TrainingRotation ScheduleDidactic ComponentsNarrative Description of Training Program

Practice-Based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystems-Based PracticeImaging Examinations PerformedResident Information

Resident/Faculty RatioPrior Training/Clinical YearTraining Other ResidentsSubspecialty Training

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Specialty Specific PIF Page(s)Facilities and Resources

Space AllocationEquipmentRadiology Information SystemSubspecialty Chiefs

Scholarly ActivityResearch FacilitiesFaculty Scholarly ActivitiesResident PublicationsResident Research Projects

Appendix A - Clinical DataAppendix B - Goals and Objectives

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RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY515 N State, Ste 2000, Chicago, IL 60654 (312) 755-5000 www.acgme.org

SPECIALTY SPECIFIC PROGRAM INFORMATION FORM

I. PATIENT CARE

1. Is there a documented, supervised experience in interventional procedures as described in the diagnostic radiology program requirements?

2. Are the residents required to keep a log that documents their participation in interventional procedures? How often is the log reviewed by the Program Director or faculty/desingee? How does the Program Director use this information?

3. How do residents obtain:

a) clinical training and experience (modalities) in cardiac imaging?

b) didactic instruction in cardiac anatomy physiology and pathology?

4. Explain how residents will gain experience with OB ultrasound studies beyond the first trimester does each resident perform?

5. How does the program provide training in basic life support and/or advanced cardiac life-support?

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II. MEDICAL KNOWLEDGE

A. Summary of Training

Complete the outline provided here to show the typical resident assignments for the four year program. Provide the information in weeks or months, but not both.

Summary of TrainingDuration of Assignment or Rotation (Indicate Whether Weeks or Months)

General RadiologyCardiothoracicAbdominal Imaging(GI/GU)MusculoskeletalBreast ImagingNuclear radiology NeuroradiologyPediatric radiologyVascular/Interventional radiologyEmergency Radiology (if separate), including night floatUltrasoundComputed tomographyMagnetic resonance imagingPathology/AFIPResearchElective time (if not included above)VacationOther (does not fit into above categories; identify and describe)Total (weeks/months)

B. Rotation Schedule

Insert a master list of resident rotations for each year of the program. All the information requested should be included for the normal schedule of rotations rather than the exception. A legible, easily understood block diagram may be provided on a separate sheet and inserted.

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C. Didactic Components

1. Conferences/Lectures: All radiology residents are expected to attend weekly core curriculum conferences/lectures on a regular basis. Participation by both residents and teaching staff must be documented. In the table below, list the intradepartmental conferences/lectures that occur in a typical month.

Conferences, lectures, etc.

(Intradepartmental)

Frequency / Time

Individual(s)/and specialty responsible for organization of

sessions

Core or Subspecialty Teaching Conference

(specify)

2. Does the program provide the residents with the following educational experiences?

FrequencyVisiting Professors Program ..........YES ( ) NO ( )Journal Club ...................................YES ( ) NO ( )Radiology Grand Rounds ..............YES ( ) NO ( )Other Educational Experiences (Specify)

3. What percentage of the conferences are prepared by residents?

By teaching staff?

4. Are residents regularly relieved of clinical duties to attend conferences? ..............( ) YES ( ) NO

5. Does the program provide adequate financial support for residents to present at national and local meetings?................................................................................................................( ) YES ( ) NO

6. List of regional and national meetings that residents have attended in the last twelve months. Add more lines if needed.

1.2.3.

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7. Learning Resources

a. Total number of cases in site accumulated file.

b. Are all teaching files available to residents? ....................................................( ) YES ( ) NO

c. How many ACR modules are available to residents?

d. Are electronic teaching files available to the residents? ...................................( ) YES ( ) NO

D. Narrative Description of Training Program

The Residency Review Committee for Radiology must determine whether a truly educational experience is offered by your program as it is presented. The Committee recognizes that many variations exist among excellent programs and it does not intend to design or dictate curricula.

In addition to the material already provided, information of significance relative to the following questions will be helpful in evaluating your program. Insert text in the boxes below.

1. Attach as Appendix B, a sample of the goals and objectives for one assignment

2. Describe the evaluation mechanism used to determine that the program goals and objectives are met.

3. Have the curriculum outline and statement of goals and objectives been distributed to teaching staff................................................................................................................................( ) YES ( ) NO

4. Explain how instruction in pathology is provided, i.e., whether through the AFIP course, in-house training, or through a combination of the two resources.

5. Do residents receive formal instruction in radiologic physics, radiobiology and radiation protection? Where, how much and by whom?

6. Do residents receive four months training and experience in nuclear radiology? ..( ) YES ( ) NO

7. Describe the nature of resident participation on rotations at the participating sites.

8. Describe the call schedule and specify whether residents take call on-site or from home. At what level of training do the residents begin to take independent, in-house call? How is faculty back-up arranged? When are the studies obtained on call reviewed by radiology faculty?

III. PRACTICE-BASED LEARNING AND IMPROVEMENT

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Examples of Learning Activities: 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, or other examples of learning activities.

1. Describe one learning activity in which residents 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).

Limit your response to 400 words.

2. Describe one example of a learning activity in which residents 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. Give one example and the outcome of a planned quality improvement activity or project in which at least one resident participated in the past year that required 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 guided this process.


4. Describe how residents:

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.)


Diagnostic Radiology Continued Accreditation PIF ix

IV. INTERPERSONAL AND COMMUNICATION SKILLS

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


2. Describe one learning activity in which residents 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 is monitored and evaluated, and (b) the mechanism for providing residents feedback on their ability to competently maintain medical records.


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V. PROFESSIONALISM

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


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


3. How are lapses in these behaviors addressed?


Diagnostic Radiology Continued Accreditation PIF xi

VI. SYSTEMS-BASED PRACTICE

1. Describe the learning activity(ies) through which residents achieve competence in the elements of systems-based practice: 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 fulfills the requirement for experiential learning in identifying system errors.


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VII. IMAGING EXAMINATIONS PERFORMED

Site numbers are found in Common PIF.

Site #Number of Imaging

Examinations Performed12345

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VIII. RESIDENT INFORMATION

A. Resident/Faculty Ratio

What is the full-time equivalent faculty to resident ratio at the sponsoring institution and integrated site(s)? (Do not include faculty at non-integrated sites)

B. Prior Training/Clinical Year

1. Have all residents completed an ACGME accredited clinical year prior to entry into the program?................................................................................................................................( ) YES ( ) NO

2. If not, the Program Director should explain how and when the residents will complete the clinical year. If the program offers a non-accredited year, explain how the Program Director maintains oversight and assures the quality of the clinical year.

C. Training Other Residents

1. Does the program provide training for radiology residents from other programs?...............................................................................................................................( ) YES ( ) NO

2. If yes, provide names of other programs, number of trainees, clinical area of rotation, whether the rotation is observational or full participation, and length of time spent in your department.

Originating Program

# of Trainees Per Year

Clinical Area (Subspecialty)Length Of Rotation

Full participation Observational

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D. Subspecialty Training

1. List ACGME-accredited Diagnostic Radiology subspecialty programs offered by the sponsoring institution of the core program.*

Area of subspecialty trainingNumber of trainees currently in each subspecialty

program

2. List any unaccredited subspecialty training offered beyond four years of Diagnostic Radiology

Area of subspecialty trainingNumber of trainees currently in each subspecialty

program

*The subspecialty areas of Diagnostic Radiology are listed below. The underlined subspecialties are ACGME-accredited one year fellowship programs.

Abdominal RadiologyChest RadiologyMusculoskeletal RadiologyNeuroradiology

Nuclear RadiologyPediatric RadiologyVascular/Interventional Radiology

Diagnostic Radiology Continued Accreditation PIF xv

IX. FACILITIES AND RESOURCES

A. Space Allocation

Complete only for sites to which rotations total at least 3 months. Site numbers are found in the Common PIF

Allocation Of Space: (Yes/No) Primary Site #1 Site #2 Site #3 Site #4 Site #5Dedicated radiology conference room Dedicated radiology call roomDedicated resident offices/lounges (include size and capacity)

B. Equipment

Indicate the number of units available and year of most recent installation. Complete only for sites to which rotations total 3 months, 3 4-week rotations or more. Site numbers are found in the Common PIF.

Primary Site #1 Site #2 Site #3 Site #4 Site #5A. Diagnostic Radiographic Equipment

1. Radiographic units (include chest units)2. Radiographic Fluoroscopic units3. Mammography Units 4. CT Units

B. Ultrasound Units (Sonographic Equipment)C. MRI Units

1. Units on-site in hospital complex2. Units available off-site or mobile

D. Nuclear Radiology EquipmentNuclear cameras (total)

a) SPECTb) SPECT/CTc) PETd) PET/CTe) Planar

E. Angiographic UnitsSingle planeBi-plane

C. Radiology Information System

Radiology Information System Primary Site #1 Site #2 Site #3 Site #4 Site #5Is there a radiology information system in the sponsoring institution? If yes, what type? Does it interface with the hospital information system? Include the year the system was installed.Is there PACS (Picture Archiving Communication System) in the sponsoring and integrated sites? If yes, describe the modalities that are incorporated in the PACS?

D. Subspecialty Chiefs

Subspecialty Name of Subspecialty Chief

Estimate % of time devoted to the subspecialty

Abdominal Radiology (GI/GU)

Breast Imaging

Chest

Musculoskeletal

Nuclear Radiology

Neuroradiology

Pediatric Radiology

Ultrasonography (including ob & vascular ultrasound)

Vascular/Interventional Radiology

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X. SCHOLARLY ACTIVITY

A. Research Facilities

Describe the research space, equipment, and important special research facilities:

B. Faculty Scholarly Activities

List recently completed or on-going research projects (not more than ten) being conducted by members of the Department. Indicate by asterisk (*) if residents participated, list title of project, faculty mentor, and if it will be published or presented at regional and/or national meetings. Do not include past projects or those that are being planned. Do not submit copies of protocols, papers or grant applications.

C Resident Publications

List publications by the residents for the past three years. Include title of publication, date, resident name (underlined), faculty mentor, and if it was or will be presented at regional and/or national meetings. Do not submit copies of protocols, papers or grant applications. Do not include reprints.

D Resident Research Projects

List resident research projects for residents of the past two years which led or will lead to presentations at local or national meetings. Include title of project, resident name (underlined), and where and when the presentation was or will be presented.


APPENDIX A - CLINICAL DATA

All information requested must be included for each participating site as identified in, with the exception of those sites where only a limited sub-specialty rotation is employed as a part of the educational experience. Example: For a cardiovascular rotation, include only the cardiovascular examination data and equipment. Please note, however, that total statistics are required for a pediatric rotation.

Period covered by statistics (latest 12 month period available)

From: To:

Number of Exams

Primary Site #1 Site #2 Site #3 Site #4 Site #5

RadiographyMammography (Screening and Diagnostic)CTMRIUltrasoundNuclear Medicine StudiesVascular/Interventional StudiesTotal Exams


APPENDIX B - GOALS AND OBJECTIVES

Attach a sample of the goals and objectives for one assignment


Health & Medicine

THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY