RESIDENCY REVIEW COMMITTEE FOR UROLOGY

RESIDENCY REVIEW COMMITTEE FOR UROLOGY515 N State, Ste 2000, Chicago, IL 60610 (312) 755-5495 www.acgme.org

PROGRAM INFORMATION FORM

FOR NEW APPLICATIONS ONLY

GENERAL INSTRUCTIONS

Before beginning, please review the Program Requirements for Residency Education in Urology. Please read the instructions carefully before completing the forms. Only these forms may be used for supplying information and surgical statistics.

APPLICATION FOR A NEW PROGRAM: This form is for use by programs making initial application. All sections of the form applicable to the program must be completed to be accepted for review. The information provided should describe the proposed program. For items that do not apply, indicate NA 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.

Once the forms are complete, number the pages sequentially in the upper right hand corner, starting with Part 1, Section 1. Send four complete copies to the Executive Director of the RRC for Urology at the given address above. 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.

For questions regarding the site visit, contact the writer of the letter announcing the site visit.

For questions regarding the completion of the form (content), contact the Accreditation Administrator (Phone: 312-755-5495).

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

For Web Accreditation Data System questions email [email protected].

SPECIFIC INSTRUCTIONS

For Part 1, Section 4, list those faculty who currently participate directly and regularly in the education of the urology residents. 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." Programs seeking continued accreditation must use the Accreditation Data System (ADS) to enter these data. The entered information will automatically appear in Part 1, Section 4 of the PIF.

REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the program information form is being completed for a currently accredited program this is not the correct form. Use the Continued Accreditation PIF in conjunction with the Web Accreditation Data System (Web ADS). Follow the provided instructions to create the correct PIF. Go to the Web Accreditation Data System (Web ADS) found on the ACGME home page (www.acgme.org), using your previously assigned username and password, update your program and resident data, retrieve Part 1 of the PIF under the Site Visit Information section, complete the shaded items (as appropriate), print all sections of Part 1 of the PIF and sign the form. If you find items displayed incorrectly change your data using ADS update sections; in some instances you may need to contact your DIO for the entry of updated information. Next proceed to the section under the RRC for Urology to retrieve Part 2 of the PIF in either Word or WordPerfect. Complete Part 2 of the PIF using your preferred word processor (only after Part 1 has been completed). Combine Part 1 and Part 2, number the pages consecutively on the upper right corner, beginning with Part 1 Section 1 and complete the Table of Contents (found with the Part 2 instructions). Send one copy of the entire packet to the site visitor identified in your letter notifying the program of the visit ten working days prior to your site visit. After the visit, send 3 copies to the Executive Director, Residency Review Committee for Urology, 515 North State Street, Suite 2000, Chicago, IL 60610.

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PROGRAM INFORMATION FORM

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.

Part 1 Section Page(s)

General Program Information 1

Accreditation Information 1.A

Program Director Information 1.B

Participating Institutions 2

Resident Complement 3

Number of Positions 3.A

Actively Enrolled Residents 3.B

Aggregate Data on Residents Completing or Leaving the Program for the Last Three (3) Years 3.C

Residents Who Completed the Program 3.D

Withdrawn / Dismissed Residents 3.E

Scholarly Activity 3.F

Duty Hours 3.G

Faculty 4

Faculty Roster 4.A

Faculty Curriculum Vitae 4.B

Part 2 Section Page(s)

Background Information 5

Previous Citations or Concerns 5.A

Areas of Improvement 5.B

General Competencies 5.C

Pediatric Urology 6

Local Program Directors for Participating Institutions 7

Library Support 8

Educational Program 9

Block Diagram of Urology Program 10

Conferences 11

Clinics 12

Scholarly Activity 13

Evaluation 14

Instructions For Completion of Urology Surgical Operative Log Forms 15

(FOR OFFICE USE ONLY)10 Digit ACGME Program I.D. #:Program Name:

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PROGRAM INFORMATION FORM (Part 1)


SECTION 1. GENERAL PROGRAM INFORMATION

A. Accreditation Information

Date:

Title of Program:

10 Digit ACGME Program ID# (for accredited programs):

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: Changed since the Last Review? ( ) YES ( ) NO

Single Residency Sponsor? ( ) YES ( ) NO

City, State, Zip code:

Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)

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

Name of Designated Institutional Official:

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 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: Year 2: Year 3: Year 4:

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



Brief Educational Rationale:

PARTICIPATING INSTITUTION (Institution #2) Select one (if applicable)INTEGRATED ( )AFFILIATED ( )

Name:

Address:



Does this institution also sponsor its own program in this specialty?

Does it participate in any other ACGME accredited programs in this specialty?

Distance between 2 & 1: Miles: Minutes:







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Name:

Address:













Name:

Address:













Name:

Address:












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SECTION 3. RESIDENTS (P.R. III. B.)

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

Positions Year 1 Year 2 Year 3 Year 4 Total

Number of Requested Positions

Number of Filled Positions*

Date Last Resident Completed this Program (if total filled positions = 0)*:

* 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 transferring residents 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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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 ProgramNumber of Graduates Regardless of Whether They Began in this Program

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

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





E. Withdrawn/Dismissed Residents (if applicable)List residents who withdrew or were dismissed from the program for the last three years and provide the reason.

Name Start Date End DateWithdrawn or

DismissedReason

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F. Scholarly Activity (if applicable)

Based on Academic Year Ending June 30, ____. June 30, ____. June 30, ____.Number of Peer-Reviewed Published Articles Authored or Co-Authored by Residents in the Past Year.Number of Resident Presentations at Regional or National Meetings in the Past Year.

G. Duty Hours (if applicable)

For the previous four week period: Yr 1 Yr 2 Yr 3 Yr 4Excluding call from home, what was the average number of hours on duty per resident per week?Excluding call from home, what was the maximum number of continuous hours worked by any resident?

On average, how many days per week of in-house call were residents assigned?

How many times (in the last 4 weeks) have residents worked more than 30 continuous hours? (This continuous time includes in-house call that directly follows a regular duty shift. Add together the number of times for all residents.)On average, how many days (for the entire last 4 week period) did each resident have completely free from all educational and clinical responsibilities?On average, how many hours off duty did each resident have between duty shifts? (Duty shifts include in-house call.)

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SECTION 4. FACULTY

A. Faculty Roster

List all major teaching staff who participate directly and regularly in resident education.

Primary Specialty / Field Average Hours Per Week Spent On

Name (Position) DegreeBased

Primarily at Institution #*

Specialty / Field

ABMS Board Certification

(Y/N)

Most Recent Certification

Date

Years as Faculty in Specialty

Clinical Supervision

Administration Didactic Teaching

Research

(PD)

*as listed in Part 1, Section 2.

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B. 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:

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):

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PROGRAM INFORMATION FORM (Part 2)


SECTION 5. BACKGROUND INFORMATION

A. Previous Citations or Concerns (if applicable)

List the citations from the last RRC accreditation action and discuss how each cited area has been corrected. If documentation is required, provide a specific reference to information provided in the Program Information Forms such as the USOL, etc., or append additional information supporting the narrative. If no citations were listed, indicate this in your response.

B. Areas of Improvement (if applicable)

Provide a narrative describing areas of improvement since the last review.

C. General Competencies (addendum to this application) (not applicable for new applications) (P.R. V. B.)

The ACGME is monitoring the implementation of general competencies and assessment by using a common data collection tool. Log onto the Web Accreditation Data System and proceed to the Site Visit Information section and select Update/Verify Competency and Assessment Form to enter your information. Once the information has been entered and saved, select Print ADS Competency and Assessment Form to generate a printed copy of the form and attach it to the end of PIF.

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SECTION 6. PEDIATRIC UROLOGY (P.R. V. F.)

Provide the following information for each institution where residents are assigned pediatric experiences. If more than one institution provides pediatric experience, duplicate this page.

Institution: 12-month period for data from to

Number of Pediatric Urology Operative Procedures

Pediatric Urology Clinic Visits

Name of ClinicAverage # of Pediatric Urology Patients seen each week

# Clinics Seen (1/2 Days) # of Clinics that Residents Attend

Other Residents/Fellows Assigned to this Institution for Education in Pediatric Urology

Residents Name of Program Assignment Length in Months Total # per Year # Present at Any One Time

From the urology program

From other programs:

Fellows:

Total

Pediatric Urology Faculty at this Institution:

Number of pediatric urologists involved in pediatric urology education with urology residents at this institution:

Number of pediatric urologists who devote less than half-time per week to the urology residency program:

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SECTION 7. LOCAL PROGRAM DIRECTORS FOR PARTICIPATING INSTITUTIONS (P.R. IV. C.)

Complete the information for each institution participating in the program. Insert additional pages as required if more than four institutions participate with the program.

Sponsoring Institution Name:

Name of Program Director:

Approximate hours per week devoted to residency program:

Describe briefly the mode of appointment, period of service, and responsibilities of the Program Director in the Urology Program:

Participating Institution Name:












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SECTION 8. LIBRARY SUPPORT (P.R. II. B.4)

Please describe the library, journals, computer, computer search capabilities, etc. available for resident education at each institution listed on page one of these forms. Limit this narrative to ONE PAGE please.

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SECTION 9. EDUCATIONAL PROGRAM (P.R. V.)

Please provide a complete, logical and accurate description of the educational program including the goals and objectives for each of the resident assignments.

1. Provide a narrative description for the urology program to include the educational philosophy. List the goals and objectives for urology resident education for each resident assignment. (P.R. V. A., B.)

2. Provide a narrative description for each year of the urology educational program. Describe the resident assignments with respect to their duties and responsibilities in all institutions; include the length of all assignments and the goals and objectives for each assignment. Explain how graded responsibility and continuity of care are implemented. (P.R. V. A., B.)

3. Describe resident responsibility under supervision for total patient care, including admission, initial evaluation, diagnosis, selection of therapy and management of complications. Include with this description resident responsibility for continuity of care with private/non-private patients; night/week-end duty; and long-term care. (P.R. V. F.)

4. Describe the program policy regarding supervision. (P.R. V. D.)

5. Attach the program policies and procedures for resident duty hours. (P.R. V. D.)

6. Are medical students assigned as clinical clerks to the urology service? YES ( ) NO ( )

If yes, how many and how often are they assigned?

Do residents teach these students? YES ( ) NO ( )

If so, describe the responsibilities.

7. Describe in 2 or 3 sentences the responsibilities of each faculty member listed in Section 4.A. Specifically describe how the domains of Urology are covered by these faculty. (P.R. IV. C.).

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SECTION 10. BLOCK DIAGRAM OF UROLOGY PROGRAM (P.R. V. B. 1, 2)

Complete the block diagram below outlining the typical resident assignment (for one resident only) in your program. Supply this information for the urology years only. Do NOT include the pre-urology years. For each assignment indicate: a. The type of experience: e.g., inpatient private service, inpatient non-private service, outpatient research, etc. b. The name of the institution(s) used for each experience.

EXAMPLE:

6 Months 3 Months 3 Months

URO-1 Non-Private (University)OP (University)Specialties IP (VA)

Private Service (St. Mary’s)

BLOCK DIAGRAM OF THE PROGRAM FOR THE UROLOGY YEARS ONLY:

URO-1

URO-2

URO-3

URO-4

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SECTION 11. CONFERENCES (P.R. V. E.)

1. Regularly Scheduled Conferences For the previous 12 months, list the conferences, rounds, combined mortality and morbidity conference for all participating hospitals, urological radiology, urologic pathology, journal review, etc. Identify the institution by NAME. For each conference indicate whether attendance is: O=Optional, R=Required. Under "Frequency" identify how often the conference is offered. Under "Conference Leader" identify the person(s) by title.

Conference Name of Institution R or O Frequency Conference Leader

2. Additional Conferences Held: For the previous 12 months, list the additional conference. Identify the institution by NAME. For each conference indicate whether attendance is: O=Optional, R=Required. Under "Frequency" identify how often the conference is offered. Under "Conference Leader" identify the person(s) by title.

Conference Name of Institution R or O Frequency Conference Leader

3. Insert a narrative describing the conferences. Include the general organization and structure of the conferences and the responsibility of the residents and faculty in preparing and presenting conferences.

4. For the site visit have a documents related to conferences: list of guest speakers, or similar material pertinent to the organization of the conferences.

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SECTION 12. CLINICS (P.R. V. F.)

Attach a brief description of each clinics used in the urology educational program. Provide the following information:

1. What is the general organization of the clinic? What radiologic, cystoscopic, and other special facilities are available?

2. What are the resident objectives for participation in this clinic?

3. How are the residents supervised? Are all residents supervised at all times? (P.R. V. D. 4)

4. Is there opportunity for following inpatients? If so, how is this accomplished?

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SECTION 13. SCHOLARLY ACTIVITY (P.R. V. C.)

Answer each of the following questions for every institution providing research experience for the urology residency program.

Institution:

1. Are laboratories for research available for the Department of Urology? YES ( ) NO ( )

If yes, describe briefly the research space and important special research facilities in use. Do not list all the items of equipment.

2. Attach a list of all clinical and basic research projects conducted by urology faculty and indicate in which ones the urology residents participate.

3. Attach a list of the past three years’ publications for the urology faculty and residents. Provide no more than a maximum of 25 publications for the whole group that reflects the interests and activities of the faculty and residents. UNDERLINE the names of all residents so that the Committee can evaluate resident involvement in faculty research (Do not submit reprints).

4. How does the program provide residents with exposure to research sufficient to result in an understanding of the basic principles of study design, performance, analysis, and reporting?

5. Describe resident participation in educational meetings outside the program, i.e., attendance at meetings and conferences, visits by external authorities, and presentations at scientific meetings.

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SECTION 14. EVALUATION (P.R. VI)

Attach a brief description of internal evaluations in the urology educational program. Provide the following information:

1. Explain how the resident semiannual evaluations are conducted. Include a description of the specific performance measures used. Attach a copy of the blank form as supplementary information.

Explain how the evaluation affects the resident progression in the program

Explain how the program certifies that residents who completed the program are competent to practice independently. (P.R. VI. A.)

2. Describe the procedure for evaluation of the faculty by the program director and the residents.

How are residents ensured confidentiality in the process? (P.R. VI. B.)

3. Describe the procedure for annual program evaluation.

How are residents ensured confidentiality in the process? (P.R. VI. C.)

4. How has the program used the results of the resident and faculty evaluations of the program to improve the program’s educational effectiveness? (P.R. VI. C.)

5. What is the institutional policy and procedure for internal review of the program? What is the date of the last review?

How has the program used the results of this internal evaluation to strengthen the program? (P.R. VI. C)

6. How has the program used the results of the American Board of Urology Qualifying and Certifying Examinations to modify and improve the educational program? (P.R. VI. C. 3)

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SECTION 15. INSTRUCTIONS FOR COMPLETION OF UROLOGY SURGICAL OPERATIVE LOG FORMS

A. Resident and Program Director Responsibilities:

At the conclusion of urology residency program, each chief resident must provide the Program Director with the SIGNED surgical log documenting his/her 36 or 48 months of clinical urology operative experience. It is the resident's responsibility to keep copies of dictated operating room reports on all cases in which he/she is listed as the responsible surgeon. The operative log submitted to the RRC must be countersigned by the Program Director who will attest to the accuracy of the data submitted. Logs without BOTH the resident and Program Director signatures will be returned.

B. Frequently asked questions:

1. Can a resident obtain credit as surgeon for more than one operation when performing a surgical procedure?

In most cases the answer is no. For example, the resident who performs a radical nephrectomy cannot take credit for a nephrectomy, adrenalectomy, and retroperitoneal lymphadenectomy. However, there are some multi-component operations that incorporate individual procedures that are commonly performed as individual operations, i.e. pelvic lymphadenectomy. In certain cases credit for more than one procedure can be obtained.

Approved Examples of Exceptions:

Operations Report

Radical Retropubic Prostatectomy 1 Radical prostatectomy and

1 Pelvic lymphadenectomy

Radical Cystectomy with urinary continent diversion or reconstruction

1 Radical cystectomy and

1 Pelvic lymphadenectomy

and either: a.) conduit, ileal or colonic;

b.) any continent cutaneous diversion

c.) orthotopic neobladder, any type

Urinary Diversion with Transureteroureterostomy 1 Transureteroureterostomy and

1 Ureteroneocystostomy with bladder flap

2. Can two residents obtain credit as surgeon during one operation?

Yes, in certain circumstances. When one resident is performing a radical prostatectomy, he can permit another resident to make the incision and perform the pelvic lymphadenectomy before performing the radical prostatectomy. In this case, one resident is the assistant on the lymphadenectomy and the surgeon on the prostatectomy, and the other resident is the surgeon on the lymphadenectomy and the assistant on the prostatectomy.

In cases where a bilateral operation is performed, two residents can obtain credit for unilateral procedures, e.g. bilateral orchiopexy, adrenalectomy, simple nephrectomy, ureteral re-implantation.

3. What is the definition of surgeon and assistant?

The resident who performs 50% or more of a case is considered the surgeon. Assistant refers only to first assistant.

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RESIDENCY REVIEW COMMITTEE FOR UROLOGY

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