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NEUROCRITICAL CARE PROGRAM ACCREDITATION APPLICATION PROGRAM INFORMATION FORM (PIF) FOR NEW APPLICATIONS ONLY Revised: 12/16/13 A. INTRODUCTION The mission of the United Council for Neurologic Subspecialties (UCNS) is to provide an accreditation and certification process for fellowship training programs with the goals of enhancing quality training in Neurologic subspecialties and quality patient care. The Accreditation Council (AC) strives to develop evaluation methods and processes that are valid, effective, fair, open and ethical. The AC is a voluntary accreditation organization and functions as a council of the UCNS. To be an accredited program by the UCNS, compliance with the program requirements is monitored through completion of the Program Information Form (PIF). In creating this form, the AC has referenced the model used by the Accreditation Council for Graduate Medical Education (ACGME). B. INSTRUCTIONS APPLICATION FOR NEW PROGRAM: This form is for use by programs making initial application only. All programs, new and existing, must complete the entire Program Information Form. For new training programs where statistical data are not available, e.g., number of graduates, you should mark that section as “NA” (not applicable). The PIF and Appendix A-G template should be downloaded and completed off- line. The PIF question fields should not be altered. The space in text and tables for responses will expand to accommodate your program’s needs. The page numbers will automatically reformat. Once it is completed, submit the PIF form and Appendices A-G document electronically via e-mail to the UCNS at [email protected] . The UCNS will send a confirmation acknowledging receipt of the application. Should you require additional space in specific fields, please e-mail the UCNS. UCNS Program Accreditation Application Page 1 of 34 Neurocritical Care 2009

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NEUROCRITICAL CAREPROGRAM ACCREDITATION APPLICATION

PROGRAM INFORMATION FORM (PIF)FOR NEW APPLICATIONS ONLY

Revised: 12/16/13

A. INTRODUCTION

The mission of the United Council for Neurologic Subspecialties (UCNS) is to provide an accreditation and certification process for fellowship training programs with the goals of enhancing quality training in Neurologic subspecialties and quality patient care. The Accreditation Council (AC) strives to develop evaluation methods and processes that are valid, effective, fair, open and ethical. The AC is a voluntary accreditation organization and functions as a council of the UCNS. To be an accredited program by the UCNS, compliance with the program requirements is monitored through completion of the Program Information Form (PIF). In creating this form, the AC has referenced the model used by the Accreditation Council for Graduate Medical Education (ACGME).

B. INSTRUCTIONS

APPLICATION FOR NEW PROGRAM: This form is for use by programs making initial application only.

All programs, new and existing, must complete the entire Program Information Form.

For new training programs where statistical data are not available, e.g., number of graduates, you should mark that section as “NA” (not applicable).

The PIF and Appendix A-G template should be downloaded and completed off-line. The PIF question fields should not be altered. The space in text and tables for responses will expand to accommodate your program’s needs. The page numbers will automatically reformat. Once it is completed, submit the PIF form and Appendices A-G document electronically via e-mail to the UCNS at [email protected]. The UCNS will send a confirmation acknowledging receipt of the application. Should you require additional space in specific fields, please e-mail the UCNS. The Program Director is responsible for the content of the completed form, and the information will not be considered complete without the Program Director’s signature. All sections of the form applicable to the program must be completed in order to be accepted for review. If any requested information is not available, an explanation should be given in the appropriate place on the form.

Many items require a composed response to a specific question. Please respond briefly and concisely.

The form also includes requests for the following additional data. Please use the Appendix A-G template to provide this information.

Appendix A: participating institution letter(s) from Department Chair(s) of the participating institution(s) (not the full affiliation agreement; not Program Letter of Agreement)

Appendix B: one page curriculum vitae (Program Director and faculty)

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Appendix C: list of clinical conferences at each institution; list of clinical lectures, conferences, courses in other areas; list of other lectures

Appendix D: list of neurocritical care meetings attended by fellowsAppendix E: list of research projects by fellowsAppendix F: list of publications by fellowsAppendix G: evaluation form samples

Please do not attach any unnecessary materials such as reprints, brochures, annual reports, schedules, minutes of meetings and conferences, etc. The UCNS considers only the information requested on the PIF form and provided in the appendices. Any extra material not requested will be discarded. C. APPLICATION FEE

The UCNS has two program application categories: New Applicant and Continuing Applicant. You are applying for program accreditation as a New Applicant.

New Applicant $3,500 Application Fee ($1,500 first-year accreditation fee + $2,000 non-refundable application fee)

The accreditation year is the academic year, July 1 through June 30. An annual accreditation fee will be assessed at $1,500. Fees are subject to change.

D. PAYMENT

The UCNS accepts checks (or money orders) only at this time. Please submit payment in US funds (payable to United Council for Neurologic Subspecialties) to the UCNS Executive Office, 201 Chicago Avenue, Minneapolis, MN 55415.

E. APPLICATION DEADLINE

The UCNS accepts applications throughout the year and reviews applications twice per year, in the spring and fall. Your application must be submitted and payment received by December 1 for spring review and June 1 for fall review.

F. PROGRAM SITE REVIEW

A site review of the program will not normally be required for the first application of programs.  Should the UCNS determine that a site visit is necessary, you will be notified and provided additional information.

G. QUESTIONS

Contact the UCNS with questions: UCNS, 201 Chicago Avenue, Minneapolis, MN 55415 Tel: 612-928-6399 Fax: 612-454-2750 E-mail: [email protected]. H. GLOSSARY OF TERMS

A glossary of terms used in the Program Requirements and PIF can be found on the UCNS website at www.ucns.org.

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I. TABLE OF CONTENTS

Section 11 Program Information

1.A Program Identification1.B Program Director Information2 Institutional Affiliates3 Fellow Information

3.A Number of Positions3.B Actively Enrolled Fellows3.C Aggregate Data on Fellows Completing or Leaving the Program for the Last Three (3) Years3.D Fellows Completing the Program in the Last Three Years4 Faculty and Personnel

4.A Program Director4.B Required Faculty4.C Other Teaching Faculty5 Facilities and Resources

5.A Facilities5.B Library Facilities6 Educational Program

6.A Curriculum6.B Seminars and Conferences6.C Educational Program6.D Program Policies7 Research and Scholarly Activity

7.A Fellow Meeting Attendance7.B List of Research Projects by Fellows7.C List of Publications by Fellows7.D Scholarly Activity Summary8 Evaluation

8.A Fellow Evaluation8.B Faculty Evaluation8.C Program Evaluation8.D Curriculum Development8.E Curriculum Evaluation9 Signatures

Appendix A: participating institution letter(s) from department chair(s) of participating institution(s) (not the full affiliation agreement; not Program Letter of Agreement)

Appendix B: one page curricula vitae (Program Director and faculty)Appendix C: list of clinical conferences at each institution; list of clinical lectures, conferences,

courses in other areas; list of other lecturesAppendix D: list of Neurocritical Care meetings attended by fellowsAppendix E: list of research projects by fellowsAppendix F: list of publications by fellowsAppendix G: evaluation form samples

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PROGRAM INFORMATION FORM (PIF)

SECTION 1. PROGRAM INFORMATION

A. Program Identification

Date:      Name of Primary Institution:      Title of Program:      Does your program currently have fellows? Yes NoIf yes, how many fellows do you have each year?      How many years is the fellowship?      10 Digit UCNS Program ID# (for office use only):      

B. Program Director (PD) Information

Name:      Title:      Address:      City, State, Zip code:      Telephone:       FAX:       Email:      Date PD First Appointed:      Term of PD Appointment:      Primary Specialty Board Certification:       Most Recent Certification Date:      Secondary Specialty Board Certification:       Most Recent Certification Date:      Number of years spent teaching in GME in this subspecialty:      Is the Program Director a full-time staff member of the sponsoring institution? YES NODoes the Program Director hold a current license to practice medicine in the state of the sponsoring institution? YES NO

Is the Program Director ABMS or RCPSC certified? YES NOIs the Program Director UCNS certified in NCC? YES NOPD based at primary teaching institution? YES NONumber of hours per week PD spends in: (Do NOT use percentages)Clinical Supervision:       Administration:       Research:       Didactics/Teaching:      

Is PD also Department Chair? YES NOIf No, Chair Name:      

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SECTION 2. INSTITUTIONAL AFFILIATES (Program Requirements II, A, B)

SPONSORING INSTITUTION: (Institution #1) (The university, hospital, or foundation that has ultimate responsibility for this program and must meet the current ACGME Institutional Requirements.)Name of Sponsor:      Address:       Sponsoring Core Residency Program?

YES NOCity, State, Zip code:      Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School):      Ownership Type: (e.g., State, Corporation, Church):      Is Institution ACGME Accredited YES NO Length of Accreditation:       Next review date:      Name of DIO (Designated Institutional Official) Responsible for Oversight of Training at this Institution:      Does SPONSOR have an affiliation with a medical school (could be the sponsoring institution)? YES NO

If yes, name the medical school below.Name of Medical School #1:      Name of Medical School #2:      

PRIMARY INSTITUTION (Institution #2) If different than the sponsoring institution.Name:      Address:      City, State, Zip Code:      Name of Individual Responsible for Oversight of Training at This Institution:      Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School):      

PARTICIPATING INSTITUTION (Institution #3) If more than one participating institution, e-mail [email protected]:      Address:      City, State, Zip Code:      Distance between Institutions 1 & 2:

Miles:       Minutes:      

Type of Rotation (select one) Elective Required Both

Length of Fellows Rotation (in months) Year 1:       Year 2:      

Name of Individual Responsible for Oversight of Training at This Institution:      Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School):      Brief Educational Rationale for Use of This Institution:      

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RELATED CORE PROGRAM IN NEUROLOGYName of Institution or Hospital:      Address:      City, State, Zip Code:      Website Address:      Date Program Approved for Accreditation:      Next Review Date:      Name of Program Director:      Total Number of Faculty:      

SECTION 3. FELLOW INFORMATION

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

Positions Year 1 Year 2 TotalNumber of Requested Positions                  Number of Filled Positions*                  

*For established programs without currently active fellows, complete table with 0 and indicate here when last fellow finished:For programs that have never had fellows, complete table with “NA”.

Note: The total number of fellows should not exceed the 1:1 faculty to fellow ratio for the fellowship program. Faculty included in determining the ratio are those listed in section 4.B. See Program Requirements IV.

B. Actively Enrolled Fellows (if applicable) (Program Requirements III)

1. List all fellows actively enrolled in this program as of August 31 of current academic year (see Section 3.A). List names alphabetically. Indicate fellows accepted as transfer with an asterisk (*).

YEAR ONE

Name Medical School Prior GME training program

ABPN/RCPSC eligible or Certified?

                  YES NO                  YES NO                  YES NO                  YES NO                  YES NO                  YES NO

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YEAR TWO

Name Medical School Prior GME training program

ABPN/RCPSC eligible or Certified?

                  YES NO                  YES NO                  YES NO                  YES NO                  YES NO                  YES NO

2. Are you planning to train non-ACGME or non-RCPSC trained fellows? If yes, be aware that non-UCNS certifiable trainees must be included in the faculty to fellow ratio. What effect will this have on your faculty to fellow ratio?     

C. Aggregate Data on Fellows 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                  Number of Fellows Who Withdrew from the Program*                  Number of Fellows Who Transferred Out of the Program                  Number of Fellows on Leave of Absence from the Program                  

Number of Fellows Dismissed from the Program                   *Please provide reason(s) for fellows who left the program in the last three years (e.g., withdrawn, transferred, leave of absence, or dismissed).

     

D. Fellows Completing Program in the Last Three Years (if applicable). List all fellows who have completed all training for this subspecialty based on the last academic year ending June 30,     .

Name Start Date Actual Date of Completion

Practice Position

ABPN Certified?

UCNS Certified?

                        YES NO YES NO                        YES NO YES NO                        YES NO YES NO

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List fellows who have completed all training for this subspecialty based on the academic year ending June 30,     .

Name Start Date Actual Date of Completion

Practice Position

ABPN Certified?

UCNS Certified?

                        YES NO YES NO                        YES NO YES NO                        YES NO YES NO

List fellows who have completed all training for this subspecialty based on the academic year ending June 30,     .

Name Start Date Actual Date of Completion

Practice Position

ABPN Certified?

UCNS Certified?

                        YES NO YES NO                        YES NO YES NO                        YES NO YES NO

SECTION 4. FACULTY AND PERSONNEL

A. Program Director (Program Requirements IV, A, B)

1. Describe the Program Director’s qualifications in Neurocritical Care

Indicate appropriate qualifications, including a description of the Program Director’s clinical on-service time in an ICU environment. This should include the number of years of experience in caring for a neurocritical care patient population, the average number of weeks on-service per year, the average number of patients seen per day, how the ICU team is organized (i.e. residents, NPs, nurses, pharmacists), and a description of how evening and weekend coverage is arranged.

     

2. List the Program Director’s educational experience and abilities

Examples should be submitted documenting the Program Director’s prior and ongoing experience teaching, lecturing, or writing on topics related to neurocritical care as well as experience in administration of educational programs.

     

3. List the Program Director’s CME activities related to neurocritical care or critical care medicine in general in past three years

     

4. Give a brief description of the Program Director’s responsibilities and activities. Attach one page curriculum vitae (Appendix B) for the Program Director (use Appendix B form). CVs using the NIH Biographical Sketch format will NOT be accepted.

     

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B. Program Teaching Staff—Neurocritical Care (Program Requirements IV, C, D, E, F)

List all members of the program responsible for training in the ICU setting. Program teaching staff refers to faculty intensivists who supervise fellows in the daily practice of neurocritical care. For those with dual appointments, identify primary appointment (neurology or other department) in parentheses.

Note: These faculty members count toward the program’s faculty to fellow ratio. See Section 2 for institution numbers.

Name, Degree, Title and Position

Privileges at Institution

#1,2,3,4Full-Time

If Part-time, StateNCC CertificationWks/

YrHrs/Wk

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

Attach a one page curriculum vitae (Appendix B) for each of the faculty listed above (use Appendix B form). CVs using the NIH format Biographical Sketch format will NOT be accepted.

If additional rows are needed to list more than 11 faculty, please e-mail [email protected].

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C. Other Teaching Staff

List other teaching staff (non-intensivists) regularly involved in teaching fellows, including consultants and basic science faculty. Examples of other teaching staff may include neurosurgeons or anesthesiologists who train fellows for specific procedural competencies, or neurological subspecialists (i.e., stroke, epilepsy, or neuromuscular diseases) who provide training for specific aspects of the Neurocritical Care Core Curriculum. Note their department, title and certifying credentials, and supervisory responsibilities to the program.

See Section 2 for institution numbers.

Name, Degree, Title and Position

Privileges at Institution

#1,2,3,4Full-Time

If Part-time, StateNCC CertificationWks/

YrHrs/Wk

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

            YES NO             UCNS Certified UCNS Eligible

Role in Curriculum:      

Attach a one page curriculum vitae (Appendix B) for each of the faculty listed above (use Appendix B form). CVs using the NIH format Biographical Sketch format will NOT be accepted.

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SECTION 5. FACILITIES AND RESOURCES (Program Requirements V, G)

A. Facilities

1. Facilities and resources for training

See Section 2 for institution numbers.Are the following office space and resources available?

Faculty and Resources Inst1

Inst2

Inst3

Inst4

a. Neurocritical Care Faculty Offices and Facilities YES NO

YES NO

YES NO

YES NO

Is there administrative support for the Fellowship & Program Director?

YES NO

YES NO

YES NO

YES NO

b. Fellow Offices and Resources

Does each fellow have his/her own office? YES NO

YES NO

YES NO

YES NO

Are the offices for groups of fellows? YES NO

YES NO

YES NO

YES NO

Is there dedicated administrative support for fellows? YES NO

YES NO

YES NO

YES NO

Does the fellow have access to other office equipment such as copiers, slide projectors, PowerPoint, video projector equipment or technology services for slide presentations, illustration services?

YES NO

YES NO

YES NO

YES NO

c. Dedicated Neuro-ICU Facilities YES NO

YES NO

YES NO

YES NO

d. General Medical-Surgical ICU Facilities YES NO

YES NO

YES NO

YES NO

e. Emergency Room Facilities YES NO

YES NO

YES NO

YES NO

f. TCD/Doppler Laboratory YES NO

YES NO

YES NO

YES NO

g. 24-Hour CT YES NO

YES NO

YES NO

YES NO

h. MRI Scanner YES NO

YES NO

YES NO

YES NO

i. Parenchymal ICP Monitors YES NO

YES NO

YES NO

YES NO

j. Continuous EEG monitoring YES NO

YES NO

YES NO

YES NO

2. Briefly describe conference facilities at each institution that will be used for Neurocritical Care conferences.

     

3. Briefly describe the space provided for Neurocritical Care program faculty and fellow research at each institution. (Program Requirements V, F)

     

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B. Library Facilities

Use the table below to describe the institutional and departmental library holdings and other reference resources at each institution.

See Section 2 for institution numbers.Are the following facilities and resources available?

Library Facilities Inst1

Inst2

Inst3

Inst4

a. Journals

Access to Medline YES NO

YES NO

YES NO

YES NO

b. Computer databases available YES NO

YES NO

YES NO

YES NO

Access in hospital YES NO

YES NO

YES NO

YES NO

Access in library YES NO

YES NO

YES NO

YES NO

24 hour access YES NO

YES NO

YES NO

YES NO

Access to major texts and full text journals YES NO

YES NO

YES NO

YES NO

Internet search capabilities YES NO

YES NO

YES NO

YES NO

c. Library available on site YES NO

YES NO

YES NO

YES NO

Library with major texts in all areas of medicine on site or nearby

YES NO

YES NO

YES NO

YES NO

Interlibrary loan capability YES NO

YES NO

YES NO

YES NO

Textbook availability YES NO

YES NO

YES NO

YES NO

Major Neurocritical Care texts on wards YES NO

YES NO

YES NO

YES NO

Major Neurocritical Care texts in clinic YES NO

YES NO

YES NO

YES NO

Teleconference capability YES NO

YES NO

YES NO

YES NO

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SECTION 6. EDUCATIONAL PROGRAM

A. Curriculum

1. Please provide a detailed narrative overview of this training program. Include a discussion of strengths and challenges.     

2. Rotationsa. List required rotations:

     

b. List elective rotations:     

3. Please provide a description of the program’s overall goals and objectives as well as goals and objectives for each rotation and curricular element (i.e. both block and longitudinal activities)

     

4. Graphic display of curriculum:

Describe in block form the typical curriculum for fellows by months (or four-week stints), not weeks, including the institution (#1, 2, 3, 4) as listed in Section 2. If you require an extended table, please email your request to [email protected].

Curricular components may be offered in blocks or longitudinally. An example of the latter is a regularly scheduled clinic attended over a period of time while assigned to other rotations. Those components offered in block assignments each year should be recorded in the block template. Those clinical experiences offered longitudinally should be recorded separately in the longitudinal templates by year. You should not include conferences, lectures or other didactic experiences in the longitudinal template.

Have these goals and objectives been provided to the fellows? YES NO

BLOCK ROTATIONS –YEAR 1 July August September October November December January February March April May June                                                                       

LONGITUDINAL EXPERIENCES - YEAR 1Type Of Experience Time Commitment/Weekly Structured Number Of Weeks/Year Amount Of Time in Months (e.g. 40 Half Days=1 Month)                                                                     

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BLOCK ROTATIONS –YEAR 2July August September October November December January February March April May June                                                                       

LONGITUDINAL EXPERIENCES - YEAR 2Type Of Experience Time Commitment/Weekly Structured Number Of Weeks/Year Amount Of Time in Months (e.g. 40 Half Days=1 Month)                                                                     

B. Seminars and Conferences (Program Requirements V, C)

1. Attach a schedule of clinical conferences for fellows in each institution (Appendix C). Name the faculty member assigned to each conference. Indicate which conferences are mandatory for fellows.

2. Attach a list of the courses, conferences and/or lectures given in each of the other areas required in the program (Appendix C).

3. Attach a list of lectures not already supplied, such as lectures by visiting neuroscientists (Appendix C).

4. Is there a journal club? YES NO

Specify attendance by fellow and faculty, the frequency of meeting, and the organization of the club. If there is no journal club, what substitutes for it?     

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C. Educational Program

1. What teaching responsibilities do fellows have?

     

2. Describe the organizational features of the ICU itself, including whether the practice environment is a dedicated neurological or multi-specialty unit, whether the admission and coverage model is open or closed, a description of the patient population that is cared for (i.e. stroke, trauma), and the role of consulting services from other specialties.

     

3. Describe how the program has integrated the six Accreditation Council for Graduate Medical Education (ACGME) core competencies (www.acgme.org) listed below into the didactic and clinical curriculum. Describe the method(s) used to evaluate fellow performance in each area (e.g. fellow, director, and faculty evaluation also known as 360 degree evaluation; patient surveys; portfolios; record review; simulations; standardized oral exams; standardized patients; written examinations; etc.)

a. Patient care

     

b. Medical knowledge

     

c. Practice-based learning and improvement

     

d. Interpersonal and communication skills

     

e. Professionalism

     

f. Systems-based practice

     

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4. Clinical Components (Program Requirements V, D)How are experiences structured? Provide the amount of time required.

TYPE OF EXPERIENCE LOCATION INTHE PROGRAM

AMOUNT OF TIME

ICU (primary team)            ICU (consultative)            Inpatient step-down or intermediate care unit (primary team)            Inpatient floor service (primary team)            Inpatient consultation (including rapid response teams)            Emergency room experiences            Operating room or post-anesthesia recovery room            Outpatient clinic            Other            

Tally block rotations by months (or 4 week blocks, if applicable) without subtracting imbedded longitudinal experiences. Count longitudinal experiences by converting to months (see above). Grand total may exceed 12 months.

5. Identify for each fellow if he/she has provider and/or instructor status for each of the certifications listed.

FELLOW TYPE OF SUPPORT* PROVIDER INSTRUCTOR      ACLS

ATLS PALS FCCS

YES NO YES NO YES NO YES NO

YES NO YES NO YES NO YES NO

      ACLS ATLS PALS FCCS

YES NO YES NO YES NO YES NO

YES NO YES NO YES NO YES NO

      ACLS ATLS PALS FCCS

YES NO YES NO YES NO YES NO

YES NO YES NO YES NO YES NO

      ACLS ATLS PALS FCCS

YES NO YES NO YES NO YES NO

YES NO YES NO YES NO YES NO

      ACLS ATLS PALS FCCS

YES NO YES NO YES NO YES NO

YES NO YES NO YES NO YES NO

      ACLS ATLS PALS FCCS

YES NO YES NO YES NO YES NO

YES NO YES NO YES NO YES NO

      ACLS ATLS PALS FCCS

YES NO YES NO YES NO YES NO

YES NO YES NO YES NO YES NO

* Advanced Cardiac Life Support (ACLS), Advanced Trauma Life Support (ATLS), Pediatric Advanced Life Support (PALS), Fundamental Critical Care Support (FCCS)

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6. Document how fellows are provided with direct experience in progressive responsibility for patient management.

     

7. Describe the criteria established to evaluate and document procedural competencies (i.e., both basic and advanced critical care and neurological interventions). This should include (but is not limited to) how this training is conducted, the minimum number of directly-observed procedures before a trainee can operate independently, and mentor sign-off procedures.

     

8. Core Content

Document how the program addresses the following areas of study. Please refer to the Core Curriculum for Neurocritical Care document for details regarding the content of each section. Educational methods may include didactic teaching sessions, small group seminars, assigned reading, journal clubs, attendance at weekly conferences, bedside teaching, rotations through other subspecialty ICUs, attendance at national meetings and CME events, and other approaches. Please describe how fund of knowledge and competence with procedures are evaluated throughout the course of training.

a. Neurological disease states: pathology, pathophysiology, and therapy

     

b. General medical disease states: pathology, pathophysiology, and therapy

     

c. General aspects of critical care (i.e. administration and management principles, ethical and legal aspects of critical care medicine, fundamentals of research methodology)

     

d. Procedural competencies (please include policies for bedside teaching, number of observed procedures required, and mechanism for faculty sign-off)

     

D. Program Policies (Program Requirements V, F)

1. Describe the Program Director’s supervision of fellows in each clinical setting.     

2. Describe how compliance with ACGME duty hours is maintained (www.acgme.org). Please submit a copy of the policy on duty hours and a call schedule.     

3. What policies are in place for responding to impaired fellows?     

4. How does the program monitor fellow stress and provide counseling or support services to fellows?     

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SECTION 7. RESEARCH AND SCHOLARLY ACTIVITY

A. Fellow Meeting AttendanceComment on how many and how often fellows attend local, regional, and national Neurocritical Care meetings. You should provide a list of meetings that fellows have attended over the past three years, showing the fellows by name, as Appendix D.

B. List of Research Projects by FellowsList the research projects by fellows from the section/division during the past 3 years as Appendix E.

C. List of Publications by FellowsList the publications by fellows from the section/division during the past 3 years as Appendix F. (not manuscripts submitted or in preparation)

D. Scholarly Activity (if applicable)

Based on Academic Year Ending June 30,     . June 30,     . June 30,     .Number of Nationally Peer-Reviewed Published Articles Authored or Co-Authored by Fellows during the Year                  

Number of Fellow Presentations at Regional or National Meetings in the Year                  

SECTION 8. EVALUATION (Program Requirements VI, A)

A. Fellow Evaluation

1. Describe the methods & frequency for fellow evaluation used in the program.     

2. Fellow Feedback and Records: Describe how and by whom feedback to fellows is provided and what remedial actions are taken in cases of deficiency. What kind of records of fellow evaluations does the program maintain?     

3. Final Evaluation: Please provide a copy of a final evaluation used for fellows who complete the program.      

B. Faculty Evaluation (Program Requirements VI, B)Describe how the Program Director evaluates faculty. How often? Are written evaluates by fellows incorporated into the process?

     

C. Program Evaluation (Program Requirements VI, C)Describe the system by which the program is evaluated. Are written evaluations by the fellows utilized?

     

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D. Curriculum Development

1. Describe how written evaluations by fellows are used in the curriculum development process.      

2. Describe the participation by fellows in the curriculum development and evaluation process.     

3. Describe the process by which the training program goals and objectives are developed, who participates, and how often they are revised.      

E. Curriculum Evaluation

1. Describe the criteria used in assessing the extent to which goals and objectives are met.

     

2. Explain how often the goals and objectives are reviewed and how they are evaluated.

     

3. Describe how the performance by graduates on the certifying examinations is used to evaluate the effectiveness of the program and to modify the goals and objectives?

     

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SECTION 9. SIGNATURES

If this form was completed by the Program Coordinator, please provide the following information:

Program Coordinator Name:      

Telephone Number:       E-mail:     

The signatures below attest to the completeness and accuracy of the information provided. Please insert an electronic signature, or sign and fax this page to the UCNS Executive Office at 612-454-2750.Insertion of an electronic signature:

By typing your name in the space provided, you are submitting the electronic equivalent of a legal signature. You are also asserting that you completed the application. To verify the contents of the application, the signatory must enter his/her name in the space provided Acceptable “signatures” should be preceded and followed by the forward slash (/) symbol. Acceptable “signature” should be as follows: /John Doe/.

Neurocritical Care Program Director

Name:      

Signature:       Date:      

Department Chair

Name:      

Signature:       Date:      

Please use the Appendices A-G template for submitting Appendices A-G.

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