Docstoc

THE RESIDENCY REVIEW COMMITTEE FOR PATHOLOGY

Document Sample
THE RESIDENCY REVIEW COMMITTEE FOR PATHOLOGY Powered By Docstoc
					RESIDENCY REVIEW COMMITTEE FOR PATHOLOGY
(Anatomic and/or Clinical Pathology and Selective Pathology) 515 N State, Ste 2000, Chicago, IL 60610  312-755-5025  www.acgme.org

PROGRAM INFORMATION FORM (PIF) FOR CONTINUED ACCREDITATION
GENERAL INSTRUCTIONS
REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: Use the Continued Accreditation PIF in conjunction with the Web Accreditation Data System (Web ADS) to create the correct PIF. Use the Continued Accreditation PIF in conjunction with the Web Accreditation Data System (Web ADS) 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 Designated Institutional Official (DIO) for the entry of updated information. Next proceed to the section under the RRC for Pathology to retrieve Part 2 of the PIF for continued accreditation 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). Mail one set of the forms to the site visitor at least 10 working days before the site visit. An additional copy should be held to permit corrections that may be required as the site visit proceeds. After the visit, three copies must be mailed to the Executive Director at the above address. The Institutional Requirements, the Program Requirements, and the PIF may be downloaded from the ACGME Website (www.acgme.org). Before completing the accompanying form, please review the Program Requirements for Residency Education in Pathology. For questions regarding the completion of the form (content), contact the Accreditation Administrator (Phone: 312-7555026). For word processing questions/problems, contact the ACGME Help Desk (Phone: 312-755-7464). For questions regarding the Web Accreditation Data System questions, contact 312-755-7123 to be directed to an ADS representative or email WebADS@acgme.org. For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp Residency programs are evaluated by the Residency Review committee (RRC) for Pathology, whose members are appointed by the American Board of Pathology and the American Medical Association. In Part 1, Section 4.A, list the physicians, scientists, etc. who supervise the work of pathology residents and contribute to their instruction. Order by institution. In addition, supply in Section 4.B an abbreviated, one page CV for each listed faculty. Programs seeking continued accreditation must use the accreditation data system to enter these data. The information will automatically appear in Part 1 of the PIF.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

i

RESIDENCY REVIEW COMMITTEE FOR PATHOLOGY
(Anatomic and/or Clinical Pathology and Selective Pathology) 515 N State, Ste 2000, Chicago, IL 60610  312-755-5025  www.acgme.org

PROGRAM INFORMATION FORM (PIF)
10 Digit ACGME Program I.D. #: (for continued accreditation) Program Name:

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 General Program Information Accreditation Information Program Director Information Participating Institutions Resident Complement Number of Positions Actively Enrolled Residents Aggregate Data on Residents Completing or Leaving the Program for the Last Three (3) Years Residents Who Completed the Program Withdrawn / Dismissed Residents Scholarly Activity Duty Hours Faculty / Teaching Staff Faculty Roster Faculty Curriculum Vitae Part 2 Background Information Sponsoring Institution/Single or Limited Residency Institution General Competencies Institutional Information Hospital Data Participation in Other Residencies Pathology Space Pathology Equipment/Facilities General Information General Anatomic Pathology Information Autopsy Pathology, Including Forensic Pathology Cytopathology Surgical Pathology General Clinical Pathology Blood Banking/Transfusion Medicine Medical Microbiology Section 1 1.A 1.B 2 3 3.A 3.B 3.C 3.D 3.E 3.F 3.G 4 4.A 4.B Section 5 5.A 5.B 6 6.A 6.B 6.C 6.D 7 8 8.A 8.B 8.C 9 9.A 9.B Page(s) Page(s)

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

Part 2 Chemical Pathology Hematology & Coagulation Cytogenetics Flow Cytometry/Immunology/Serology Urinalysis and Medical Microscopy Molecular Pathology Laboratory Management and Information System Resident Research Resident Certification Evaluation of Residents Evaluation of the Program Educational Experience of Residents Program Conferences Other Physician Trainees Non-Physician Trainees Program Strengths Program Needs Single Site Sponsor Letter of Commitment (if applicable)

Section 9.C 9.D 9.E 9.F 9.G 9.H 10 11 12 13 14 15 16 17 18 19 20 Supplement I

Page(s)

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

RESIDENCY REVIEW COMMITTEE FOR PATHOLOGY
(Anatomic and/or Clinical Pathology and Selective Pathology) 515 N State, Ste 2000, Chicago, IL 60610  312-755-5025  www.acgme.org

PROGRAM INFORMATION FORM (Part 2) FOR CONTINUED ACCREDITATION
SECTION 5. BACKGROUND INFORMATION
A. Sponsoring institution/Single or Limited Residency Institution (See ACGME Institutional Requirements) For those institutions, that are either a single-program institution (e.g., pathology only) or an institution with multiple residencies which are all accredited by the same Residency Review Committee (e.g., pathology and hematology), the institutional review will be conducted in conjunction with the review of the program. Programs in these two categories are to complete the following institutional questions: (See Part 1 Section 2 to determine whether you are a single site sponsor.) 1. Provide an institutional statement that commits the necessary financial, educational and human resources to support the GME program(s) and provide documentation that the statement has been approved by the governing body, the administration and the teaching staff (Supplement I). 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.

2.

3.

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

4.

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

5.

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

B.

General Competencies In 2002, the ACGME began to monitor the implementation of general competencies and assessment for all existing core programs 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 General Competency Addendum to enter your information. Once the information has been entered and saved, select Print PIF Competencies Addendum to generate a printed copy of the General Competencies Addendum and attach it to the end of PIF.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 6. INSTITUTIONAL INFORMATION
Provide the following information for each institution where residents are assigned for required rotations. If more than 4 institutions are involved, follow this same format and insert additional pages as needed. The institutions are previously identified and numbered in Part 1, Section 2. A. Hospital Data Institution 1 Institution 2 Institution 3 Institution 4 Row Total

# of Hospital Beds Total Hospital Admissions # of Clinical Pathology Tests (Billed Procedures) Current Accreditation/Licensure Dates American Association of Blood Banks College of American Pathologists Food & Drug Admin (Blood Bank) JCAHO HHS (CLIA, 1988) Other (State, etc.) B. Does Institution Participate in ACGMEAccredited Residencies below:

Institution 1 YES( ) YES( ) YES( ) YES( ) YES( ) NO( ) NO( ) NO( ) NO( ) NO( )

Institution 2 YES( ) YES( ) YES( ) YES( ) YES( ) NO( ) NO( ) NO( ) NO( ) NO( )

Institution 3 YES( ) YES( ) YES( ) YES( ) YES( ) NO( ) NO( ) NO( ) NO( ) NO( )

Institution 4 YES( ) YES( ) YES( ) YES( ) YES( ) NO( ) NO( ) NO( ) NO( ) NO( )

Internal Medicine Obstetrics/Gynecology General Surgery Pediatrics Radiology C. Pathology Space

Institution 1

Institution 2

Institution 3

Institution 4

Row Total

Square Feet of Diagnostic Lab Space Net Sq Ft Office Space for APCP Residents Pathology Research Space Total Net Square Feet D. Pathology Equipment/Facilities Institution 1 YES( ) YES( ) YES( ) YES( ) YES( ) YES( ) NO( ) NO( ) NO( ) NO( ) NO( ) NO( ) Institution 2 YES( ) NO( ) YES( ) NO( ) YES( ) NO( ) YES( ) NO( ) YES( ) NO( ) YES( ) NO( ) Institution 3 YES( ) YES( ) YES( ) YES( ) YES( ) YES( ) NO( ) NO( ) NO( ) NO( ) NO( ) NO( ) Institution 4 YES( ) YES( ) YES( ) YES( ) YES( ) YES( ) NO( ) NO( ) NO( ) NO( ) NO( ) NO( )

Is a microscope available to each resident? Is a Personal Computer (PC) or individual Personal Digital Assistant (PDA) available to each resident? Is an on-site pathology library accessible to residents at all times? Do residents have access to computer-based literature review services? Are photography facilities available to pathology in the institution? Is a photograph teaching collection maintained for pathology?

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 7. GENERAL INFORMATION
1. Describe the steps that have been taken to address the citations or recommendations by the RRC following the last accreditation review (if applicable). Describe the manner in which residents take call. How is faculty back-up for this experience structured? How are call activities reviewed by faculty and how is feedback given to resident regarding their decisions while on call? How do residents exercise graduated responsibility with regard to call?

2.

3.

Other than on-call responsibilities, do residents have a period of training in which they are responsible for activities in more than one section of the laboratory at a time? If so, please describe this experience.

4.

How are residents involved in hospital and local, regional, and/or national activities related to the practice of pathology? Give specific examples, i.e. list hospital committees on which residents serve, CAP inspections in which residents have participated and the area which they inspected, etc.

5.

How do residents participate in the educational activities of the department (medical students, medical staff, medical technologists and med tech students, cytotechnologists and cytotech students, other residents in pathology, residents in other departments, etc)?

6.

Describe examples of test/instrument evaluation procedures in which residents have participated since your last RRC review.

7.

How are residents instructed in review of the medical literature?

8.

How are residents exposed to testing procedures (concepts and interpretation) which are not performed in the laboratories through which they rotate (i.e. which are sent to reference labs)?

9.

Describe resident experience with statistical concepts used in the evaluation of testing procedures and test results (sensitivity, specificity, predictive value, correlation studies, reference range determination, etc)?

10. How does the program monitor resident stress, including mental or emotional conditions inhibiting performance or learning and drug- or alcohol-related dysfunction? How does the program ensure that residents are given reasonable duty and call assignments? Do all residents spend at least 1 full day out of 7 free of hospital duties? Are residents ever on call more often then every third night?

11. Has the sponsoring institution implemented procedures regarding academic discipline and resident complaints or grievances?

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 8. GENERAL ANATOMIC PATHOLOGY INFORMATION
A. Autopsy Pathology, Including Forensic Pathology 1. Provide the following data for each institution/location (including medical examiners) where residents are assigned for autopsy education (including Forensic experience.) If more than four institutions, follow this format and insert a page. 12-Month period covered by statistics: From: Institution Institutional Autopsy Rate Time to complete provisional anatomic diagnosis last year: Average # of Days Range in Days Time to complete final anatomic diagnosis last year: Average # of Days Range in Days Time to complete neuropathology diagnosis last year: Average # of Days Range in Days Institution 1 Are all autopsies signed out with a YES( ) NO( ) member of the teaching staff? Is there staff supervision of gross & YES( ) NO( ) microscopic descriptions? Average turn-around time for the delivery of slides and protocols to residents: 2. 2 YES( ) YES( ) NO( ) NO( ) YES( ) YES( ) 3 NO( ) NO( ) 4 YES( ) NO( ) YES( ) NO( ) 1 2 To: 3 4

Provide the following information summarizing the resident education in autopsy pathology, including forensic pathology: a. Describe the participation of the resident in autopsy pathology in: 1) Review of the clinical history/circumstances of death; 2) External examination of the body as received; 3) Review of microscopic and toxicologic findings; 4) Preparation of written descriptions of the gross microscopic findings; 5) Development of a list of diagnoses and an opinion regarding the cause of death; and 6) Review of the autopsy report with a member of the teaching staff

b.

Describe any differences in the participation of the resident between hospital and forensic autopsies.

c.

To what extent are forensic autopsies used to fulfill the requirement of 50 autopsies per resident?

d.

If forensic autopsies are not used to fulfill the autopsy requirement, describe how the residents receive training in Forensic Pathology.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

3.

For each category, give the total number of autopsies performed in all program institutions during the last academic year or calendar year for which a resident was the primary prosector. Hospital Autopsies Forensic Autopsies Stillborn Autopsies Pediatric Autopsies

4.

Describe the role of the resident in completing unfinished autopsy (hospital and forensic) reports after leaving the rotation.

5.

To what extent are two-prosector autopsies utilized in the program to fulfill the requirement of 50 autopsies per resident? If two-prosector autopsies are utilized, explain the role of each of the prosectors and the faculty supervision of each prosector.

6.

How do residents assume graduated responsibility in autopsy pathology?

7.

Explain the difference between the roles of residents and fellows in forensic pathology.

B.

Cytopathology 1. Provide the following data for each institution where residents are assigned for training in Cytopathology. 12-Month period covered by statistics: From: Institution Name of Director of Cytopathology Individual Responsible for Cytopathology education of Residents Length of cytopathology rotation (months) Total # Accessions # gynecologic # non-Gynecologic # aspiration specimens (include FNA) Do residents learn how to obtain and prepare smears? Average # of FNA performed on living patients by a resident during the program? 2. 1 2 3 To: 4 Row Total

YES( ) NO( ) YES( ) NO( ) YES( ) NO( ) YES( ) NO( )

Provide the following information summarizing resident education in cytopathology. (This information should be limited to a one page summary.) a. b. Identify the consultative reports/activities which occur commonly in this laboratory section and describe the degree of resident participation in these activities. How do residents assume graduated responsibility in this section?

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

c. d.

Explain the differences in the roles of residents and fellows? Describe: 1) 2) 3) The manner in which residents are given opportunity to function as consultants to other physicians during their cytopathology assignments. The manner in which trainees are instructed and participate in the performance of fine needle aspirations and the interpretation of resulting data, and The method of correlative study of surgical and cytological specimens.

C.

Surgical Pathology 1. Provide the following data for each institution where residents are assigned for training in surgical pathology. 12-Month period covered by statistics: From: Institution Name of Director of Surgical Pathology Individual Responsible for surgical pathology education of residents Length of surgical pathology rotation (months) Total # annual surgical pathology accessions: Adult Pediatric Gross examination only # of specimens: Bone Marrow Biopsies Breast Gastrointestinal Products of conception/placentas ENT Gynecologic Male Urological Kidney Liver Lung Endocrine Bone / Soft Tissue Skin Heart Lymph Node Brain/CNS Brain / Peripheral Nerve Solid organ transplants # of OR Consultations Referred consultations 1 2 3 To: 4 Row Total

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

2.

Provide the following information summarizing the resident education in surgical pathology. (This information should be limited to a one page summary.) a. b. c. d. e. f. g. h. i. Identify the consultative reports/activities which occur commonly in this laboratory section and describe the degree of resident participation in these activities. Explain the differences in the roles of residents and fellows. Describe the manner in which residents have the opportunity to assume increasing responsibility in surgical pathology as they progress through the program. Describe the manner in which resident are given the opportunity to function as consultant to other physicians. Do residents preview the slides before sign out? Do residents always sign out their surgical cases with a member of the staff? Does the resident who does the gross also do the microscopic? Describe the formal, structured resident education in the management of surgical pathology laboratory. Describe resident experience with specific diagnostic tests (e.g. FISH, EM).

3.

If physician assistants are employed, what is their impact on resident education?

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 9. GENERAL CLINICAL PATHOLOGY INFORMATION
A. Blood Banking/Transfusion Medicine 1. Provide the following information for each laboratory where residents are assigned rotations in blood/transfusion medicine (BB/TM). If more than one institution, follow this format and insert additional pages. Name of Institution: Blood Bank Director: Rotation Length: # Technical Staff:

Person responsible for resident education in blood banking: 12-Month period covered by statistics: From: Workload Units of Blood Collected Units Prepared & Transfused Donor Apheresis Laboratory Procedures Antibody Identification Histocompatibility Testing Transplantation Workups Therapeutic Apheresis Workups & Performance Transfusion Reactions Worked Up * Do not include cases sent to outside laboratories. 2. Limiting your narrative to one typewritten page, summarize resident education in blood banking/transfusion medicine for each institution. In addition, please answer the following questions: a. b. c. d. e. f. g. List the types of interpretive reports generated by residents in this laboratory section (type and number of each). Identify the consultative reports/activities which occur commonly in this laboratory section and describe the degree of resident participation in these activities. How do residents assume graduated responsibility blood banking/transfusion medicine? Explain the differences in the roles of residents and fellows. How are residents educated with regard to the unique computer system requirements that apply to a transfusion medicine service? Do residents actively participate in the transfusion committee? Explain. Describe the residents' experience at a donor collection facility if this experience is not included in your program description. Enter # of Procedures during the 12-months period above* # Received from Outside Sources # Prepared on Site To: # Transfused

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

B.

Medical Microbiology 1. Provide the following information for each institution where residents are assigned rotations in medical microbiology (MM). If more than one institution, follow this format and insert additional pages. Name of Institution: Medical Microbiology Director: Rotation Length: # Technical Staff:

Person responsible for resident education in Medical Microbiology: 12-Month period covered by statistics: From: To:

Workload & Extent of Services Bacteriology Mycobacteriology - Microbacteriology Mycology Parasitology Virology Molecular Methods Immunological Tests - Serology Immunological Tests - For antigens * On site only. Do not include cases sent to outside laboratories. 2.

*# of Procedures

Limiting your narrative to one typewritten page, summarize resident education in medical microbiology for each institution. In addition, please answer the following questions: a. b. c. d. e. List the types of interpretive reports generated by residents in this laboratory section (type and number of each). Identify the consultative reports/activities which occur commonly in this laboratory section and describe the degree of resident participation in these activities. How do residents assume graduated responsibility in this section? Explain the differences in the roles of residents and fellows. Do residents actively participate in (a) the infection control committee; (b) infectious disease rounds or conferences; (c) other defined activities of the Infectious Disease Division? If so, explain.

C.

Chemical Pathology 1. Provide the following information for each institution where residents are assigned rotations in chemical pathology. If more than one institution, follow this format and insert additional pages. Name of Institution: Chemical Pathology Director: Rotation Length: # Technical Staff:

Person responsible for resident education in Chemical Pathology: 12-Month period covered by statistics: From: 2. To:

Limiting your narrative to one typewritten page, summarize resident education in chemical pathology for each institution. In addition, please answer the following questions: a. b. d. e. f. List the types of interpretive reports generated by residents in this laboratory section (type and number of each). Identify the consultative reports/activities which occur commonly in this laboratory section and describe the degree of resident participation in these activities. How do residents assume graduated responsibility in this section? Explain the differences in the roles of residents and fellows. Comment on resident experience with each of the following types of tests or patient populations: (a) endocrinology, (b) obstetrics, (c) pediatrics, (d) therapeutic drug monitoring; (e) toxicology.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

D.

Hematology & Coagulation 1. Provide the following information for each laboratory where residents are assigned rotations in hematology & coagulation. If more than one institution, follow this format and insert additional pages. Name of Institution: Hematology & Coagulation Director: Person responsible for resident education in Hematology & Coagulation: Average # of bone marrow aspirations and biopsy procedures performed on living patients by residents who completed the program last year: Average # of bone marrow reports completed by individual residents during the program: 2. Limiting your narrative to one typewritten page, summarize resident education in hemostasis/coagulation for each institution. In addition, please answer the following questions: a. b. c. d. e. hematology and Rotation Length: # Technical Staff:

List the types of interpretive reports generated by residents in this laboratory section (type and number of each). Identify the consultative reports/activities which occur commonly in this laboratory section and describe the degree of resident participation in these activities. How do residents assume graduated responsibility in this section? Explain the differences in the roles of residents and fellows. Explanation of how residents are given the opportunity to learn and master bone marrow aspiration and biopsy techniques.

E.

Cytogenetics 1. Provide the following data for each institution where residents are assigned for training in cytogenetics. 12-Month period covered by statistics: From: Institution Name of Director of Cytogenetics and Departmental Affiliation Individual Responsible for Cytogenetics education of residents Length of Cytogenetics assignment # of molecular Cytogenetic specimens Total # of specimens for karyotypic analysis 2. Limiting your narrative to one typewritten page, summarize resident education in cytogenetics for each institution. In addition, please answer the following questions: a. b. c. d. e. f. List the types of interpretive reports generated by residents in this laboratory section (type and number of each). Identify the consultative reports/activities which occur commonly in this laboratory section and describe the degree of resident participation in these activities. How do residents learn about the procedures for preparation of cytogenetic specimens from different services? How do residents assume graduated responsibility in this section? Explain the differences in the roles of residents and fellows. How are cytogenetic studies correlated with anatomic and clinical pathology data? 1 2 To: 3 4 Row Total

F.

Flow Cytometry/Immunology/Serology 1. Provide the following information for each institution where residents are assigned rotations in flow cytometry. If more than one institution, follow this format and insert additional pages. Name of Institution: Flow Cytometry Director: Rotation Length: # Technical Staff:

Person responsible for resident education in Flow Cytometry:

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

2.

Limiting your narrative to one typewritten page, summarize resident education in flow cytometry / immunology / serology for each institution. In addition, please answer the following questions: a. b. c. d. e. List the types of interpretive reports generated by residents in this laboratory section (type and number of each). Identify the consultative reports/activities which occur commonly in this laboratory section and describe the degree of resident participation in these activities. How do residents assume graduated responsibility in this section? Explain the differences in the roles of residents and fellows. Provide the type and number of each of the following procedures and laboratory tests performed in your institution: (a) transplant; (b) immunodeficiency work-ups (immunophenotyping and/or CD4/CD8 counts); (c) serologic tests for infectious disease; (d) serologic autoimmune work-ups (excluding those performed in blood bank); (e) other immunologic or histocompatibility testing procedures.

G. Urinalysis and Medical Microscopy 1. Provide the following information for each institution where residents are assigned rotations in urinalysis and medical microscopy. If more than one institution, follow this format and insert additional pages. Name of Institution: Medical Microscopy Director: Rotation Length: # Technical Staff:

Person responsible for resident education in Medical Microscopy: 2. Limiting your narrative to one typewritten page, summarize resident education in Urinalysis and Medical Microscopy for each institution. In addition, please answer the following questions: a. b. c. d. e. f. List the types of interpretive reports generated by residents in this laboratory section (type and number of each). Identify the consultative reports/activities which occur commonly in this laboratory section and describe the degree of resident participation in these activities. How do residents assume graduated responsibility in this section? Explain the differences in the roles of residents and fellows. What percentage of urinalyses have associated microscopic examinations? Identify the number of each of the following types of body fluids examined: (a) pleural; (b) peritoneal; (c) cerebrospinal; (d) synovial; (e) other (specify).

H.

Molecular Pathology 1. Provide the following information for each institution where residents are assigned rotations in Molecular Pathology. If more than one institution, follow this format and insert additional pages. Name of Institution: Molecular Pathology Director: Rotation Length: # Technical Staff:

Person responsible for resident education in Molecular Pathology: 2. Limiting your narrative to one typewritten page, summarize resident education in Molecular Pathology for each institution. In addition, please answer the following questions: a. b. c. d. e. List the types of interpretive reports generated by residents in this laboratory section (type and number of each). Identify the consultative reports/activities which occur commonly in this laboratory section and describe the degree of resident participation in these activities. How do residents assume graduated responsibility in this section? Explain the differences in the roles of residents and fellows. List the type and number of Molecular Pathology studies performed in this laboratory and indicate if additional molecular techniques are part of other laboratory sections.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 10. LABORATORY MANAGEMENT AND INFORMATION SYSTEMS
Please limit the following narratives to one typewritten page. 1. Summarize structured resident education in laboratory management. How are residents educated with regard to costeffective use of the laboratory and how do they share this knowledge as a consultant to the clinical staff? How are residents acquainted with management issues in the areas of personnel, budget preparation, regulatory agencies (CAP, HCFA, CLIA, AABB, FDA, OSHA, JCAHO), risk management, and laboratory safety? How are residents involved in quality assurance activities? Summarize resident experience with pathology laboratory information systems, database management techniques, etc. Describe resident education in medical informatics and how residents apply this training in support of laboratory management and patient care. Give specific examples.

2.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 11. RESIDENT RESEARCH
Describe the research/investigation work by residents during the last three years (including work in progress.) List resulting publications, underlining resident author names. Do not enclose reprints or manuscripts. Add additional pages as needed.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 12. RESIDENT CERTIFICATION
Resident performance on the ABP Certifying Examination. 1. Please complete the information who took the APCP Exam during the past five (5) years. Year # Who Took Exam for the 1st Time # of 1st Time Exam Takers who Passed # Who Took Exam Other than 1st Time # of Repeaters who Passed

2.

Please complete the information who took the AP-only Exam during the past five (5) years. Year # Who Took Exam for the 1st Time # of 1st Time Exam Takers who Passed # Who Took Exam Other than 1st Time # of Repeaters who Passed

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 13. EVALUATION OF RESIDENTS
How does the program ensure that the Program Director, with participation of members of the teaching staff: 1. At least semi-annually evaluate the knowledge skills, and professional growth of the residents, using appropriate criteria and procedures. Are there regular, formal, written evaluations of residents by the teaching staff? Are evaluations completed at least once every 6 months and after rotations outside the primary institutions or to specialty experiences? Are evaluations discussed with the residents at least once each year?

2.

Communicate each evaluation to the resident in a timely manner.

3.

Advance residents to positions of higher responsibility on the basis of evidence of their satisfactory progressive scholarship and professional growth.

4.

Maintain a permanent record of evaluation for each resident and have it accessible to the resident and other authorized personnel.

5.

Complete a written final evaluation for each resident who completes the program. The evaluation must include a review of the resident's performance during the final period of training and should verify that the resident has demonstrated sufficient professional ability to practice competently and independently. This final evaluation should be part of the resident's permanent record maintained by the institution.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 14. EVALUATION OF THE PROGRAM
How is the educational effectiveness of the program evaluated in a systematic manner? In particular, how is the quality of the curriculum and the extent to which the educational goals have been met by residents assessed? As part of this process, do residents provide periodic written evaluations of the program and teaching staff?

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 15. EDUCATIONAL EXPERIENCE OF RESIDENTS
Provide a block diagram of each PGY-IV's rotations/assignments. The sample below is provided as an illustration and should not be viewed as a recommendation. In the sample, the Anatomic Pathology rotations included are Autopsy, Cytopathology, Forensic, and Surgical Pathology. Neuropathology, Dermatopathology, etc. may also be identified. Similarly, the Clinical Pathology assignments identified are Chemistry, Microbiology, Hematology, Blood Banking/Transfusion Medicine and Immunopathology. Cytogenetics, coagulation, toxicology, virology, etc. may also be included. Sample APCP - 4 Block Diagram 12 Months Inst. # 1 Surgical Pathology

1st Year In Program

Inst. # 2 Autopsy

Inst. # 2 Forensic

Inst. #1 Informatics

2nd Year In Program

Inst. # 1 Chemistry

Inst. # 1 Microbiology

Inst. # 1 Hematology

Inst. # 1 Transfusion Medicine / Blood Banking

3rd Year In Program

Inst. # 1 Immunology/ Immunopath

Inst. # 1 Molecular Biology

Inst. # 1 Surgical Pathology Subspecialties

Inst. # 1 Pediatric Pathology

Inst. # 1 Cytopathology

4th Year In Program

Elective, research, etc.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

APCP - 4 Resident's Educational Program Specific blocks of rotations/assignments separated by vertical lines, should be identified for each year in the program. The participating institution at which each rotation takes place should be identified by number as designated in Part 1 of this form. Duplicate this section as needed. Name of Resident 12 Months 1st Year In Program

2nd Year In Program

3rd Year In Program

4th Year In Program

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 16. PROGRAM CONFERENCES
List the conferences, seminars, journal clubs, etc. in which residents participate. Name of Conference Medical Mortality Conference Surgical Mortality Conference Pediatric Mortality Conference Gross Pathology Conference Surgical Pathology Conference Journal Club/Research Conference Hematology Conference Clinical Pathology Conference On-call Review Other (specify): Frequency held Individual(s) or Department Responsible for Organization of Sessions

Limiting your narrative to the space below, summarize resident participation in (attendance, planning, presenting, etc.) conferences.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 17. OTHER PHYSICIAN TRAINEES
List other physician trainees (not listed as APCP residents) in the pathology department who have been associated with the APCP program during the current year but are not part of the core program. Include pathology subspecialty fellows and the graduate medical education (GME) trainees from other specialties who are rotating through AP and/or CP. Months In Years of GME Pathology this Year Pathology Assignment

Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Medical Specialty

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 18. NON-PHYSICIAN TRAINEES
Medical Technologists: Provide the following information if program facilities are used for training of medical technologists and/or medical laboratory technicians. List type of technology program (MLT, 3+1 MT, 2+2 MT, other). Educational Program Name & Type # of Trainees

Other educational programs: List other programs using APCP facilities (e.g., medical school courses, post-sophomore fellowships, cytotechnologists, pathology assistants, or masters, doctoral and postdoctoral programs for clinical scientists. Educational Program Name & Type # of Trainees

Limiting your narrative to the space below, summarize resident opportunities to teach medical students, trainees from other specialties, etc.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 19. PROGRAM STRENGTHS
Describe the strengths of the program.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

SECTION 20. PROGRAM NEEDS
Describe those areas of the program that could be strengthened. What plans are there to address these areas?

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc

DOCUMENTS THAT MUST BE AVAILABLE FOR REVIEW BY THE SITE VISITOR
These materials should not be submitted with the PIF. A. B. Current, written institutional and interinstitutional agreement. (Program Requirements II.B.3) The written statement outlining the educational goals of the program with respect to the knowledge, skills, and other attributes of residents for each major assignment. (Program Requirements V.A.1.) The academic and clinical curriculum specified in Program Requirements V.A.2. Program policies and procedures regarding duty hours, call, and moonlighting. (PR V.F.5.) If the program has been granted an exception to the program requirement regarding the 80 hour per week duty limit for residents, documentation of Residency Review Committee approval must be provided for site visitor review. PR V.F.2.b. and V.F.6. The programs record of the semiannual evaluation of residents. (Program Requirements VI.A.1.b.)

C. D. E.

F.

G. Final written evaluations of residents who have completed the program. These evaluations must include a review of a resident’s performance during the final period of education and verify that the resident has demonstrated sufficient professional ability to practice competently and independently. (Program Requirements VI.A.2.) H. I. Resident evaluations of faculty. (Program Requirements VI.B.) Agenda and/or minutes of faculty meetings devoted to evaluation of program goals, objectives and effectiveness. (Program Requirements VI.C.1.) Documentation that the institution has conducted an internal review of the program (Institutional Requirements I.B.3.d.). A copy of the report resulting from this review should not be included in the material reviewed by the site visitor.

J.

30e7104e-7b6f-45b1-86f0-03e9e6668e81.doc


				
Lingjuan Ma Lingjuan Ma
About