To be completed and submitted to the GME Office AT LEAST 10 DAYS prior to the Internal Review.

I. PROGRAM OVERVIEW

1. Briefly describe the training program and scope of specialty. Include overview of numbers of residents, faculty, participating institutions and other relevant information. Insert as Attachment A in Section XIII a copy of any ACGME correspondence.

1. Program Director:
   
   
   1. Briefly describe the program director’s qualifications and responsibilities.
      
   2. Length of time in this position.
      
   3. Percent of time allotted to program administration and teaching.
      
   4. Any funds provided to support program administration?
   
   
2. Describe the administrative system that will oversee the training program including identification of membership of the committee that oversees graduate medical education within the department.

III. PARTICIPATING INSTITUTIONS

1. Please list all sites, inpatient and ambulatory, that the residents will regularly rotate at least 1 month or longer. Include any private practice sites. Insert as Attachment B in Section XIII a copy of the program’s Special Provisions for each site.
   
2. Please list all preceptors (non UA/UPI physicians) that will participate in the teaching program. Are appropriate agreements in place with these preceptors?

IV. FACILITIES AND SUPPORT SERVICES

1. Describe the inpatient facilities at each of the participating institutions. Include such items as number of beds, case mix, and support services.
   
2. Describe the outpatient facilities (including case mix, support services, number of visits) used as a part of the program.
   
3. Is there sufficient equipment available to support the educational requirements of the program: Briefly explain.
   
4. Are the support services adequate? (Include both clinical support services and academic support services such as library)

V. TEACHING FACULTY

1. Provide the number of teaching faculty (full-time and part-time) involved in residency education. Include the percentage of clinical faculty who are Board certified. What is the ratio of faculty to residents at each institution: Are there adequate numbers of teaching faculty?
   
2. Are faculty actively involved in scholarly activity? Describe the scholarly activity that the faculty is involved in the residency program. Comment on publications in peer review journals, presentations and investigative research.BR>
3. How are the teaching faculty supported in their teaching endeavors? Are there any departmentally sponsored faculty development programs? Is teaching time given a high enough priority?

VI. CLINICAL TEACHING

1. Are the number of and variety of patients adequate to support the educational requirements of the program? Explain.
   
2. Is there adequate supervision of resident activities in the inpatient and outpatient facilities? Explain. Describe how the program ensures that there is appropriate and adequate supervision of residents as the progress through the program. Insert in Attachment C in Section XIII a copy of the Supervision Policy.
   
3. Describe the opportunities available to residents to provide continuing care in both the ambulatory and inpatient settings.
   1. Are there sufficient medical procedures and/or surgical procedures to ensure that residents have an adequate clinical experience? Explain.

VII. EDUCATIONAL PROGRAM

1. ACGME General Competencies. (Complete the Competency Checklist and insert as Attachment D in Section XIII.)
   
   1. Please provide evidence of a curriculum (complete with goals and objectives) that is used by the program for teaching the six general competencies: patient care skills, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and systems-based practice. Is the curriculum reviewed on a regular basis with teaching faculty?
      
   2. Insert as Attachment G in Section XIII copies of all evaluation forms for your residency; include those tools used to evaluate the competencies.
      
   3. Please provide evidence of developing or using dependable measures to access the residents’ competencies in each of the six areas. (Note: Dependable measures may not have been developed until the program has had an opportunity to evaluate its residents over a period of time using various evaluation tools and analyzing the results.)
      
   4. Please provide evidence of a process developed to link educational outcomes with program improvement. (Note: Evidence of program improvement may not be available until the program has had an opportunity to develop and analyze its outcome measures over a period of time.)
   
   
2. Outline a typical rotation schedule for each PGY level in the program. Insert as Attachment E in Section XIII a copy of the program's educational goals and objectives with respect to knowledge, skills and other attributes for each rotation.
   
3. Explain how the residents assume progressively increasing responsibility for patient care according to their level of training, their ability and their experience.
   
4. Insert as Attachment F in Section XIII a copy of the didactic program for residents. Comment on the following: how is resident and faculty attendance documented, quality of presentations, whether all the areas in the relevant RRC and Essential Requirements are covered. Do patient care experiences interfere with attendance at teaching rounds or conferences?
   
5. Describe resident participation in departmental quality assurance/performance improvement activities. Describe the program’s approach to reviews of morbidity and mortality. Insert in Attachment C in Section XIII a copy of the program’s Quality Assurance Policy.
   
6. Are residents allowed to take away electives from the affiliated hospitals? If so, how do these electives enhance the educational program?
   
7. Are residents encouraged to participate in investigative work or scholarly activity with the faculty? If yes, what percent participate in investigative research? Is there a research requirement for all residents? How is research time funded? List all resident publications for each of the past 3 years.
   
8. Insert in Attachment C in Section XIII the program's policy on the effects of leave of absence on satisfying criteria for completion of the residency program.

1. Describe the program’s process and/or policy for evaluation and promotion of residents. Is there a summative letter prepared for graduating residents which indicates that they are competent to practice independently?
   
2. Does the program director or designee meet with each resident to review the residents’ progress and status in the program? How often? How is this documented? Are residents assigned a faculty advisor or mentor?
   
3. Briefly describe any voluntary terminations (dropouts), retentions, dismissals or major disciplinary actions involving your residents within the last 3 years.
   
4. Does the program require the residents to take an in-training examination? If yes, provide summary results for each of the past 3 years. How is this information used in evaluating the resident? The program?
   
5. Over the past 3 years how have graduates performed on the board certification exam?

1. How are faculty evaluated by the residents? Insert in Attachment G in Section XIII a copy of the form. How does the program ensure that these evaluations are anonymous and confidential? Who reviews this information with the faculty?
   
2. Does the program perform reviews of faculty mid-cycle and prior to site visits? This should include a review of teaching abilities, commitment to the educational program, clinical knowledge, and scholarly activities. Annual written confidential evaluations by residents must be included in this process.
   
3. Describe the formal mechanism used for evaluation of the educational effectiveness of your training program; including review of goals and objectives, review of rotations, and a review of faculty. Residents must participate in this review and the review should occur at least annually. Insert as Attachment H in Section XIII a copy of the most recent departmental review of your training program.
   
4. Describe how residents participate in the governance of the residency program. Describe how they have input to changes in the curriculum. Provide documentation that shows how the residents’ rotation, faculty and program evaluations are used to improve the program.

X. WORKING CONDITIONS

1. Describe how the program complies with RRC requirements for duty hours and on-call schedules. How do you document duty hours? Insert in Attachment C in Section XIII a copy of the program’s Duty Hours Policy and attach program's documentation for duty hours compliance for the past year.
   
2. Is supervision readily available for residents on-call?
   
3. Describe how faculty and residents are educated to recognize the signs of fatigue. Describe how the program adopts and applies policies to prevent and counteract the potential negative effects of sleep deprivation.
   
4. Describe the program’s procedure for monitoring resident moonlighting activities. Insert in Attachment C in Section XIII a copy of the program’s Moonlighting Policy.
   
5. How are residents taught about physician impairment, including substance abuse?

1. Describe the program’s selection process indicating membership on the selection committee, numbers of applicants, number interviewed and number ranked. For each of the past 3 years indicate whether or not the program filled in the Match, and, if so, how far on the rank order list you went. Insert in Attachment C in Section XIII a copy of the program’s Resident Selection Policy.

XII. ATTACHMENTS
Please attach the following materials. More information may be found in the Institutional and Common Program Requirements.

1. Last ACGME Letter and any correspondence since then.
   
2. Program Policies
   
   1. Duty Hours (Common Program Req. VI.)
      
   2. Effects of leave of absence on satisfying criteria for completion of the residency program (Institutional Req. III.D.1.)
      
   3. Moonlighting (Common Program Req.)
   4. Quality Assurance/Improvement (Institutional Req. II.D.)
      
   5. Resident Selection (Institutional Req. III.A.)
      
   6. Supervision (Institutional Req. IV.B.5)
   
   
3. Competency Checklist
   
4. Educational goals of the program with respect to the knowledge, skills and other attributes of residents for each major assignment and each level of the program (Common Program Req. V.A.)
   
5. Academic and clinical curriculum including lectures, conferences, case presentations, teaching rounds, etc. (Common Program Req. V.B.)
   
6. Evaluation forms for residents and for faculty (Common Program Req. V.II.)
   
7. Annual Program Review (Common Program Req. VII.C.)
   

DEPARTMENTAL REVIEW and CERTIFICATION
The completed Program Questionnaire should be signed and dated by the Program Director and Department Head before submission to the GME Office.
December 2006.