new application only

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY515 N State, Ste 2000, Chicago, IL 60654 (312) 755-5000 www.acgme.org

FOR NEW APPLICATIONS ONLY - CLINICAL NEUROPHYSIOLOGY

GENERAL INSTRUCTIONS

APPLICATIONS FOR A NEW PROGRAM: This Program Information Form (PIF) is for programs applying for INITIAL ACCREDITATION ONLY (for Continued Accreditation or re-accreditation, use the CONTINUED ACCREDITATION PIF in conjunction with the Web Accreditation Data System).

All sections of the form applicable to the program must be completed in order to be accepted for review. The information provided should describe the proposed program. For items that do not apply indicate N/A in the space provided. Where patient numbers are requested, estimate what you expect will occur. 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 bottom center. Send three complete copies to the executive director of the Residency Review Committee for Neurology at the address above. They must be identical and final. Draft copies are not acceptable. The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two or three ring binders, spiral bound notebooks, or any other form of binding.

The program director is responsible for the accuracy of the information supplied in this form and must sign it. It must also be signed by the designated institutional official of the sponsoring institution.

Review the Program Requirements for Residency Education in Clinical Neurophysiology. The Program Requirements or the Institutional Requirements may be downloaded from the ACGME website (www.acgme.org):

For questions regarding:

-the completion of the form (content), contact the Accreditation Administrator.

-the Accreditation Data System, email [email protected].

For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp

Clinical Neurophysiology i

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

Attach the following documents to the application:

References to Common Program and Institutional Requirements are in parentheses

The Designated Institutional Official should provide the following:

1. Policy for supervision of fellows (addressing fellow responsibilities for patient care, progressive responsibilities for patient management, and faculty responsibility for supervision) (CPR VI.B)

2. Program policies and procedures for fellows’ duty hours and work environment, including grievance and due process (CPR VI; IR II.D.4.e.; IR II.D.4.i.; IR III.B. 3.)

3. Moonlighting policy (CPR VI.E)

4. Documentation of monitoring of fellow duty hours to determine compliance with the requirements (CPR VI.C.1-3)

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

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

The Program Director should provide the following:

1. Document delineating the eligibility criteria to enter the program (CPR III.A)

2. Document delineating the skills and competencies the fellow will be able to demonstrate at the conclusion of the program (CPR IV.A.1)

3. Evaluations:

a) Objective assessments for the six competencies (Patient Care, Medical Knowledge, Practice-based learning & improvement, Interpersonal & Communication Skills, Professionalism, Systems-based Practice) showing input from multiple evaluators (faculty, peers, patients, self, and other professional staff) (CPR V.A.1.b.(1) and (2))

b) Documentation of fellows’ semiannual evaluations of performance with feedback (CPR V.A.1.b.(3))

c) Final (summative) evaluation of fellows, documenting performance during the final period of education and verifying that the fellow has demonstrated sufficient competence to enter practice without direct supervision (CPR V.A.2)

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

4. Files of current fellows and most recent program graduates

Single Program Sponsors only, attach the following additional documents to the application:

1. Copy of the 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. (IR I.B.2)

2. Copy of the fellow contract with the pertinent items required by the Institutional Requirements highlighted and numbered according to the Institutional Requirements (IR II.C-D).

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

4. Institutional policy for discipline and dismissal of fellows (IR III.B.7)

Clinical Neurophysiology ii


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

TABLE OF CONTENTS

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

Common PIF Page(s)Accreditation InformationParticipating Sites

Single Program Sponsoring Institutions (if applicable)Faculty/Resources

Program Director InformationPhysician Faculty RosterFaculty Curriculum VitaeNon Physician Faculty RosterProgram Resources

Fellow AppointmentsNumber of PositionsActively Enrolled Fellows (if applicable)

Skills and CompetenciesGrievance ProceduresMedical Information AccessEvaluation (Fellows, Faculty, Program)Fellow Duty Hours

Specialty Specific PIF Page(s)Site DirectorsFellows

Clinical Neurophysiology FellowsOther Clinical Neurophysiology FellowsOther Fellows In Training

Clinical And Educational Facilities and ResourcesFacilitiesSupporting Facilities

Educational ProgramCurriculum Basic and Clinical Neurophysiology Sciences Instruction and LecturesClinical and Basic ScienceClinical Teaching – OutpatientClinical Neurophysiology EEG/EMG/Sleep Outpatient Diagnostic CategoriesOutpatient Specialty ClinicsEducational Program

Research and Scholarly Activity

Clinical Neurophysiology iii

Specialty Specific PIF Page(s)Fellow Meeting AttendanceFellow Research ProjectsFellow Publications

EvaluationFellow EvaluationImpaired FellowsFellow Stress

Appendix A - Written Goals and Objectives by Rotation

Clinical Neurophysiology iv



A. ACCREDITATION INFORMATION

Date:Title of Program:Core Program InformationTitle of Core Program: Core Program Director:10 Digit ACGME Program ID#:Accreditation Status:

Effective Date:

Next Review Date:

Last Review Date: Cycle Length:

The signatures of the director of the program 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 Core Program Director (and Date):

Signature of Designated Institutional Official (DIO) (and Date):

1. Respond to previous citation(s)

Provide a concise update on each previous citation and indicate how each has been addressed (if applicable).

2. Describe changes not mentioned above

Provide a concise update explaining any major changes, not described in your response to question # 1, to the fellowship program since the last site visit (for example, changes in program format, fellow complement, program leadership, or participating sites).

3. Planned start date for the first class of fellows (answer only if this is a new application)

Clinical Neurophysiology 1

B. PARTICIPATING SITES

SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.) Name of Sponsor: Address: Single Program Sponsor? ( ) YES ( ) NOCity, State, Zip code: Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)

Name of Designated Institutional Official: Mailing Address: Phone Number:

Email:

Name of Chief Executive Officer:

PRIMARY SITE (Site #1) Name:Address:City, State, Zip Code:Clinical Site? ( ) YES ( ) NOType of Rotation (select one) Elective ( ) Required ( ) Both ( )Length of Fellow Rotations (in months)CEO/Director/President’s Name: Joint Commission Accredited? ( ) YES ( ) NO If no, explain:

The Program Director must submit any participating sites routinely providing an educational experience, required for all fellows, of one month full time equivalent (FTE) or more. Duplicate as necessary.

PARTICIPATING SITE (Site #2) Name:Address:City, State, Zip Code:Integrated: ( ) YES ( ) NODoes this site also sponsor its own program in this subspecialty? ( ) YES ( ) NODoes it participate in any other ACGME-accredited programs in this subspecialty?

( ) YES ( ) NO

Distance between #2 & #1:

Miles: Minutes:

Type of Rotation (select one)

( ) Elective ( ) Required ( ) Both

Length of Fellow Rotations (in months)CEO/Director/President’s Name:Brief Educational Rationale:


1. Single Program Sponsoring Institutions (Institutions that sponsor a single core or subspecialty program, or a single core program and its subspecialties).

For those institutions which are either a single-program sponsoring institution (e.g., medical genetics only), or an institution with multiple residencies accredited by the same Residency Review Committee (RRC), the institutional review will be conducted in conjunction with the review of the program. Only programs in these two categories are to complete the following institutional questions.

a) 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. (IR I.B.2)

b) Describe the formal method by which a periodic evaluation of the program’s educational quality and compliance with the program requirements occurs. Explain how fellows and faculty in the program are involved in the evaluation process. (CPR V.C; IR IV)

c) 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 fellows in accordance with the Program and Institutional Requirements. (IR II.A-B)

d) Summarize how the institution complies with the ACGME Institutional Requirements regarding fellow support, benefits and conditions of employment to include the details of the fellow contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the fellow contract/agreement to the PIF but state when it is given to the fellows 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.) (IR II.C-D)

e) Describe in detail the grievance (due process) procedure(s) that is available to fellows, 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 fellow’s contract, or other actions that could significantly threaten a fellow’s intended career development. (IR II.D.4.c-d)


C. FACULTY / RESOURCES

1. Program Director Information

Name: Title: Address: City, State, Zip code:Telephone: FAX: Email:Date First Appointed as Program Director: Principal Activity Devoted to Fellow Education? Yes: No:Term of Program Director Appointment: Date first appointed as faculty member in the program:Number of hours per week Director spends in: Clinical Supervision:

Administration: Research: Didactics/Teaching:

Primary Specialty Board Certification: Most Recent Year:Subspecialty Board Certification: Most Recent Year: Number of years spent teaching in this subspecialty:

a) Is the program director familiar with and does he/she oversee compliance with ACGME/RRC policies and procedures as outlined in the ACGME Manual of Policies and Procedures (found at http://www.acgme.org/acWebsite/about/ab_ACGMEPoliciesProcedures.pdf)?.......................................................................................................................( ) YES ( ) NO

b) Using the form provided in section C.3. provide a one page CV for the program director.


http://www.acgme.org/acWebsite/about/ab_ACGMEPoliciesProcedures.pdf

2. Physician Faculty Roster

List alphabetically and by site all physician faculty who devote at least 10 hours a week to resident education. Using the form provided below, supply a one page CV for each faculty listed.

Name (Position) Degree

Based Primarily at Site #

Primary and Secondary Specialties / Fields

Years as Faculty

in Specialt

y

Average Hours Per Week Spent On:

Specialty / Field

Board Certification

(Y/N)†

Most Recent Certification

DateClinical

Supervision AdminDidactic Teaching Research

(PD)

† Certification for the primary specialty refers to ABMS Board Certification. Certification for the subspecialty refers to ABMS sub-board certification.


3. Faculty Curriculum Vitae

First Name: MI: Last Name:Present Position:Graduate Medical Education Program Name(s); include all residencies and fellowships:

Certification and Re- Certification Information Current Licensure Data

SpecialtyCertification

YearRe-Certification

Year StateDate of Expiration

(mm/yyyy)

Academic Appointments - List the past ten years, beginning with your current position. Start Date (mm/yyyy)

End Date(mm/yyyy) Description of Position(s)

Present

Concise Summary of Role in Program:

Current Professional Activities / Committees:

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 10 in the last 5 years):

Participation in Local, Regional, and National Activities / Presentations - Abstracts (Limit of 10 in the last 5 years):

If not ABMS board certified, explain equivalent qualifications for Review Committee consideration:

4. Non Physician Faculty Roster

List alphabetically the non-physician faculty who provide required instruction or supervision of fellows in the program.

Name (Position) Degree

Based Primarily at

Site #Subspecialty /

FieldRole In

Program

# of Years Teaching as

Faculty in Subspecialty


5. Program Resources

a) How will the program ensure that faculty (physician and nonphysician) have sufficient time to supervise and teach fellows? Include time spent in activities such as conferences, rounds, journal clubs, research, mentoring, teaching technical skills etc. if relevant.

b) Briefly describe the educational and clinical resources available for fellow education.[The answer must include how specialty specific reference materials are accessible. It should also include resources provided by the program and the institution.]


D. FELLOW APPOINTMENTS

1. Number of Positions (for the current academic year)

Number of Requested PositionsNumber of Filled Positions**Not applicable to new programs with no fellows on duty. Count part-time residents as 0.5 FTE.

If the number of filled positions exceeds the number of positions approved by the Review Committee, provide an explanation of this variance.

2. Actively Enrolled Fellows (if applicable)

a) List alphabetically all fellows actively enrolled in this program as of August 31 of current academic year.

Name

Program Start Date

Expected Completion

DateYear in

ProgramYears of

Prior GME

Specialty of Most Recent Prior GME

Has completed an

ACGME-accredited specialty program

(Y/N) If no, explain

b) Did you obtain documentation that each fellow has met the eligibility criteria? ( ) YES ( ) NO




I. SITE DIRECTORS

List the person responsible for supervising the fellow education activities of your program at each site.

Site # Site Director1.2.3.4.


II. FELLOWS (PR I)

A. Clinical Neurophysiology Fellows

What mechanism is there to ensure that the Program Requirement I.B.1 concerning prerequisite training is met?

B. Other Clinical Neurophysiology Fellows

List those clinical neurophysiology fellows who do not meet the ABPN’s preliminary training requirements before beginning the program.

Name

Year in program

Type of position

Years of prior GME

Specialty of prior training Medical school

Year of medical school graduation

Program start date

Expected completion date

Status in program

C. Other Fellows in Training

List the graduate medical education (GME) residents (fellows) from other specialties who rotated through clinical neurophysiology during the last academic year.

Specialty & years of GME (e.g. PGY-2 child)

Number of these residents in the last year

Months each resident spent in clinical neurophysiology

Clinical neurophysiology assignment (EEG, EMG, sleep, other)

Adult neurology PGY-Child neurology PGY-Neurosurgery PGY-Physical medicine & rehabilitation PGY-Psychiatry PGY-Other PGY-


III. CLINICAL AND EDUCATIONAL FACILITIES AND RESOURCES (PR III)

A. Facilities

1. Describe the physical facilities at each site for the clinical neurophysiology outpatient and inpatient evaluation and care of patients with seizure, neuromuscular, and sleep disorders.

2. Describe the availability of the office space at each site for faculty, clinical neurophysiology fellows, and support staff.

3. Indicate if the following office spaces and resources available. See the Common PIF for site numbers. Duplicate this section if more than 4 sites are used.

Site Site #1 Site #2 Site #3 Site #4Faculty office and facilities Are there offices for clinical neurophysiology faculty?

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

Is there secretarial office space for clinical neurophysiology?


Is there a departmental library?


Clinical neurophysiology fellow offices and resourcesDoes each clinical neurophysiology fellow have his/her own office?


Are there offices for groups of clinical neurophysiology fellows?


Do the offices have computers and computer internet search capabilities?


Do the clinical neurophysiology fellows have secretarial support?


Do the clinical neurophysiology fellows have access to other office equipment such as copiers, slide projectors, equipment or services to make slides, illustrations services?



Site Site #1 Site #2 Site #3 Site #4Do the clinical neurophysiology fellows have access to major texts in the office?


3. Describe the clinical neurophysiology laboratory facilities at each site, including mechanisms for reporting of test results.

4. Describe clinical neurophysiology conference facilities at each site.

5. Describe the space provided for clinical neurophysiology faculty and clinical neurophysiology fellow research at each site.

6. Describe for each site how the charts or medical records are made available for inpatients, outpatients, and consultation use.

B. Supporting Facilities

Indicate whether the facilities and resources listed below are AVAILABLE for all participating sites listed in the Common PIF. If more than four sites, duplicate the section and include after this page.

Diagnostic Resources Site #1 Site #2 Site #3 Site #4Electroencephalography

EEG ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOAmbulatory EEGs ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOVideo-EEG monitoring


Intraoperative monitoring


Electromyography:EMG/NCV ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NONeuromuscular transmission testing including single fiber studies


Cranial nerve testing including blink reflexes and facial nerve evaluation


Sleep Lab:Polysomnography ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOMultiple sleep latency ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO

Other clinical neurophysiology modalities:


Diagnostic Resources Site #1 Site #2 Site #3 Site #4Evoked potentials ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOVisual ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOAuditory ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOSomatosensory ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOAutonomic testing ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOMovement disorder assessment with botulinum toxin therapy


Central EMG ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOMagnetoencephalography


Electroretinograms (ERGs)


Diagnostic neuroimaging services


MRI and MRA ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOCT ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOSPECT ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOPET ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO

Related diagnostic and therapeutic services:Cytogenetics and genetic testing


Genetic counseling service


Occupational therapy ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOPain management ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOAdult rehabilitation medicine


Pediatric rehabilitation medicine


Physical therapy ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO


IV. EDUCATIONAL PROGRAM

A. Curriculum (PR V.A.)

Describe in block and longitudinal templates the typical curriculum for clinical neurophysiology fellows. Curricular components may be offered in blocks or longitudinally. Those components offered in block assignments during this subspecialty year should be recorded in the block template by months, not weeks, including the site (#1,2,3,4) and the experience on each rotation. Clearly identify elective time. Exclude mention of vacation time. Obvious examples include EEG, EMG, Sleep, Seizure clinic, Neuromuscular clinic, etc.

An example of longitudinal curriculum is a regularly scheduled clinical neurophysiology activity or clinic attended over a period of time while assigned to other rotations.

Both longitudinal and block components can be applied toward FTE minimums described in the program requirements. For example, one half-day per week for ten months of a longitudinal clinic would count for one month FTE.

SAMPLE BLOCK ROTATIONS - PG-2

July August September October NovemberDecembe

rJanuary February March April May June

Intro to CNP

Site 1

Intro to CNP

Site 1

EEG Site 1

EEG Site 1

EEG Site 1

EEG Site 3

Sleep Site 2

Sleep Site 2

EMG Site 1

EMG Site 1

EMG Site 1

EMG Site 1

SAMPLE LONGITUDINAL EXPERIENCES - PG-2

Type Of Experience* Weekly Structured Amount Of Time (FTE)EEG including adult and child 1/2 day each week 52 weeksEMG including adult and child 1/2 day each week 52 weeksOther Clinical neurophysiology

SleepEvoked PotentialsSeizure Clinics

One half day per week forOne half day per week forOne half day per week for

2 months6 months12 months

BLOCK ROTATIONS – PG-1 YEAR IF THE PROGRAM IS A 4-YEAR PROGRAM

July August September October November December January February March April May June

LONGITUDINAL EXPERIENCES - PG-1

Type Of Experience* Weekly Structured Amount Of Time (FTE)


B. Basic and Clinical Neurophysiology Sciences Instruction and Lectures

1. Basic science clinical neurophysiology curriculum

2. List of lectures, conferences, courses in applied clinical neurophysiology

3. List of neurology clinical conferences which the clinical neurophysiology fellow is expected to attend or participate in.

4. List of clinical courses, conferences and/or lectures given in the subspecialties of epilepsy, neuromuscular diseases, autonomic disorders, sleep, and vestibular disorders at each site.

C. Clinical and Basic Science

Site #1 Site #2 Site #3 Site #4EEG Name of director(s)Number of studies per yearEEG: adult/childOtherMonths fellows assignedFellows’ responsibilitiesEMGName of director(s)Number of studies per yearEMG: adult/childOtherMonths fellows assignedFellows’ responsibilitiesSleepName of director(s)Number of studies per yearEMG: adult/childOtherMonths fellows assignedFellows’ responsibilities


Site #1 Site #2 Site #3 Site #4NeuropathologyName of director(s)CNS surgical specimens per yearMuscle biopsiesNerve biopsiesMonths fellows assignedFellows’ responsibilitiesAutonomicName of director(s)Number of studies per yearEMG: adult/childOtherMonths fellows assignedFellows’ responsibilities

D. Clinical Teaching – Outpatient

1. Clinical neurophysiology fellow outpatient experience can include block time and longitudinal time in the outpatient clinics described under curriculum (V.A. above).

For non-continuity and clinical neurophysiology related clinics, list the following as averages per fellow per clinic half-day:

# New patients seen # Follow-up patients seen Staff/ fellow ratio

2. For the continuity seizure and/or neuromuscular longitudinal clinics, list the following as averages per fellow per clinic half-day.

# New patients seen # Follow-up patients seen Staff/ fellow ratio

3. What is the role of the clinical neurophysiology fellow in the performance of and interpretation of clinical neurophysiology studies of adult patients?


E. Clinical Neurophysiology EEG/EMG/SLEEP Diagnostic Categories

Provide the number of patients in each of the following diagnostic categories that were available in the program for the past year. Each patient should be listed only once in the most appropriate category.

Site #1 Site #2 Site #3 Site #4Epilepsy (adult/child)Generalized

Tonic-clonicAbsenceMyoclonic

Localization-relatedSimple partialComplex partialSecondarily generalizedSyncopeVasovagalIndeterminate spells

Other alterations of consciousnessComa

Motor unit disorders (adult/child)Motor neuron disordersNerve root disordersPlexopathiesPolyneuropathiesMononeuropathiesCranial nerve disorderNeuromuscular junction disorder

Muscle disorderDystrophiesCongenital myopathiesChannelopathiesInflammatory

Sleep DisordersDysomniasObstructive sleep apneaCentral sleep apneaNarcolepsyPeriodic limb movementsParasomnias

Autonomic Disorders (adult/child)Stroke related disordersNeoplastic diseaseMovement disorderCognitive disorderMultiple SclerosisMetabolic disorderTrauma


Site #1 Site #2 Site #3 Site #4Drugs and other toxic disordersPsychiatric disorders

TOTAL

F. Outpatient Specialty Clinics

Site Site #1 Site #2 Site #3 Site #4Specialty ClinicsClinic Name: Seizure

Number of clinics per monthAverage number of visits per clinicPercent visits seen by clinical neurophysiology fellows

Clinic Name: NeuromuscularNumber of clinics per monthAverage number of visits per clinicPercent visits seen by clinical neurophysiology fellows

Clinic Name: SleepNumber of clinics per monthAverage number of visits per clinicPercent visits seen by clinical neurophysiology fellows

* If more specialty clinics need to be listed, attach as supplemental pages.

G. Educational Program

1. What teaching responsibilities do clinical neurophysiology fellows have? (PR IV.C.II)

2. Outline fellow responsibility and frequency on night call at each site.

3. What provision is there to assure increasing patient responsibility and professional maturation of clinical neurophysiology fellows? (PR IV.)

4. Briefly describe how and when the following additional curricular areas taught (PR IV.)

Medical Ethics

Quality Assurance


Health Care Organization, Practice Management

Financing of Health Care

Management Information Systems


V. RESEARCH AND SCHOLARLY ACTIVITY (PR IV.C.10.)

A. Fellow Meeting Attendance

Provide a list of local, regional, and national neurological meetings that clinical neurophysiology fellows have attended over the past three years, showing the clinical neurophysiology fellows by name.

B. Fellow Research Projects

Describe the research projects, supervisors and their specialties, and the nature of the clinical neurophysiology fellows’ involvement in clinical neurophysiology research during the past five years. List by name those clinical neurophysiology fellows who participated in such research, the duration of their assignment, and whether full-time or part-time.

C. Fellow Publications

List the publications of clinical neurophysiology fellows from the clinical neurophysiology section/division during the past 36 months. (Do not include manuscripts submitted or in preparation)


VI. EVALUATION

A. Fellow Evaluation (PR III.A.2.g)

1. Does the faculty review a representative sample of the clinical neurophysiology fellow’s written patient records and reports?..............................................................................( ) YES ( ) NO

2. Does the program provide feedback to clinical neurophysiology fellow on audits of their written patient records? ( ) YES ( ) NO

3. Does the program perform a formal, observed clinical evaluation exercise (CEX) on clinical neurophysiology fellows at least once? .............................................................( ) YES ( ) NO

4. Describe the standardized methods for fellow evaluation used in the program (e.g., an in-service training exam).

5. Over the past 5 years what proportion of clinical neurophysiology fellows has taken these examinations?

B. Impaired Fellows

How does the program deal with impaired clinical neurophysiology fellows?

C. Fellow Stress

How does the does the program monitor clinical neurophysiology fellow stress, provide counseling and support services?


APPENDIX A - GOALS AND OBJECTIVES FOR THIS CLINICAL NEUROPHYSIOLOGY RESIDENCY PROGRAM


new application only

Documents

program requirements

program director

program cpr iv

new program

common program

program policies

proposed program

institutional requirements