Download - Program Requirements Pediatric Hematology-Oncology, III

PEDIATRIC HEMATOLOGY-ONCOLOGY 3/04

RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS515 N. State St., Suite 2000

Chicago, IL 60610

INSTRUCTIONS FOR COMPLETING PROGRAM INFORMATION FORMS FOR PROGRAMS IN Pediatric HEMATOLOGY-ONCOLOGY

The same program information form (PIF) is used for those making initial application and those undergoing periodic re-review. This program information form is to be used in conjunction with the Program Requirements for Residency Education in Pediatric Hematology-Oncology.

Applications: The RRC will evaluate an application for a new program without a prior site visit. Contact the RRC office for deadlines. Note that a subspecialty program must function in conjunction with a fully accredited program in pediatrics that is in good standing.

Title: The title of a subspecialty program should correspond to the title of the affiliated pediatrics program to facilitate cross-referencing. The official name of the core program and ID number may be obtained from the institution or from the director of the core pediatrics program.

Refer to the Program Requirements in the Subspecialties of Pediatrics II.A Sponsor: Identify as the SPONSORING INSTITUTION that entity which has final administrative

responsibility for the program, as evidenced by the fact that it monitors the quality of the education and coordinates the accreditation activity. This must be the same sponsor as for the core pediatrics residency. If the SPONSORING INSTITUTION and the PRIMARY HOSPITAL are one and the same, the hospital's name should be entered in both sections.

Before work is begun on this form, the Program Requirements for Subspecialties of Pediatrics and the Program Requirements for Residency Education in Pediatric Hematology-Oncology should be thoroughly reviewed. Copies of these documents may be obtained from the ACGME website (www.acgme.org).

If more than one hospital participates in the program, information on each hospital should be given as requested. The program director is responsible for gathering the requested data from the participating institutions and consolidating the information on one form.

The total length of time subspecialty residents are assigned to each participating hospital should be filled in as requested on Pages 1 and 2.

It is important that the original pagination remain the same. If necessary, paginate the forms by hand in the upper right corner. See note below.

All sections of the form must be completed. If any requested information is not available, an explanation should be given in the appropriate place on the form. The completed form should be prepared as a single document with all added pages numbered in sequence as requested. INCLUDE ONLY THE REQUESTED INFORMATION. INCOMPLETE APPLICATIONS WILL BE RETURNED, WHICH COULD DELAY THE DECISION MAKING PROCESS.

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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 Department Chair/Chief of Service and the Designated Institutional Official (DIO) of the sponsoring institution.

ALL PAGES INCLUDED IN THE FORM SHOULD BE 8 2" BY 11". DO NOT USE UNDERSIZED OR OVERSIZED SHEETS. Each copy of the completed form may be secured with a rubber band, a clip, or it may be loosely enclosed in protective materials. DO NOT punch holes in the form. Remove all staples within the form, e.g., from the CV's. DO NOT use any kind of process to bind the form or attach it to anything. DO NOT insert section dividers. The number of copies to be submitted will vary as follows:

New application: Send four complete copies to the Executive Director of the Residency Review Committee for Pediatrics at the above address.

Resurvey: See letter announcing the site visit.

Resident: Resident and subspecialty resident are used interchangeably in this document.Pediatric residents are referred to as such.

If you have questions about the form, contact the Accreditation Administrator (Phone: 312-755-5044). For word processing questions/problems, contact the ACGME Help Desk (Phone: 312-755-7464). For questions regarding a site visit, contact the writer of the letter announcing the survey.

NOTE THAT THE DOCUMENT IS SET FOR AUTOMATIC PAGE NUMBERING. IF THIS PRESENTS A PROBLEM, GO TO THE TOP OF THE FIRST NUMBERED PAGE 1, TURN PAGE NUMBERING OFF BY CLICKING ON FORMAT, PAGE, AND THEN NUMBERING. IF YOU TURN THIS FEATURE OFF, HAND NUMBER ALL PAGES SEQUENTIALLY IN ACCORDANCE WITH THE INSTRUCTIONS.

Peds\pif-pd\327pif03.doc

THE RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS

Pediatric Hematology-OncologyPROGRAM INFORMATION FORM CHECKLIST

Use this checklist before submitting the forms to the RRC office. The RRC considers it the responsibility of the program director to ensure that the application materials are complete. The signature of the program director on the forms indicates his/her approval of the content. A review of the instructions provided at the beginning of the form and on individual pages is suggested.

Have the appropriate person(s) signed page 1 of the forms where requested?

_______ Has Appendix A, the program director=s CV, been attached?

_______ Has Appendix B, the one-page CV of each essential faculty member, been included according to the instructions?

Is the form free of unrequested schedules, printouts, reprints, catalogs, brochures, etc.?

Are all requested official letters of agreement/affiliation appended as requested on pages 1 and 2?

Has the final copy been carefully proofread, and has it been checked to see that every question has been answered, every chart completed, etc.?

Once the preparer is satisfied that the form has been completed and assembled correctly, make the appropriate number of copies. After the copies have been made, review the individual sets to be sure that all of the copied pages are legible and that each set of forms contains all of the pages in the original. ALL PAGES INCLUDED IN THE FORM SHOULD BE 8-1/2" by 11". DO NOT USE UNDERSIZED OR OVERSIZED SHEETS. The completed copies of the form may be secured with one large rubberband or enclosed in a folder. DO NOT STAPLE INDIVIDUAL SECTIONS. Holes should not be punched in the form and it should not be attached to the folder.

DO NOT INCLUDE THIS PAGE IN THE PROGRAM INFORMATION FORMS.

3/04 RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS515 North State Street, Suite 2000, Chicago, Illinois 60610

PROGRAM INFORMATION FORMPEDIATRIC HEMATOLOGY-ONCOLOGY MEDICINE

Date:

New Program Application: Yes No

TITLE OF PROGRAM: (Use first line of program listing on the ACGME Website for core Pediatrics program to which this program is attached.)

10-digit ACGME Subspecialty Program ID # 327____________

Title of Core Pediatrics Program:

10-digit ACGME Core Pediatrics Program ID#

Accreditation Status of Core Pediatrics Program:

Name and mailing address of Pediatric Hematology-Oncology Program Director:

Name: Full Time: YES NO

Title:

Address:

E-mail Address:

Telephone: Fax:

The signatures of the director of the program and the chief of the department attest to the completeness and accuracy of the information provided on these forms.

Pediatric Hematology-Oncology Program Director Name (typed):

Chief of Pediatrics/Department Chair Name (typed):

Signature: Signature:

Program Requirements for Subspecialties of Pediatrics II.A.

SPONSORING INSTITUTION: (Name the entity, i.e., the university, hospital, or foundation that has administrative responsibility for this program. Must be the same as the sponsor of the core pediatrics program.)

Name of Sponsor:

Address:

Name of Designated Institutional Official (DIO) (Typed):

Signature:

Is there an affiliation with a medical school? If so, name: Yes No

Program Requirements for Subspecialties of Pediatrics II.B. 2

PRIMARY HOSPITAL (Hospital 1)

Name:

Address:

Total number of months Pediatric Hematology-Oncology subspecialtyresident is assigned to this institution in each year of training:

Year 1: Year 2: Year 3:

Chief/Chair, Department of Pediatrics:

For each participating institution provide letters of agreement specifying the administrative and organizational relationships which bear upon the educational program. Attach as Appendix C.

OTHER PARTICIPATING INSTITUTION (Hospital 2)

Name:

Address:

Total number of months Pediatric Hematology-Oncology subspecialty resident is assigned to this institution in each year of training:

Year 1: Year 2: Year 3:

Distance between 2 and 1 in: Miles: Minutes:

Is this hospital used for: (Please X appropriate box) Requiredrotations?

Electiverotations?

Both?

OTHER PARTICIPATING INSTITUTION (Hospital 3)

Name:

Address:

Total number of months Pediatric Hematology-Oncology subspecialtyresident is assigned to this institution in each year of training:

Year 1 Year 2 Year 3

Distance between 3 and 1 in: Miles: Minutes:

Is this hospital used for: (check appropriate box) Requiredrotations?

Electiverotations?

Both?

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BACKGROUND INFORMATION

Provide a response for each of the points below. If a category is not applicable, list it and indicate N/A.

1. PREVIOUS CITATIONS AND/OR CONCERNS:

List each of the citations and/or concerns, if any, from the notification letter that was sent following the last survey and review of the program and briefly and concisely describe the steps that have been taken to correct the problem. If such correction is documented in the program information form you prepare for this review, provide page references

2. CHANGES:

Briefly describe major changes, other than those included in the response to previous citations and/or concerns (above), that have been implemented since the last survey and review. Include changes in sponsoring organization, participating hospitals, required rotations, program director, essential faculty, resident complement, etc.

4SUBSPECIALTY RESIDENTS

Programs making initial application should provide ONLY THE INFORMATION marked by an asterisk (*) in the top section of the page.

Program Requirments for Subspecialties of Pediatrics II.C.

*Number of positions offered: Year 1 Year 2 Year 3

*Number of positions filled: Year 1 Year 2 Year 3

*Source of salary support for subspecialty residents: Add the salaries of all residents and indicate what percent of the total is supplied by each of the following services:

% from NIH:

% from other non-federal programs:

% from hospital:

% from other federal programs:

% from practice-generated income:

% from other:

*Does the program have a funded training grant?

YES *If yes, supply the following:

NO

*Grant: *Amount *Project Director:

CURRENT SUBSPECIALTY RESIDENTS (Refer to the Program Requirements for Subspecialties of Pediatrics II.C.)Provide the following information regarding the current residents in the program:

Name

Name of ACGME-accredited pediatric residency program

completed/or other*

Date of completion of

residencyDate of ABP

Certifi.*

Date began Hematology-Oncology

program

Example: John Doe State Univ. School of Med. 1997 1997 July 1, 1997

Example: Mary Smith Foreign Country Med. School

1993 N/A July 1, 1997

*Explain exceptions (Insert text in box and limit your response to this page) Example: Mary Smith completed a pediatrics training program in a foreign country and was judged suitable for participation in subspecialty training. She will not be eligible to sit for the sub-board certifying examination.

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SUBSPECIALTY RESIDENTS (continued)

Provide the following information regarding those who have completed the program in the last seven years. Use additional pages as necessary, numbered 5a, 5b, etc. A program will be judged deficient if, over a period of 5-10 years, fewer than 75% of those completing the program have taken the certifying examination.

Total number of graduates who have completed the program in the last seven years:

Number of graduates who have taken the sub board certifying examination. Of this number, indicate how many have passed.

#Graduates

Total_____

# Takers

Total___

# Passed

Total___

Program Requirements in the Subspecialties of Pediatrics VIII.List residents in sequence by year of completion hematology-oncology program

List Graduates of Last 7 Years Date completed hematology-

oncology program

Took & Passed subspecialty

certification exam and date

Failed subspecialty certification

exam and date

Name of ACGME accredited

pediatric residency program

completed or

Date of completion

of residency

Date of ABP

Certifi.*

other*

Example: John Doe July 1, 2000 Yes8/13/2000

State Univ. School of Med.

1997 1997

Example: Mary Smith July 1, 1997 N/A N/A Foreign Med. School*

1992 N/A

*Explain exceptions (Insert text in this box and limit your response to this page) Example: Mary Smith completed a pediatrics training program in a foreign country and was, therefore, ineligible to sit for the sub-board certifying examination.

PROGRAM FACULTYProgram Requirements for Subspecialties of Pediatrics, IVProgram Requirements Pediatric Hematology-Oncology, II

A. PROGRAM DIRECTOR (Program Requirements for the Subspecialties of Pediatrics IV.A.)

Explain on a page numbered 6a how the program director meets the Program Requirements with regard to: a) Board and Sub-board certification (If not certified by the American Board of Pediatrics' Sub-board of Pediatric Hematology-Oncology, provide evidence of appropriate educational qualifications); b) Competence as a teacher and researcher; c) Adequate administrative experience to direct the program; and d) list other professional responsibilities; such as, division chief, department chair, private practice, and amount of time devoted to each. Attach as Appendix A the program director's full curriculum vitae and complete bibliography of articles in peer-reviewed journals.

B. FACULTY (Program Requirements for Hematology/Oncology II.A.)

Identify the essential faculty members who are direct contributors to the program (Refer to Section II of Program Requirements for Hematology-Oncology) , including the program director. List the Pediatric Hematology/Oncology subspecialists. Also include and identify any research mentors who participate in training in addition to the pediatric hematology-oncology subspecialists.

1. Provide details of each individual's role in this training program. If not certified in Pediatric Hematology-Oncology, provide evidence of appropriate educational qualifications. Specify the type of contact with the residents, e.g., lectures, group discussions, ward rounds, laboratory supervision, patient care activities, consultations. Indicate clearly how the reported time is distributed. Include research mentors. Use additional pages as needed, numbered as 6a, 6b, etc.

2. Attach curriculum vitae using the CV format contained on the page identified as Appendix B at the end of this form and follow its instructions. Do not include the CV for the program director as part of Appendix B.

Name Primary specialty

Time contributed to subspecialty

program Location/Hospital 1, 2, 3

Certification

Hours per

week

Weeks per year

Primary Board &

year

Recertify& year

Sub-Board & year

Sub-Board

Recertify year

State primary role in program

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PROGRAM FACULTY (Continued) 7

C. OTHER PHYSICIAN TEACHING AND CONSULTANT FACULTY (working with Pediatric Hematology-Oncology) at participating hospitals:

Complete the following chart identifying the main person involved. It is understood that certification is not available in all of the disciplines listed below. List most recent certification or recertification, name of Board, and date. (If adult specialists coverpediatric subspecialties, enclose name or number in parentheses.) DO NOT include CVs.

If any of the above are not housed predominantly in the primary hospital, provide specific details of their availability to the program. Include on a page numbered 7a.Program Requirements in Pediatric Hematology-Oncology II.B.

Discipline NameHospital 1,

2, or 3Certification/

Sub-certification/Recertification

Name of Board/Sub-board

Year of cert./

recert.

SPECIFIC TO HEMATOLOGY-ONCOLOGY

Gynecology

Hematopathology

Neuro-oncology

Pain Control

Radiation Oncology

Physical Medicine and Rehabilitation

PEDIATRIC SUBSPECIALTIES

Adolescent Medicine

Cardiology

Critical Care

Emergency Medicine

Endocrinology

Gastroenterology

Hematology/Oncology

Infectious Diseases

Neonatal-Perinatal

Nephrology

Pulmonology

Rheumatology

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Discipline NameHospital 1,

2, or 3Certification/

Sub-certification/Recertification

Name of Board/Sub-board

Year of cert./

recert.

SURGICAL

Pediatric Neurosurgery

Pediatric

Pediatric Surgery

Pediatric Urology

OTHER DISCIPLINES

Anesthesia

Genetics

Immunology

Nuclear Medicine

Child Neurology

Surgical Pathology

Child and Adolescent Psychiatry

Radiology

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PROGRAM FACULTY (Continued)

D. OTHER PROFESSIONAL PERSONNEL

List only the numbers of those who work in the Pediatric Hematology-Oncology training program:

Number of staff in these categories Hospital 1 Hospital 2 Hospital 3

Psycho-Social support staff

Social Service staff

Pediatric Dietary Service/Nutrition staff

Nurse Specialists and/or Physician Extenders (e.g., pediatric nurse practitioners and/or physician's assistants trained in this specialty

Pediatric occupational and physical therapists

Respiratory therapists

Other (specify)

Describe the involvement of the staff in each of these categories in the Pediatric Hematology-Oncology program:

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FACILITIES AND SERVICES

Indicate the availability of the following:

Program Requirements for the Subspecialties of Pediatrics V.B.&D.Program Requirements for Pediatric Hematology-Oncology III.

Facility/Service

Hospital 1 Hospital 2 Hospital 3

Yes No Yes No Yes No

Are there separate divisions of hematology and oncology*

Space in an ambulatory setting for optimal evaluation and care of patients

An inpatient area with full pediatric and related services (including surgery and psychiatry) staffed by pediatric residents and faculty

Full support services including radiology laboratory, nuclear medicine and pathology

Pediatric intensive care unit

Neonatal intensive care unit

Using the hospital designated as Primary Hospital 1, provide the following information:

Primary Hospital 1 only Number of Beds

Inpatient Pediatrics exclusive of ICU

PICU

NICU

*Provide a description of the organization if separate divisions are indicated. Specifically state the administrative and teaching role of each division in the training program.

Provide a detailed explanation if NO is indicated for any of the facilities and/or services across all hospitals.

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FACILITIES AND SERVICES

Program Requirements Pediatric Hematology-Oncology, III

Indicate the availability of the following:

ServiceHospital 1 Hospital 2 Hospital 3

Yes No Yes No Yes No

DIAGNOSTIC RADIOLOGY

1. Angiography

2. Nuclear medicine capabilities

3. Computerized tomography

4. Ultrasonography

5. Magnetic resonance imaging

6. PET scanner

PROCEDURAL EXPERIENCE

7. Bone marrow/PBSC transplantation

8. Solid organ transplantation

9. Renal hemodialysis

10. Limb-saving procedures

ADMINISTRATIVE

11. Tumor registry

12. Tumor board Cancer rehabilitation program

CLINICAL PROGRAMS

13. Transfusion medicine program

14. Hemophilia program

15. Sickle cell/hemoglobiopathy program

FAMILY SUPPORT

16. Hospice program for children

17. Parent support group

18. Cancer rehabilitation program

19. Radiation Oncology facility

If NO is indicated for any facilities and/or services in the primary institution (Hospital 1) above, explain how the service is provided in either hospital 2 or 3 or in some other location.

Describe the clinical laboratory facilities available to the residents in support of patient care. Are they convenient to patient care areas? To what extent are they used by residents?

12

SUPPORT SERVICESProgram Requirements Pediatric Hematology-Oncology, III

Place a check mark in the appropriate spaces where these particular services are available at the participating institutions in the program. This list is for screening purposes only. It does not include all tests or services though desirable for training, nor must all of the services listed be available for a program to be accredited.

AVAILABLE AVAILABLE24 HOURS/DAY

Hospital 1 Hospital 2 Hospital 3 Hospital 1 Hospital 2 Hospital 3

1. Drug assays

2. Antibiotic

3. Radioisotopic cardiac imaging

4. Echocardiography

5. Diagnostic microbiology

6. Diagnostic virology

7. Hemoglobin electrophoresis

8. Red cell enzyme studies

9. Tissue typing laboratory

10. Coagulation laboratory (factor assays, platelet function)

11. Karyotyping and molecular cytogenetics

12. Molecular genetics laboratory

13. Flow cytometery

13PATIENT DATA

Provide the requested information for the most recent 12 month period or academic year using the same timeframe for all patient and procedural data on subsequent pages.

Program Requirements for the Subspecialties of Pediatrics V.C.Program Requirements for Pediatric Hematology-Oncology IV.

Inclusive dates: From (mo/day/yr): To (mo/day/yr):

A. INPATIENT Hospital 1 Hospital 2 Hospital 3

1. Total number of admissions for whom the pediatric hematology service assumed major clinical responsibility

a. Average daily census of patients on the pediatric hematology-oncology service

b. Number of new patients admitted each year (“new” refers to those who are being seen by hematologists/oncologists for the first time)

c. Average length of stay of patients on the pediatric hematology-oncology service

2. Number of consultations by pediatric hematologists/oncologists on other inpatients

a. Are consultations provided to the NICU?

Yes or No

If yes, how many?

b. Are consultations provided to the PICU? Yes or No

If yes, how many?

If the program does not have a sizable population of patients with nononcologic hematologic disorders, such as one basedin a cancer center, explain how residents gain exposure to sickle cell disease, hemophilia, and other acute and chronic hematologic problems.

AMBULATORY PEDIATRIC HEMATOLOGY-ONCOLOGY EXPERIENCEFOR ALL YEARS OF TRAINING

Name of ExperienceHospital/Other Setting Identifier

Duration ofExperience(in wks/yr)

Number ofSessions Per

Week PerResident

Number ofNew Patients

PerResident

Per Session

Number ofReturn

Patients Perresident

Per Session

AverageNumber

Other TraineesPer Session

AverageNumberTeaching

AttendingsPer Session

FacultySupervision

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

1. If the experience is in a private office, provide full details, including name and credentials of supervisor, numbers and types of patients, degree of resident responsibility for their care, frequency of attendance at office, how director monitors the experience and resident performance. Include as pages 14a, 14b, etc.

2. Explain how the residents have the opportunity to provide outpatient care for patients whom they treated on the inpatient service.

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15LIST OF DIAGNOSES

List 150 consecutive inpatient admissions (A) and consultations (C) from the general pediatric service to the Pediatric Hematology-Oncology service during the same 12-month period as used on previous pages. Use additional pages as necessary. Submit a separate list for each hospital that provides required rotations. Number these pages as 15a, 15b, etc.

Hospital:

Give inclusive dates during which these admissions/consultations occurred: From (mo/day/yr): To (mo/day/yr):

Patient ID Number of days in hospital

Primary Hematologic/Oncologic Diagnosis (i.e. Osteosarcoma,

Thalassemia)

Reason for Admission (I.e. Sepsis, Aplastic Crisis, Chemotherapy, etc. OutcomeA or C Number Age

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12-MONTH SUMMARY - INPATIENT SERVICE

Summarize how many pediatric patients with the following hematologic-oncologic problems were admitted to or consulted on by the Hematology-Oncology service at the primary hospital. This should cover the same 12-month period used on the previous pages. Extract the information from the list of diagnoses on page 15 of this form. FOR NEW APPLICATIONS FILL IN ONLY THE FIRST TWO COLUMNS.

Hospital Name:

Inclusive Dates: From (mo/day/yr): To (mo/day/yr):

Program Requirements for Pediatric Hematology-Oncology IV.B.

Disorders

Number of patients Number seen by residents

Number on hem/onc service

Number seen in consultation

Number on hem/onc service

Number of consultations

1. Leukemia, active treatment

2 Solid tumors, active treatment

3. Lymphomas, active treatment

4. Oncology patients in follow-up

5. Bone marrow failure

6. Disorder of red cell membrane and red-blood-cell metabolism

7. Autoimmune disorders including hemolytic anemia

8. Nutritional Anemia

9. Hemoglobinopathies

10. Thalassemia Syndromes

11. Disorders of white blood cells

12. Platelet disorders

13. Hemophilia and other inherited bleeding disorders

14. Other coagulation/hemostatic disorders

15. Congenital and acquired thrombotic disorders

16. Immunodeficiencies (congenital and acquired)

17. Other Disorders: (please specify)

17

OUTPATIENT VISITS

Provide the requested information for the most recent 12 month period or academic year using the same timeframe for all patient and procedural data on subsequent pages.


AMBULATORY VISITS Hospital 1 Hospital 2 Hospital 3

1. Is there a separate Hematology-Oncology clinic? Yes or No

2. If not, where are the ambulatory pediatric Hematology-Oncology patients seen (e.g. offices, clinics, location?

3. Number of pediatric hematology-oncology ambulatory visits per year available to residents.

4. Of this number, how many are new patients? (Anew@ refers to those who are being seen by members of the Hematology-Oncology service for the first time.):

5. Number of Pediatric Hematology-Oncology clinic sessions per week:

6. Estimate the number of pediatric Hematology- Oncology clinics a resident attends per year in the program.

1st Year 2nd Year 3rd Year

7. If the experience is in a private office remote from the primary or affiliated institutions, provide full details,

including name and credentials of supervisor, numbers and types of patients, degree of resident responsibility for their care, frequency of attendance at office, how experience and resident performance are monitored. Include as pages 17a, 17b, etc.

8. Explain how the residents have the opportunity to provide outpatient care for patients whom they treated on the inpatient service.

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12-MONTH SUMMARY - OUTPATIENT SERVICE

Summarize how many visits and pediatric patients with the following hematologic-oncologic problems were seen or consulted on by the Hematology-Oncology service at the primary hospital. This should include all procedures in the same 12-month period used on the previous pages. FOR NEW APPLICATIONS FILL IN ONLY THE FIRST TWO COLUMNS.

Hospital Name:


Disorders

Total Number seen by residents

Number of visits on hem/onc service

Number of new patients

Number of visits on hem/onc service

Number of new patients

1. Leukemia, active treatment

2 Solid tumors, active treatment

3. Lymphomas, active treatment

4. Oncology patients in follow-up

5. Bone marrow failure

6. Disorder of red cell membrane and red-blood-cell metabolism

7. Autoimmune disorders including hemolytic anemia

8. Nutritional Anemia

9. Hemoglobinopathies

10. Thalassemia Syndromes

11. Disorders of white blood cells

12. Platelet disorders

13. Hemophilia and other inherited bleeding disorders

14. Other coagulation/hemostatic disorders


16. Immunodeficiencies (congenital and acquired)


18. Other Disorders: (please specify)

19

TRANSPLANTS

Indicate the number of transplants performed on patients 18 years or younger for the most recent 12 month period or academic year using the same time frame for all patient and procedural data as provided on subsequent pages. (Specify inclusive dates: from month/day/ year to month/day year.)


DiagnosisAllogeneic Autologous Bone Marrow Peripheral

Blood Stem Cell

Umbilical Cord

Leukemias

Lymphomas solid tumors

Hematologic disorders

Immunologic disorders

Metabolic disorders

CURRICULUM

The purpose of a block diagram is to give the Residency Review Committee an overview of what takes place during each year of training.

1. In each block indicate the periods of time (1 month or one 4-week block) and percentages (100% clinical 50%, research, etc.) that represent the program. Designate clinical (C), research (R), elective (E), call from home (H), in-house called required (IH). Include vacation.

2. If one month is both clinical and research, indicate both in the block with percentages.

3. Identify the site in which each occurs (i.e., Hospital 1, Hospital 2, Site A, B, etc.) as designated on pages

1-3of this form. Asterisk the rotations that are call free.

Program Requirements for the Subspecialties of Pediatrics VI.D.Program Requirements for Pediatric Hematology-Oncology IV.D.

Example:

Month/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13

Experience or rotations

Hemonc (C)*

100% 1 IH

Hemonc (C)*

100% 1IH

Hemonc (C)100%

1

Rad. Oncology (C)

100% 1

Rad. Oncology (C)

100% 1

Neuro Oncology (C)

100% 1

Hemonc (C) 100%

1

Hemonc (C)100% 1 H

Research (R) 100%1

H

Research (R)

100% 2

Research* (R)

100% 1 VAC N/A

*Asterisk rotations that are call free FIRST YEAR BLOCK DIAGRAM

Month/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13


SECOND YEAR BLOCK DIAGRAM

Month/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13


THIRD YEAR BLOCK DIAGRAM

Month/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13


Total number of months clinical_____________.

Total number of months research___________. 20

21

CURRICULUM (Continued)

If there are any exceptions to the training program as outlined on the previous page for any of the current residents, describe these exceptions below:

SERVICE DUTIES (Program Requirements for Subspecialties of Pediatrics, VI.F.)Describe the call schedule and specify whether it is on-site or from home. Demonstrate how the schedule allows the subspecialty residents a monthly average of one day in seven away from program duties.

Describe the night call responsibilities during all rotations, including research, and whether call is done in-house or from home.

22

HAVE CONFERENCE SCHEDULE AVAILABLE FOR REVIEW BY SITE VISITOR. DO NOT APPEND CONFERENCE SCHEDULE.

CONFERENCES

List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the Pediatric Hematology-Oncologytraining program. Identify the "INSTITUTION" by using the corresponding number as appears on the first and second pages of this form. Indicate the frequency, e.g., weekly, monthly, etc., and whether conference attendance is required (R) or optional (0).

Program Requirements for the Subspecialties of Pediatrics VI.E.Program Requirements for Pediatric Hematology-Oncology IV.D.

Conference R/O FrequencyPerson(s) responsible for

conducting conferenceHospital

1, 2, 3

Describe how residents participate in these activities:

Describe the mechanisms that are used to assure subspecialty resident attendance at required conferences. State to what degree faculty attendance is expected and how it is monitored:

23

NARRATIVE DESCRIPTION

Provide a narrative description of this subspecialty program. The points listed below should be covered in the narrative. Note that the boxes will expand as text is entered and pages will automatically number. If page numbering becomes a problem, turn off the page numbering function, and number pages sequentially by hand. See page 2 of the instructions for further information.

A. PROGRAM GOALS AND OBJECTIVES (Program Requirements for Subspecialties of Pediatrics IV.A.2.)

1. Describe how the written statement outlining the goals of the program for each level of training with respect to knowledge, skills, and other attributes, and for each major rotation or other program assignment are distributed to subspecialty residents and members of the teaching staff. The written statement outlining the educational goals as required in IV.A.2 must be made available to the site visitor. Do not include with the program information form.

2. Describe how goals and objectives are reviewed and revised. Describe the role of the subspecialty resident and faculty in this process.

3. Describe how the written guidelines describing supervisory lines of responsibility for the care of patients are communicated to all members of the program staff.

B. RELATIONSHIP TO OTHER PROGRAMS (Program Requirements for the Subspecialties of Pediatrics I. & VI.E.)

1. Describe the differences in responsibilities for the subspecialty residents at each level of training from those of the pediatric residents.

2. Describe how patients are assigned or apportioned between the pediatric residents and those in this subspecialty program.

3. Describe how those in this subspecialty program are involved with other pediatric subspecialty residents, other clinics, departments and accredited residency programs.

C. SPECIALTY EXPERIENCES (Program Requirements for the Subspecialties of Pediatrics VI.B. and Program Requirements for Pediatric Hematology-Oncology IV.B.)

1. Provide a general description of each year of training.

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NARRATIVE DESCRIPTION (Continued)

2. Inpatient experiences

a. Describe the responsibilities do the subspecialty residents have for inpatients when assigned to inpatient services.

b. Describe how and by whom the subspecialty residents are they supervised in the outpatient setting.

c. State how many hours per week the subspecialty residents participate in rounds with faculty. Describe this

experience.

3. Outpatient experiences (If applicable)

a. Describe the degree of responsibility do the residents have for required outpatient care.

b. Describe the continuity of care experience they receive during their period of assignment to the outpatient

clinic. To what extent do they have the opportunity to provide outpatient care for patients whom they treated on the inpatient service?

c. Describe how and by whom the subspecialty residents are supervised in the outpatient setting.

d. Describe any additional outpatient facilities where residents gain ambulatory experience, e.g. emergency department and other clinics. Include the nature of the experience, location, supervision and the educational rationale for each.

4. Core Curriculum

a. Describe how the program provides instruction in the related basic sciences, including the structure and function

of hemoglobin and iron metabolism, the phagocytic system, splenic function, cell kinetics, immunology, coagulation, genetics, the principles of radiation therapy, the characteristics of malignant cells, tissue typing, blood groups, pharmacology of chemotherapeutic agents, molecular biology, microbiology and anti-infective agents in the compromised host, and nutrition.

b. Describe how the subspecialty resident acquire information and experience in cultural, social, family, behavioral and economic issues such as confidentiality of information, indications for life support systems, and allocation of limited resources. How is information regarding the social and economic impact of the resident=s decisions on patients, the primary care physician and society incorporated into their training.

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c. Provide a description of the method by which residents acquire skills in the following:

1. Performance and interpretation of bone marrow aspiration and biopsy; 2. Lumbar puncture with evaluation of cerebrospinal fluid;

3. Microscopic interpretation of peripheral blood films; and4. Interpretation of other hematologic laboratory diagnostic tests.

d. Describe how the subspecialty residents become familiar with all aspects of chemotherapy, surgical therapy and radiotherapy, including treatment protocols and management of complications, diagnosis and treatment of

infections in the compromised host, appropriate use of transfusion of the various blood components, including apheresis plateletpheresis and stem cell harvest and infusion.

e. Describe any special sessions/coursework/special laboratory experiences in which the residents participate.

f. Describe how psycho-social aspects and ethical issues related to this subspecialty are taught to the residents.

Do they obtain experience in the process of obtaining informed consent from patients and/or families.

g. Describe the residents’ instruction and experience in the administration of a Pediatric Hematology-Oncology facility.

D. TEACHING AND ADMINISTRATIVE EXPERIENCE (Program Requirements for the Subspecialties of Pediatrics VI.E. and Program Requirements for Pediatric Hematology-Oncology IV.E.)

1. Describe the residents' opportunity to teach and to assume some departmental administrative responsibilities.

2. Describe how these teaching experiences correlate basic biomedical knowledge with the clinical aspects of the subspecialty.

3. Describe how the program provides instruction in curriculum design and in the development of teaching material for the subspecialty residents.

26NARRATIVE DESCRIPTION (Continued)

4. Describe how the subspecialty residents are involved in the education of more junior trainees; such as, medical students, and pediatric residents.

E. FACULTY RESEARCH (Program Requirements for Subspecialties of Pediatrics, VI.G.)

1. Describe how the program director is directly involved in a research program.

2. Describe participation of other faculty in this subspecialty who are actively engaged in a research program.

F. RESIDENT RESEARCH PROGRAM

1. Describe how the program ensures a meaningful supervised research experience for the residents, beginning in their

first year and extending throughout their training. Include a description of how they learn experimental design, data collection and analysis, and laboratory techniques used in this subspecialty research. Include the plans for frequency and duration of these sessions and the year of training in which they occur. Identify the teacher/supervisor in each case, and specify call-free research time.

2. Within the research conferences and clinical experiences, describe how the residents are exposed to the concept of

multi institutional collaborative research.

3. If faculty outside the division are actively involved in (research) mentoring the residents, list and provide details.

4. Describe the support and guidance the subspecialty residents receive in the preparation of manuscripts, presentations, and the process of grant application.

5. Describe research facilities, space and equipment directly related to this subspecialty program and the residents' research activity.

27NARRATIVE DESCRIPTION (Continued)

6. List active research projects in this subspecialty. Include the title of the project, the principal investigator(s), and the amount, dates and source(s) of financial support.

RESEARCH PROJECTS

Title of Project Principal Investigator(s) Amount of Financial Support

Dates of Financial Support Source(s) of Financial Support

7. To enable the Committee to assess the scholarly environment that has occurred in the program, provide a list of scholarly publications and presentations at regional, national and international meetings by faculty and residents within the program for the last five years only. Do not duplicate citations. Underline the names of subspecialty residents. List journal articles, presentations and abstracts separately under those headings.

G. EVALUATION (Program Requirements for Subspecialties of Pediatrics, VII)Do not attach evaluation forms but have them available for inspection by the site visitor. Demonstrate to the site visitor that the pediatric core=s evaluation mechanisms were adopted.

1. Evaluation of subspecialty residents

a. Describe the frequency and by whom the residents in this program formally evaluated.

b. Describe the formal mechanisms for monitoring each resident=s acquisition of skills utilized in this subspecialty. Describe what part this process plays in the evaluation of subspecialty residents.

c. Describe how the program demonstrates that it has an effective plan for assessing resident performance throughout the program and for utilizing assessment results to improve resident performance.

d. Explain the process, frequency and by whom these written evaluations are discussed and whether they have the opportunity to read and respond to their evaluations.

e. Describe the information that is in the final written evaluation for each subspecialty resident who completes the program and where the evaluation is kept.

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2. Evaluation of faculty

a. Describe the mechanism, frequency and by whom faculty are evaluated on their teaching ability, clinical knowledge and scholarly activity.

b. Describe how the subspecialty residents in this training program participate confidentially in the process.

3. Evaluation of program by staff and residents.

a. Describe the mechanisms for periodic evaluation of the training program by the staff and the residents.

b. Explain how these evaluations are used in program planning and development.

c. Describe the mechanism by which the subspecialty residents participate confidentially in program evaluation.

Appendix BCURRICULUM VITAE

CV should be condensed to fit this page. Do not addadditional pages except as directed below.

.

Name:

Position:

Address:

Professional Education (including dates and degrees obtained):

Hospital Training (including dates of internships, residencies, fellowships, etc.):

Current professional appointments:

Primary certification* (including name & date): Subspecialty certification* (including date:) Recertification (including date):

Professional activities/committees:

Provide a brief description of your teaching role in this subspecialty program:

Include a bibliography for the past FIVE YEARS, limited to articles published or in press and abstracts presented. (May be listed on a separate page.)

*If not Board Certified, provide evidence of appropriate educational credentials.

C O N T E N T S

PROGRAM NAME:PROGRAM #:Retain our pagination followed through the form, e.g., 8, 8a, 8b, etc. When you finish, go through the form, number each page sequentially with black ink or typed in upper right hand corner. Report this pagination on this page. Place this page at the front of the form.

SECTION IN PROGRAM INFORMATION FORM Page Number(s)

1. Training Sites

Sponsoring Institution

Participating Institutions

2. Background Information

Previous Citations and/or Concerns

Changes

3. Pediatric Hematology-Oncology Residents

4. Program Faculty

A. Program Director

B. Faculty

C. Other Physician Teaching and Consultant Faculty

D. Other Professional Personnel

5. Facilities and Services

6. Patient Data

Inpatient Service

Ambulatory Experience

7. List of Diagnoses

8. 12 Month Summary: Inpatient Services

9. Outpatient Visits

10. 12 Month Summary: Outpatient Services

11. Transplants

12. Curriculum

Block Diagram

Service Duties

13. Conferences

14. Narrative Description of the Pediatric Hematology-Oncology

Program

A. Program Goals and Objectives

B. Relationship to Other Programs

C. Specialty Experiences

D. Teaching Experience

E. Faculty Research

F. Resident Research Program

G. Evaluation

15. Appendices

Appendix A (Program Director’s Full CV)

Appendix B (Teaching Staff CV’s)

Appendix C (Letters of Agreement)

Download - Program Requirements Pediatric Hematology-Oncology, III

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