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If not, explain why.JIf applicable, attach a detailed description of any innovative project(s).Through a match (NRMP, SFM) Total ENumber of full-time non-physician faculty (specify credential)-QNumber of part-time non-physician faculty (specify credential)=Site and Site Status (primary site, integrated site, major participating site, participating affiliate site, other)/(Affiliate Name and Status)9Was verification of training obtained before acceptance?&Was verification of training provided?Department Chairperson: Signature: Report Date:4 6Reporting Period (acad year): ___/20____ to ___/20___M assurance of the safety and welfare of patients entrusted to their care?4 provision of patient- and family-centered care?) assurance of their fitness for duty?M management of their time before, during, and after clinical assignments?` recognition of impairment, including illness and fatigue, in themselves and in their peers?$ attention to lifelong learning?M the monitoring of their patient care performance improvement indicators?a honest and accurate reporting of duty hours, patient outcomes, and clinical experience data?~Attach as an appendix a summary of de-identified deviations from the standards from the most recently completed academic year.IV.B.3. How many faculty have been involved in productive scholarship (original research or review articles) during the most recently completed academic year? What percent of the teaching faculty does this represent?II.B.5.b).(2) 5Does the program provide objective assessments of competence in patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice based on the specialty-specific milestones? If not, explain why.   # of applications received # of candidates interviewed # of candidates ranked # ranked need to fill5 # of unfilled positions during match/after match' # of positions filled through NRMPQ # of positions filled outside NRMP (or other match); please provide reasons.J # of waivers requested from/approved by NRMP; please provide reasons.3 # of residents/fellows promoted from each year6 # of residents/fellows completing program on timeW # residents/fellows with a delayed program completion. Provide reasons for delay.. # of adverse promotion/evaluation actions/ # of residents/fellows formally remediated( # of residents/fellows not promoted5 # of residents/fellows terminated or non-renewedAre residents taught and assessed to work in interprofessional teams to enhance patient safety and patient care quality? Please specify some interprofessional QI activities used.# of site facultyPLA present (Y/N)last PLA renewal dateduration (rotations/year)rotations here required (Y/N)Urotation content (didactic, consult, OPD, inpatient, ED, ICU, subspecialty, research)CParticipating Sites - please provide details in accompanying table. I.B.1.a) I.B.1.b) I.B.1.c) I.B.1.d) I.B.2. Yes/No/NA ExplanationAppendix Table I What percent of the program director's effort is protected for his or her educational and adminstrative responsibilities to the program? fList sources of financial support for the PDs role and educational and administrative responsibilitiesI. Institutions II. Program Personnel and Resources II.A. Program Director yIs there a single program director, approved by the GMEC, with authority and accountability for operation of the program?II.A.1. II.A.2. II.A.3.a) Does the PD have requisite specialty expertise and documented educational and administrative experience acceptable to the RRC? nParticipating Sites Working Environment and Ancillary Services - please provide details in accompanying table.Appendix Table I.A.(UHB at Long Island College Hosp.!Call room HVAC, privacy, securityOn call/sleep rooms available&Call room furnishing: bed, chair, deskSecure locker or storage &Housekeeping services: linen, cleaningRegular hour food services3Off hour food availability (incl. vending machines)Medical records access!Patient transport/escort servicesMessanger/transport servicesPhlebotomy servicesIntravenous access servicesLaboratory services+Safety and security of persons and property-Monitoring and security of parking facilities5Monitoring and security of access to transit services"Security of on-call/sleep quartersSecurity of department spaceSecurity of clinical care areas Electronic health records systemImaging retrieval systemsLaboratory retrieval systemsCLibrary resources and services including electronic database accessInstructional spaceResearch space and support#Diagnostic and procedural equipment Performance improvement programs%Resident involvement in PI activitiesGResident involvement in quality improvement and patient safety programs.Provision of patient- and family-centered careGAvailability of individual resident patient care performance indicatorseAvailability of schedules informing all of attending and resident responsible for each patient's care0Off hours escort or transport services for staffPGuidelines for circumstances in which residents must contact supervising faculty4Residents work as members of interprofessional teams)Guidelines for supervision and escalationParticipating SitesVI.A. 9Professionalism, Personal Responsibility, Patient Safety VI.A.1. VI.A.2. Are residents and faculty educated in professional responsibilities of physicians to appear for duty appropriately rested and fit to provide the services required by their patients? Please briefly describe how, and if not, explain why.  VI.A.3. In the appendix, attach a list of residents and the QI and patient safety programs in which they were actively involved during the most recent complete academic year.Are residents integrated into and actively participate in interdisciplinary clinical quality improvement and patient safety programs? If not please explain why, otherwise attach list of residents and their activities. VI.A.4.a) Is there an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events? Attach a list of regularly scheduled clinical teaching and didactic activities.rAttach a list of regularly scheduled clinical teaching and didactic activities/events from the last academic year. VI.A.4.b) How does the program assure that program learning objectives are not compromised by excessive reliance on residents to fulfill non-physician service obligations?How does the program demonstrate a commitment to and responsibility for promoting patient safety and resident well-being in a supportive educational environment?  If the last ACGME Annual Resident Survey reflects less than 80% compliant response rate for excessive service obligations, describe how this is being addressed by the program.VI.A.5. wDoes the program director ensure a culture of professionalism that supports patient safety and personal responsibility?VI.A.6. VI.A.6.a) VI.A.6.b) How do residents and faculty demonstrate an understanding and acceptance of their personal role in each of the following areas: VI.A.6.c) VI.A.6.d) VI.A.6.e) VI.A.6.f) VI.A.6.g) VI.A.6.h) In reference to standards VI.A.6.a-h,< attach as an appendix de-indentified examples of any deviations from these standards and how the deviations were addressed and rectified.Table I: Affiliated SitesTable VI: Resident Transfers Table V: Faculty List and Status(Table III: Program Resident DemographicsTable IV: Faculty DataTable II: NRMP DemographicsVI.A.7.oDo all residents and faculty members demonstrate responsiveness to patient needs that supersedes self-interest?Do residents and faculty demonstrate recognition that under certain circumstances the best interests of the patient may be served by transitioning that patient s care to another qualified and rested provider?VI.B. Transitions of Care VI.B.1. qHas the program designed clinical assignments to minimize the number of transitions in patient care? Explain how.VI.B.2. VI.B.3. V.A.2.b).(1) Does the final summative evaluation become part of the resident s permanent record, maintained by the program, and are copies forwarded to the GME Office for the institutional record, in accordance with policy?mDoes the final summative evaluation document the resident s performance during the final period of education? V.A.2.b).(2) V.A.2.b).(3) Does the final summative evaluation verify that the resident has demonstrated sufficient competence to enter practice without direct supervision?sDoes the program director provide a summative evaluation for each resident for the period completed in the program?V.B. Faculty Evaluation V.B.1. iDoes the program at least annually evaluate faculty performance as it relates to the educational program?V.B.2. Do faculty evaluations include a review of the faculty s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities? If any/all are not addressed, please explain why.V.B.3. V.C. #Program Evaluation and Improvement qDoes the program's faculty evaluation include at least annual written confidential evaluations by the residents? V.C.1. \Does the program document formal, systematic evaluation of the curriculum at least annually?nAs part of program evaluation and improvement, does the program monitor and track each of the following areas: V.C.1.a) V.C.1.b) V.C.1.c) V.C.1.d) ,Resident performance? How is this monitored?+Faculty development? How is this monitored?yGraduate performance, including performance of program graduates on the certification examination? How is this monitored?'Program quality. How is this monitored? V.C.1.d).(1) Do residents and faculty have the opportunity to evaluate the program confidentially and in writing at least annually? If so, please provide copies of the evaluation instrument used. V.C.1.d).(2)Does the program use the results of residents assessments of the program together with other program evaluation results to improve the program?V.C.2. Does the program prepare a written plan of action to document initiatives to improve performance in areas specified in V.C.1? Provide a copy of the program's action plan from the most recently completed academic year.jAttach a copy of the program's action plan for improvement from the most recently completed academic year. V.C.2.a) mIs the program's action plan reviewed and approved by the teaching faculty and documented in meeting minutes?VI. 5Resident Duty Hours; Learning and Working Environment II.A.3.b) Does the PD have current certification in the specialty by the ABMS, or specialty qualifications that are acceptable to the RRC? II.A.3.c) II.A.4.a) {Does the PD oversee and ensure the quality of didactic and clinical education in all sites that participate in the program?cDoes the PD approve a local director at each participating site accountable for resident education? II.A.4.c) DDoes the PD approve the selection of program faculty as appropriate? II.A.4.d) %Does the PD evaluate program faculty? II.A.4.e) XDoes the PD approve the continued participation of program faculty based on evaluation? II.A.4.f) DDoes the PD monitor resident supervision at all participating sites? II.A.4.g) SDoes the PD prepare and submit all information required and requested by the ACGME?II.A.4.g).(1) FWhat is the date of the last submitted Program Information Form (PIF)?HWhat is the date of the last complete annual program updates to the ADS?)When was the last program RRC Site Visit? II.A.4.h)Ensuring compliance with grievance and due process procedures, how many grievance/due process proceedings occurred since the last annual report? Briefly identify issues. II.A.4.i) ~How many residents left the program prior to completion? Was verification of residency education provided as needed for each? II.A.4.j)Does the program have program specific policies and procedures for resident duty hours and the working environment, including moonlighting?  & II.A.4.j).(1) When and how are these policies/procedures provided to or distributed to the residents and faculty? If there have been any changes, provide a copy to the GME Office with this review.II.A.4.j).(2) D Attach additional information in appendix, if more space is needed. II.A.4.j).(3)gDescribe efforts to adjust schedules as necessary to mitigate excessive service demands and/or fatigue; II.A.4.j).(4)Describe how the program monitors the demands of at-home call and adjust schedules due to excessive service demands and/or fatigue. II.A.4.k) How is the need for and provision of back up support systems when patient care responsibilities are unusually difficult or prolonged monitored? How often are these systems implemented? II.A.4.l) Has there been any change in program policies/procedures for selection, evaluation and promotion, disciplinary action, and supervision of residents? If so, attach copies to this review.Appendix Table IIbComplete Table II and provide the following information for recently completed recruitment cycle: Outside a matchMaleFemaleWhiteBlackHispanic/Latino Asian/Pac Isl Native AmerOtherTotalCUSMG (alien, non-US citizen, requires visa (J1))[IMG (alien, non-citizen, international school, requires visa (J1)):USMG (citizen or perm resid/green card)IUS IMG (US citizen/perm resid, international school)Please provide the number of year-one residents/fellows selected through a matching program and outside a matching program by gender, ethnicity and medical school type. Also provide totals in each category.ZComplete Table III and provide the following for the most recent completed academic year: Appendix Table IIIVI.G.5.a) and NYS 405.4VI.G.5.c).(1).(a) Are circumstances of return-to-hospital activities with fewer than eight hours away from the hospital by residents in their final years of education monitored by the program director?VI.G.6. dAre residents scheduled for more than six consecutive nights of night float? If so, please explain._What is the maximum number of months (total of all weeks) of night float per year per resident?UWhat is the maximum number of consecutive wee< ks of night float assigned per resident?yAre PGY-2 residents and above scheduled for in-house call more frequently than every-third-night? If so, please explain.VI.G.7. and NYS 405.4Is time spent in the hospital by residents on at-home call counted towards the 80-hour maximum weekly hour limit and does it satisfy the 1 day per week duty free requirement?Are faculty supervision assignments of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility? In general, what is the typical duration of each faculty assignment?"Is moonlighting permitted by the program for PGY2 and above trainees? If so, please describe the circumstances for granting permission for residents to moonlight. If a program policy exists, please attach to appendix. If permission has been granted, submit copies of this documentation. If applicable, attach program specific policy addressing resident moonlighting and documentation of any permission granted by the Chair or Program DirectorIn unusual circumstances, residents on their own initiative may remain beyond a scheduled period of duty to continue providing care to only a single patient for reasons limited to severe illness, instablity, academic importance of events or humanistic attention to patient or family needs. Is each and every one of these occurrences documented, monitored and tracked by the Program Director for each individual resident and the program overall? Provide a list of incidents.?If applicable, attach a summary list of occurrences documented.VI.G.8.a).(1) VI.G.8.a) and NYS 405.4lIs at-home call not so frequent or taxing as to preclude rest or reasonable personal time for each resident? VI.G.8.b) Is all time when residents return to the hospital while on at-home call to care for new or established patients included in the 80-hour weekly maximum?VII.Does the program currently have any active innovative projects that deviate from institutional, common and/or specialty specific program requirements as approved in advance by the RRC? If so, please attach a detailed project description in the appendix.*Core Requirements: Statements that define structure, resource, or process elements essential to every graduate medical educational program. Detail Requirements: Statements that describe a specific structure, resource, or process, for achieving compliance with a Core Requirement. Programs in substantial compliance with the Outcome Requirements may utilize alternative or innovative approaches to meet Core Requirements. Outcome Requirements: Statements that specify expected measurable or observable attributes (knowledge, abilities, skills, or attitudes) of residents or fellows at key stages of their graduate medical education. ;Documentation of these actions must be copied to GME OfficeTables and Other Submit copy to GMEO(Core)(Detail) (Core) (Outcome) IV.A.5.d) How are residents taught and evaluated interpersonal/communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals?Is communication with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds taught and assessed? IV.A.5.d).(1) IV.A.5.d).(3)Are residents taught and assessed in working effectively as a member or leader of a health care team or other professional group?IV.A.5.d).(4) mAre residents taught and assessed to act in a consultative role to other physicians and health professionals?IV.A.5.d).(5) pAre residents taught and assessed to maintain comprehensive, timely, and legible medical records, if applicable?How does the program document that residents demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles?IV.A.5.e).(1) SAre residents taught and assessed in compassion, integrity, and respect for others?IV.A.5.e).(2) cAre residents taught and assessed in responsiveness to patient needs that supersedes self-interest?IV.A.5.e).(3) NAre residents taught and assessed in respect for patient privacy and autonomy?\Are residents taught and assessed in accountability to patients, society and the profession?IV.A.5.e).(4) IV.A.5.e).(5) Are residents taught and assessed in sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation?IV.A.5.f).(1) IV.A.5.f).(2) IV.A.5.f).(3) Are residents taught and assessed to incorporate considerations of cost awareness and risk benefit analysis in patient and/or population-based care as appropriate?IV.A.5.f).(4) hAre residents taught and assessed to advocate for quality patient care and optimal patient care systems? IV.A.5.f).(5)IV.A.5.f).(6) Are residents taught and assessed to participate in identifying system errors and implementing potential systems solutions? Please specify some systems errors/solutions activities used.IV.B. Residents Scholarly Activities IV.B.1. 9Does the program curriculum address residents knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care? Please specify how and when this is addressed by the program (didactics, seminars, e-learning modules, courses, etc.).IV.B.2. Do residents participate in scholarly activity? Please provide a list of scholarly activities for residents during the most recently completed academic year.V. Evaluation Does the program and/or institution allocate adequate educational resources (including dedicated time for research) to facilitate resident involvement in scholarly activities? Please list resources allocated.Year Site Joined ProgramDescribe how the program ensures that residents are informed of and adhere to established practices, policies, procedures for each site to which they are assigned.Describe the frequency and methods by which the Program Director regularly communicates with affiliate Site Director(s) to exercise oversight of the program for resident activities at all participating sites.V.A. Resident Evaluation V.A.1.a) What is the minimum frequency of resident formal summative evaluation? (i.e. monthly, bimonthly, quarterly, semiannually, other) V.A.1.b).(1) V.A.1.b).(2) V.A.1.b).(3) pHas DIO review and co-signature on all PIFs, as well as any correspondence or document submitted to the ACGME that addresses: (1) program citations, and/or, (2) request for changes in the program that would have significant impact, including financial, on the program or institution (or other as specified by RRC) been obtained? If not, explain. Please attach copies. II.A.4.b) V.A.1.b).(4) Does the program use multiple evaluators (including faculty, peers, patients, self, and other professional staff) to assess residents? If not, explain why.Does the program have a system to document progressive resident performance improvement appropriate to educational level? Please describe process. If not, explain why.Does the program conduct and provide each resident with documented semiannual evaluation of performance with feedback? If not, explain why. V.A.1.c) nAre the evaluations of resident performance accessible for review by each resident, in accordance with policy? V.A.2.a) Are specialty-specific Milestones used as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of the program? If not, explain why.V.A.2.b)%Section 1: Transfers Into the Program'Section 2:< Transfers Out of the ProgramHas the program had any residents who have transferred out to another program in the last academic year? If yes, please complete Section 2 of Appendix Table VI. Has the program accepted any resident transfers from another program in the last academic year? If yes, please complete Section 1 of Appendix Table VI.Appendix Table VI, Section 1.Appendix Table VI, Section 2.Reason for TransferProgram Level EnteringProgram Level CompletedResident Name Program Transferred From Program Transferred toSpecialty Transferred to -Was summative competency assessment received?-Was summative competency assessment provided?III.D. Does the presence of other learners interfere with the appointed residents' education? Please identify and provide the number of all other learners present in the program including but not limited to residents from other programs, subspecialty fellows, PhD students, NPs. III.C.1. III.C.2. IV. Educational Program Are overall educational goals of the program made available to residents and faculty annually? If these have changed since the last annual report, please attach a copy.I L IV.A.1.VAttach a copy of the overall program goals if they have changed since the last report.IV.A.2. FDoes the program have competency-based goals and objectives for each assignment at each educational level, which the program distributes to residents and faculty at least annually, in either written or electronic form? Have any of these changed substantially since the last annual report/review? If so, please attach a copy.hAre the goals and objectives for each assignment reviewed by the resident at the start of each rotation?kAttach a copy of any assignment goals and objectives that have changed substantially since the last report.Provide a list of regularly scheduled didactic sessions specifying duration, frequency of occurrence, target participants and identify all competencies addressed.oIn the appendix, attach list of regularly scheduled didactic sessions with additional information as specified.Does the program delineate resident responsibilities for patient care, progressive responsibility for patient management, and supervision of residents over the continuum of the program? Please provide a copy of policy describing this delineation of responsiblities and supervision.vIn the appendix, attach a copy of the delineation of resident/fellow responsibilities and resident/fellow supervision.IV.A.5. ACGME Competencies How many residents in each training year participate in scholarly activities? What percent of residents in each year does this represent? Please provide a list of resident scholarly activity not previously identified.In the appendix, list by resident name with program level and date of all published or presented original research, review articles, textbook chapters, case reports and/or case series by residents not already reported for faculty.Are residents supported to attend regional and national scholarly meetings and conferences? Please list those attended by residents in the last academic year.-# of residents at each level assigned to siteprogram site director name UHB at Long Island College Hosp. NY Harbor VA Hospital - Brooklyn=Brief summary of role and contribution of site to the programpIn the appendix, attach a copy of any substantial change to the program curriculum since the last report/review.Has the program developed specific outcome measures to assess resident progression in each competency? If so, please describe.Does the program track development of resident competence in all medical, diagnostic and surgical procedures considered essential for the area of practice? Describe the method used and how residents are apprised of their progress.%Does the program use objective measures of resident progress in acquisition of medical knowledge of established and evolving biomedical, clinical, epidemiologic and social-behavioral sciences and its application to patient care? Specify what measures are used and the frequency of assessment.Have Milestones been defined for this specialty? If so, provide a copy of those required to be tracked by the RC and/or Medical Specialty Board as well as any other required by the program. HIn the appendix, attach a copy of Milestones required for all residents.Has the program implemented any new evaluation tools or instruments since the last review/annual report? If so, please provide copies._Attach a copy of any new or substantially changed evaluation instruments since the last report.IV.A.3. IV.A.4. III.B.1. IV.A.5.b) Do faculty devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities? (yes/no)xNDo faculty demonstrate strong interest in the education of residents? (yes/no)FDo faculty administer and maintain an educational environment conducive to educating residents in each of the ACGME competency areas? (yes/no) IV.A.5.c) Do residents self-assess and develop individual learning plans for improvement at least as part of their semi-annual evaluations? How and with whom are these reviewed with the residents? Provide a sample of the instrument used.IV.A.5.c).(4) BIs formative evaluation feedback incorporated into daily practice? IV.A.5.c).(5)IV.A.5.c).(6) Are residents taught to use evidence-based medicine? Briefly describe how they are taught to locate, appraise and assimilate evidence from scientific studies related to patients' health problems, and to use information technology to optimize learning.Are residents taught how to teach patients, families, students, resident peers and other health professionals? Briefly describe how they are taught to teach. IV.A.5.c).(8) II.A.4.n) Before submitting any/all information or requests to the ACGME has review and approval of the sponsoring institution s GMEC/DIO been obtained?(core) II.A.4.n).(2)II.A.4.n).(3) II.A.4.n).(4)II.A.4.n).(5) II.A.4.n).(6) aHave there been any requests to RRC for increases or any change to resident duty hours? Explain. II.A.4.n).(7)II.A.4.n).(8) II.A.4.n).(9) RHas there been a program presentation to a Board of Appeal or the ACGME? Explain.=Have there been any changes in resident complement? Explain.\Has there been a request for voluntary withdrawal of an ACGME-accredited program? Explain. II.A.4.n).(10)^Have there been proposals to ACGME for approval of innovative educational approaches? Explain. II.A.4.o) YHave there been any major changes in program structure or length of training? Describe. lHave any progress reports been requested by the Review Committee and have any been submitted? Attach copy. ]Have responses to any/all proposed adverse actions been submitted? Explain and attach copy. BHas there been a request for appeal of an adverse action? Explain.II.B. Faculty II.B.1.Appendix Table IVProgram Year or LevelGenderSelf-identified EthnicityMedical Degree SourceUS MDUS DOUS IMG Alien US MD Alien IMGParticipating Site$Number of full-time physican faculty%Number of part-time physician facultyUniversity Hospital of BrooklynUHB at Long Island College HospKings County Hospital CenterBrooklyn VA HospitalComplete Table IV. Is the number and variety of faculty with required documented qualifications to instruct and supervise all residents at each participating site sufficient to fill RRC standards? If not, explain.VI.D.6. VI.E. Clinical Responsibilities Are the clinical responsibilities assigned for each resident based on PGY-level, patient safety, resident education, severity and complexity of patient illness/condition and available support services? Please describe the program's approach to making this determination.Does the program satisfy expectations for optimal clinical workload as specified by its Revie< w Committee in all clinical settings (outpatient, ED, inpatient, ICU, OR)? If not, please explain.VI.F. Teamwork jDo residents care for patients in an environment that maximizes effective communication? If not, explain.Do residents have the opportunity to work as a member of effective interprofessional teams appropriate to the delivery of care in the specialty? If not, explain.VI.G. Are duty hours limited to 80 hours per week, averaged over a fourweek period, inclusive of all in-house call activities and all moonlighting? If not or if there have been any violations, please explain and descibe how they were corrected. VI.G.1.a).|Has the program been granted any duty hour limit exception by ACGME? If so, describe the exception and when it was granted? VI.G.2.a) VI.G.2.b) If moonlighting is permitted, is all time spent moonlighting counted towards resident maximum duty hours and against duty free periods? VI.G.2.c) +Are PGY-1 residents permitted to moonlight?$Resident Duty Hours and Moonlighting{Are residents scheduled for a minimum of one day free of duty every 7 days (during which at-home call cannot be assigned)? VI.G.3. and NYS 405.4VI.G.1. and NYS 405.4 VI.G.4.a) ?Do duty periods of PGY-1 residents exceed 16 hours in duration? VI.G.4.b) wDo duty periods of PGY-2 residents and above exceed a scheduled maximum of 24 hours of continuous duty in the hospital? VI.G.4.b).(1)Does the programs encourage residents to use alertness management strategies in the context of patient care responsibilities (e.g. strategic napping)? If so, briefly identify strategies used.VI.G.4.b).(2) and NYS 405.4VI.G.4.b).(3) lAre residents assigned any additional clinical responsibilities after 24 hours of continuous in-house duty. vDoes the period of time residents remain on-site for effective transitions in care ever exceed three additional hours? VI.G.4.b).(4)Does the program comply with the standard that all residents should have 10 hours free of duty, and must have eight hours between scheduled duty periods, and all residents must have at least 14 hours free after 24 hours of in-house duty?Briefly describe how the program ensures and monitors effective, structured hand-over processes facilitating continuity of care and patient safety.zBriefly describe how the program ensures resident competence in communicating with team members in the hand-over process. VI.B.4. Are there schedules available informing all members of the health care team of attending physicians and residents currently responsible for each patient s care? If not, why?VI.C. (Alertness Management/Fatigue Mitigation VI.C.1.a) VI.C.1.b) Does the program educate all faculty members and residents in alertness management and fatigue mitigation processes? How often and in what format?Does the program educate all faculty members and residents to recognize the signs of fatigue and sleep deprivation? How often and in what format? VI.C.1.c) Does the program have residents adopt fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, such as naps or back-up call schedules? If not, explain why.VI.C.2. Does the program have a process to ensure continuity of patient care in the event that a resident may be unable to perform his/her patient care duties? If not, explain why.VI.C.3. Are there adequate sleep facilities and/or safe transportation options for residents who may be too fatigued to safely return home? If not, explain why.VI.D. Supervision of Residents VI.D.1. Does each patient have an identifiable, appropriately-credentialed and privileged attending physician who is ultimately responsible for that patient s care? If not, why. VI.D.1.a) tIs the identity of the attending responsible for each patient available to residents, faculty members, and patients? VI.D.1.b) pDo residents and faculty members inform patients of their respective roles in each patient s care? Describe how.VI.D.2. zHow does the program ensure that the appropriate level of supervision is in place for all residents who care for patients?VI.D.3. To ensure oversight of resident supervision and graded authority and responsibility, has the program classified levels of supervision consistent with ACGME definitions? Describe program specific supervision policies and requirements.VI.D.4. Is the privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident assigned by the program director and faculty members? Describe the program's approach to making this determination. VI.D.4.a) Does the program director evaluate each resident s abilities based on specific criteria and, when available, guided by specific national standards-based criteria? Please describe the approach used. VI.D.4.b) Do faculty members functioning as supervising physicians delegate portions of care to residents based on the needs of the patient and the skills of the residents? If not, why. VI.D.4.c) Do senior residents or fellows serve in a supervisory role of junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow? If not, why. VI.D.5. Attach a copy of any new or substantially changed self-assessment and individual learning plan instruments since the last report.Has the program set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members (e.g.transfer of a patient to an ICU, end-of-life decisions, adverse events)? Please attach a copy of the guidelines. hIn the appendix, attach a copy of the guidelines requiring communication with the supervising attending. VI.D.5.a) Does each resident know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence? Briefly describe how this is ensured.VI.D.5.a).(1) xAre PGY-1 residents supervised either directly or indirectly with direct supervision immediately available? If not, why?Appendix Table VProgram DirectorDepartment ChairpersonAssociate Program DirectorSpecialty and Subspecialty"Number of Years Teaching SpecialtyIn Table V, provide a faculty roster listing faculty by site, then specialty then alphabetically by name. A complete faculty roster from ACGME WebADS may be attached. SupervisionTeachingResearch2Avg. # hours/week dedicated to residents'/fellows'ProgramCurrent Licensure and YearParticipating Site Name (LN, FN) and title Board Certification/Recert. YearClinical Credentials`Status (Associate PD, Site Director, Core Faculty, Key Clinical Faculty, etc.) Administrat.(Current Institutional Appointment (Y/N)?II.B.5. Does the faculty of the program establish and maintain an environment of inquiry and scholarship with an active research component. II.B.5.a)PWhat percentage of the faculty regularly participate in organized journal clubs?NWhat percentage of the faculty regularly participate in organized conferences? II.B.5.b) How many of the faculty have peer-reviewed funding? What percent of the faculty is this number? Provide a list of all peer-reviewed funding held by current faculty during the most recently completed academic year.EAttach list of all pe<er-reviewed funding held by faculty in appendix.+How many textbook chapters have there been?7How many peer-reviewed review articles have there been?II.B.5.b).(3) In the appendix, attach a list of all case reports and clinical case series published or presented at professional meetings arranged by faculty member names. Identify faculty by bold type and identify residents by underlining their names.In the appendix, attach a list of all peer-reviewed original research articles, review articles and textbook chapters arranged by faculty member names. Identify faculty by bold type and identify residents by underlining their names. II.B.5.c) II.C. Other Program Personnel Does the program have availability of all necessary professional, technical, and clerical personnel for the effective administration of the program as specified by RRC? Please list all such personnel with name, title and fte dedicated to the program.II.D. Resources Does the program have availability of adequate resources for resident education, as defined in the specialty program requirements? Please itemize specified resources.II.E. Medical Information Access Do residents have ready access to specialty-specific and other appropriate reference material in print or electronic format at each participating site? Are electronic medical literature databases with search capabilities available? Please specify for each participating site.III. Resident Appointments III.A. Does the program director comply with the criteria for resident eligibility as specified in Downstate GME Policy, Program and Institutional Requirements? If no, please explain.III.B. OWhat is the program's RC approved regular complement for each year of training?Does the program have approval for a temporary complement increase? If so, please provide number of positions, training level and period of approval (dates).uAre more residents appointed to the program than approved by the RC? Than approved by GMEC? If yes, please explain.III.C. Resident Transfers ACGME Standard SpecificationgNote: The term  resident in this document refers to both specialty residents and subspecialty fellows.I.A. Sponsoring Institution Program Director:Program Coordinator: ACGME ID: Program Name:2GME Annual Program Report to the GMEC and the DeanI.B. I.B.1. CategorySite >Indicate if characteristics are adequate: (Yes-No-Marginal-NA)4Systems errors analysis and quality of care programs[Table I.A.: Participating Sites - The Clinical Learning Environment, Resources and ServicesGUse of effective, structured hand-over processes in transitions of caretDoes the PD receive financial support for his or her educational and administrative responsibilities to the program?`Is the percent effort and financial support toward that effort sufficient to meet RRC standards?bFor participating sites, does each Program Level Letter of Agreement (PLA) specify the following: m Identity of the faculty who will assume both educational and supervisory responsibilities for residents?^ Faculty responsibilities for teaching, supervision, and formal evaluation of residents? < The duration and content of the educational experience?[ The policies and procedures that will govern resident education during the assignment?Have there been any additions or deletions of participating sites routinely providing a required educational experience of one month FTE or more and has this been submitted to ACGME through ADS? If so, comment in explanations.B K X ` { =How long has the program director continued in this position?2Does the PD possess current NYS medical licensure?GDoes the PD possess current appropriate SUNY medical staff appointment?Are residents taught and assessed to work effectively in various health care delivery settings and systems relevant to their clinical specialty? Participating settings/systems should be as listed in Table I.[Are residents taught and assessed to coordinate patient care within the health care system?UWhen and how are resident duty hours monitored in accord with institutional policies?ZDescribe and discuss any duty hours violations and how they were addressed and resolved. How many faculty have participated in national committees or educational organizations during the most recently completed academic year? What percent of the teaching faculty does this represent?]How many peer-reviewed original hypothesis-driven research journal articles have there been? How many clinical case series have been published (articles) or presented (abstracts, workshops, courses, forums) at local, regional or national professional meetings in the most recently completed academic year?How many case reports have been published (articles) or presented (abstracts, forums, symposia, etc) at local, regional or national professional meetings in the most recently completed academic year?Does the program have a curriculum in which all of the competencies specified by the RC are addressed? If there has been any substantial change in the curriculum, please describe and attach a copy.Do residents analyze systematic practice using quality improvement methods, and implement changes with goal of improvement? Briefly describe how and in what setting. ( / B (Affiliate Name)sWhat percentage of the faculty regularly participate in organized/planned/scheduled clinical discussions or rounds? 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