Program requirements for fellowship education in venous and lymphatic medicine

I.A. Sponsoring Institution

One sponsoring institution must assume ultimate responsibility for the program, as described in the Institutional Requirements, and this responsibility extends to fellow assignments at all participating sites.

The sponsoring institution and the program must ensure that the program director has sufficient protected time and financial support for his or her educational and administrative responsibilities to the program.

I.B. Participating sites

I.B.1. There must be a program letter of agreement (PLA) between the program and each participating site providing a required assignment. The PLA must be renewed at least every five years.

The PLA should:

I.B.1.a)  identify the faculty who will assume both educational and supervisory responsibilities for fellows;

I.B.1.b)  specify their responsibilities for teaching, supervision, and formal evaluation of fellows, as specified later in this document;

I.B.1.c)  specify the duration and content of the educational experience; and

I.B.1.d)  state the policies and procedures that will govern fellow education during the assignment.

I.B.2. The program director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all fellows, of one month full time equivalent (FTE) to the ABVLM.

I.B.3. Integrated Sites

A program that uses integrated sites must ensure the provision of a unified educational experience for all fellows. Each participating site must offer significant educational opportunities. Sites may be integrated with the sponsoring institution through an integration agreement specifying that the program director must:

I.B.3.a)  appoint the members of the faculty at the integrated site;

I.B.3.b)  appoint the chief or director of the teaching service in the integrated site;

I.B.3.c)  appoint all fellows in the program; and,

I.B.3.d)  determine all rotations and assignments of both fellows and members of the faculty including duration of the experience as well as educational and supervisory responsibilities.

I.B.4. If integrated sites are in geographic proximity, fellows will be permitted to attend joint conferences, basic science lectures, and morbidity and mortality reviews on a regular documented basis at a central location. If the sites are geographically so remote that joint conferences cannot be held, an equivalent educational program of lectures and conferences at the integrated site may be available and should be documented.

I.B.5. State the policies and procedures that will govern fellow education during the assignment.

II.A. Program Director

II.A.1. There must be a single program director with authority and accountability for the operation of the program. The sponsoring institution’s GMEC must approve a change in program director.

II.A.1.a) The program director must submit this change to the ABVLM.

II.A.2.  Qualifications of the program director must include:

II.A.2.a) requisite specialty expertise and documented educational and administrative experience acceptable to the Review Committee;

IIA.2.a).(1)  demonstrated experience and expertise in venous and lymphatic medicine as a board certified physician in good standing in a relevant medical/surgical discipline.

IIA.2.a).(2)  experience as a teacher in graduate medical education of residents and/or fellows in a relevant specialty; and

IIA.2.a).(3)  an ongoing clinical practice in venous and lymphatic medicine.

II.A.2.b) current certification by an ABMS recognized specialty in which venous and lymphatic medicine was part of the core curriculum, or specialty qualifications that are acceptable to the Review Committee; and,

II.A.2.c) current medical licensure and appropriate medical staff appointment.

II.A.2.c).(1)  The program director must possess a license in good standing in the state in which the program exists.

II.A.2.c).(2)  The program director must be based at a teaching site that is encompassed within the Program.

II.A.3. The program director must administer and maintain an educational environment conducive to educating the fellows in each of the ACGME competency areas. The program director must:

II.A.3.a)  prepare and submit all information required and requested by the ABVLM;

II.A.3.b)  be familiar with and oversee compliance with ABVLM Fellowship Accreditation and Oversight (A&O) Committee policies and procedures;

II.A.3.c)  obtain review and approval of the sponsoring institution’s GMEC/DIO before submitting information or requests to the ABVLM, including:

II.A.3.c).(1)   all applications for ABVLM accreditation of new programs;

II.A.3.c).(2)   changes in fellow complement;

II.A.3.c).(3)   major changes in program structure or length of training;

II.A.3.c).(4)   progress reports requested by the Review Committee;

II.A.3.c).(5)   responses to all proposed adverse actions;

II.A.3.c).(6)   requests for increases or any change to fellow duty hours;

II.A.3.c).(7)   voluntary withdrawals of accredited programs;

II.A.3.c).(8)   requests for appeal of an adverse action; and,

II.A.3.c).(9)   appeal presentations to a Board of Appeal or the ABVLM.

II.A.3.d) obtain DIO review and co-signature on all program information forms, as well as any correspondence or document submitted to the ABVLM that addresses:

II.A.3.d).(1)   program citations, and/or

II.A.3.d).(2)   request for changes in the program that would have significant impact, including financial, on the program or institution.

II.A.3.e) devote sufficient time to the administrative and teaching tasks inherent in achieving the goals of the program;

II.A.3.f) ensure that fellows’ service responsibilities are limited to patients for whom the teaching service has diagnostic and therapeutic responsibility;

II.A.3.g) be available and accessible to fellows at the primary clinical site;

II.A.3.h) oversee and ensure the quality of didactic and clinical education in all sites that participate in the program;

II.A.3.i) approve a local director at each participating site who is accountable for fellow education;

II.A.3.j) approve the selection of program faculty as appropriate;

II.A.3.k) evaluate program faculty and approve the continued participation of program faculty based on evaluation;

II.A.3.l) monitor fellow supervision at all participating sites;

II.A.3.m) provide each fellow with documented quarterly evaluation and feedback of their performance;

II.A.3.n) provide verification of fellowship education with case documentation for all fellows, including those who leave the program prior to completion;

II.A.3.o) be responsible for monitoring fellow stress, including mental or emotional conditions inhibiting performance or learning, and drug- or alcohol-related dysfunction.

II.A.3.o).(1)   Both the program director and faculty should be sensitive to the need for timely provision of confidential counseling and psychological support services to fellows.

II.A.3.o).(2)   Situations that demand excessive service or that consistently produce undesirable stress on fellows must be evaluated and modified;

II.A.3.p) ensure that departmental clinical quality improvement programs are integrated into the fellowship program;

II.A.3.q) ensure that the fellowship does not place excessive reliance on fellows for service as opposed to education;

II.A.3.r) participate in academic societies and in educational programs designed to enhance his or her educational and administrative skills.

II.B. Faculty

II.B.1. There must be a sufficient number of faculty with documented qualifications to instruct and supervise all fellows.

II.B.1.a)  The physician faculty must possess the requisite specialty expertise and competence in clinical care and teaching abilities, as well as documented educational and administrative abilities and clinical experience in venous and lymphatic medicine.

II.B.1.b)  While the expertise of any one faculty member may be limited to a particular aspect of venous and lymphatic medicine, the training program must provide comprehensive experience in venous and lymphatic medicine, including both technical aspects and clinical patient evaluation and management.

II.B.1.c)  In the short-term absence of the program director, one member of the teaching staff must assume the responsibility for the direction of the program.

II.B.2. The faculty must devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities and demonstrate a strong interest in the education of fellows.

II.B.2.a)  The faculty must demonstrate a commitment to the field of venous and lymphatic medicine.

II.B.2.a).(1)   Such commitment includes membership in professional societies in this field, publications in this field, and a minimum of 30 hours of CME Category I credit per year relevant to venous and lymphatic medicine.

II.B.3. The physician faculty must have current certification by the American Board of Medical Specialties or possess qualifications acceptable to the Review Committee.

II.B.4. The physician faculty must possess current medical licensure and appropriate medical staff appointment.

II.B.4.a)  Faculty must possess a license in good standing in the state in which the program exists.

II.B.5. The faculty must establish and maintain an environment of inquiry and scholarship, which would ideally include an active research component.

II.B.5.a)  The faculty must regularly participate in organized clinical discussions, rounds, journal clubs, and conferences.

II.B.5.b)  Some members of the faculty should also demonstrate scholarship by one or more of the following:

II.B.5.b).(1)   peer-reviewed funding;

II.B.5.b).(2)   publication of original research or review articles in peer reviewed journals, or chapters in textbooks;

II.B.5.b).(3)   publication or presentation of case reports or clinical series at local, regional, or national professional and scientific society meetings; and/or

II.B.5.b).(4)   participation in national committees or educational organizations.

II.B.5.c)  There must be education on the basic principles of research, study design, and evaluation of published literature.

II.B.6. Nonphysician faculty must be appropriately qualified and credentialed in their field and must hold appropriate institutional appointments.

II.B.7. Faculty members should participate in faculty development programs to enhance the effectiveness of their teaching.

II.B.8. For programs not affiliated with a medical school, all physician faculty should be members of the medical staff of at least one of the participating sites.

II.B.9. Faculty members must always be available for back-up when fellows are on night, weekend, or holiday call.

II.B.10. Faculty members must review all diagnostic images and sign all fellows reports within 24 hours.

II.B.11. Faculty members must provide didactic teaching and direct supervision of fellow performance in peri-procedural patient management and of the procedural, interpretative, and consultative aspects of VLM.

II.B.12. Faculty members must supervise all invasive procedures.

II.B.12.a)  Faculty members should determine the appropriate level of direct or indirect supervision for the following procedures: diagnostic ultrasound, application of bandaging and compression, and sclerotherapy.

II.B.12.b)  All other percutaneous image-guided invasive procedures must be directly supervised by faculty members.

II.C. Other Program Personnel

The institution and the program must jointly ensure the availability of all necessary professional, technical, and clerical personnel for the effective administration of the program.

II.C.1. Fellows should have an opportunity to work with health care personnel and receive timely and appropriate consultation, when appropriate, from other specialties such as radiology, interventional radiology, vascular surgery, vascular medicine, anesthesiology, dermatology, and others.

II.D. Resources

The institution and the program must jointly ensure the availability of adequate resources for fellow education, as defined in the specialty program requirements.

II.D.1. Adequate space, clinical patient volume, and administrative support staff must be available to enable every fellowship trainee access to the following key training opportunities:

II.D.1.a)  A diverse population of patients with venous and lymphatic disorders must be available, from which a broad experience in venous care can be obtained.

II.D.1.b)  A sufficient number of patients must be available to enable each fellow to achieve the required educational outcomes.

II.D.1.c)  A clinic in which to practice clinical patient assessment (history and physical) of venous and lymphatic diagnosis is required. Exposure to a wound care clinic or center is highly desired.

II.D.1.d)  An adequately staffed and equipped accredited vascular ultrasound laboratory is required.

II.D.1.e)  Program laboratories should be in compliance with all federal, state, and local regulations regarding a work environment (e.g. OSHA)

II.D.1.f)  Adequate space dedicated to the performance of vein procedures is required. It is desirable for this to include facilities for office-based procedures, outpatient procedures that utilize fluoroscopy, and hospital-based procedures that utilize fluoroscopy.

II.D.1.g)  Inpatient and outpatient systems must be in place to prevent fellows from routinely performing clerical functions, including but not limited to scheduling tests and appointments, and retrieving records and letters.

II.D.1.h)  There should be adequate space and equipment including meeting rooms, examination rooms, computers, visual and other educational aids, and work/study space.

II.D.1.i)  It is highly desirable for the institution to provide laboratory and ancillary facilities to support research projects.

II.D.1.j)  Access to an electronic health record should be provided. In the absence of an existing electronic health record, institutions must demonstrate institutional commitment to its development and progress toward its implementation.

II.D.1.k)  If needed, affiliations with other institutions may be utilized to ensure that fellowship trainees have access to the above mentioned key resources.

II.E. Medical Information Access

Fellows must have ready access to specialty-specific and other appropriate reference material in print or electronic format. Electronic medical literature databases with search capabilities should be available.

III.A. Eligibility Criteria

All required clinical education for entry into the fellowship program must be completed in an ACGME-accredited residency program, or in an RCPSC-accredited or CFPC-accredited residency program located in Canada, and/or meet other eligibility criteria as specified by the Review Committee.

III.A.1. The program must document that each fellow has met the eligibility criteria.

III.B. Number of Fellows

The program’s educational resources must be adequate to support the number of fellows appointed to the program.

III.B.1. The program director may not appoint more fellows than approved by the Review Committee, unless otherwise stated in the specialty-specific requirements.

III.B.2. The Review Committee will approve the number of fellows based upon established written criteria that include the adequacy of resources for fellow education (e.g., the quality and volume of patients and related clinical material available for education), faculty-fellow ratio, institutional funding, and the quality of faculty teaching.

III.B.3.  Fellow Transfers: To determine the appropriate level of education for fellows who are transferring from another program, the program director must receive written verification of previous educational experiences and a statement regarding the performance evaluation of the transferring fellow prior to their acceptance into the program. A program director is required to provide verification of education for fellows who may leave the program prior to completion of their education.

III.B.4.  Appointment of Other Students: The appointment of fellows from other programs, residents or students must not dilute or detract from the educational opportunities available to regularly appointed fellows. Prior approval for changes in the approved resident/fellow complement must be obtained by the Review Committee.

IV.A. The curriculum must contain the following educational components

IV.A.1. Skills and competencies the fellow will be able to demonstrate at the conclusion of the program. The program must distribute these skills and competencies to fellows and faculty annually, in either written or electronic form.

IV.A.1.a)  These skills and competencies should be reviewed by the fellow at the start of each rotation;

IV.A.2. ACGME Competencies

The program must integrate the following ACGME competencies into the curriculum:

IV.A.2.a)  Patient Care and Procedural Skills

IV.A.2.a).(1)   Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows:

IV.A.2.a).(2)   Fellows must be able to competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice. (See Appendix 1 for specific procedural requirements)

Fellows:

IV.A.2.a).(2).(a.)  must demonstrate manual dexterity appropriate for the procedures they perform;

IV.A.2.a).(2).(b.)  must develop and execute appropriate patient care plans;

IV.A.2.a).(2).(c.)  must have technical skills essential for practitioners that can be acquired only through personal experience and education. The program must provide sufficient clinical and operative experience to educate competent practitioners. A sufficient number and distribution of venous and lymphatic cases must be provided for the achievement of adequate procedural skill and clinical judgment. The program director must ensure that the procedural and clinical experience of the individual fellows in the same program is comparable;

IV.A.2.a).(2).(d.)  are considered to be accomplished practitioners when they can document a significant role in the following aspects of patient management: determination or confirmation of the diagnosis; provision of pre-procedure care; selection and performance of the appropriate procedure; direction of post-procedure care; and performing sufficient follow-up which demonstrates knowledge of the disease and the anticipated outcome of its treatment. Participation in procedure only, without pre-procedure and post-procedure care, is inadequate;

IV.A.2.a).(2).(e.)  must have continuity of primary responsibility for patient care. This must be taught in a longitudinal way, and must include ambulatory care, inpatient care, referral and consultation, and utilization of community resources when appropriate;

IV.A.2.a).(2).(f.)  must be provided with clinical responsibilities for the total care of patients, including preoperative evaluation, appropriate use of diagnostic tests, therapeutic decision-making, procedural and clinical experience, and post-procedure management;

IV.A.2.a).(2).(g.)  must have the opportunity to provide consultation with faculty supervision. They should have clearly defined educational responsibilities for other residents, medical students, and professional personnel participating in their clinical program. These teaching experiences should correlate basic anatomic, physiologic, pathophysiologic, and biomedical knowledge with the clinical aspects of patients with venous and lymphatic disease;

IV.A.2.a).(2).(h.)  should act as teaching assistants, when clinical and procedural experience justifies a teaching role and should report such cases to the Review Committee residency;

IV.A.2.a).(2).(i.)  must receive education on the specific diagnostic techniques for the management of venous and lymphatic disease. It is essential that fellows understand the methods and techniques of venous duplex ultrasound. Fellows must be capable of performing venous duplex ultrasound when acute DVT is suspected. They must be capable of performing and interpreting tests for venous reflux of the superficial and deep venous systems and perforating veins. In addition, general knowledge and skills in the assessment of pelvic veins, inferior vena cava, renal veins, gonadal veins, and upper extremity veins is required. Fellows must have a working knowledge of physiologic testing of the venous system, which includes audible venous Doppler, photoplethysmography, air plethysmography, venous outflow studies, and venous pressure measurements.

IV.A.2.a).(2).(j.)  must be knowledgeable about computed tomographic venography (CTV) and magnetic resonance venography (MRV) and their arterial counterparts. That includes the risks and benefits of the procedures, their strengths and weaknesses and in particular how to best apply these techniques to patients with venous and lymphatic disease.

IV.A.2.a).(2).(k.)  must be knowledgeable with the proper indications of and interpretation of ascending and descending phlebography and the indications for and role of arteriography for evaluating patients with vascular malformations and selected patients with venous disease. In addition, knowledge, skill set, and interpretation of venographic studies including pelvic veins and the inferior vena cava, renal veins and gonadal veins is expected.

IV.A.2.a).(2).(l.)  must have experience with outpatient activities, as these constitute an essential component of the care of patients with venous and lymphatic disease. Three days per week, on average, should be devoted to outpatient activities.

IV.A.2.a).(2).(m.)  must be knowledgeable about diagnostic tests for lymphedema and proper interpretation; specifically, the proper performance, and interpretation of lymphoscintigraphy.

IV.A.2.b) Medical Knowledge

Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Fellows:

IV.A.2.b).(1)  must be able to critically evaluate and demonstrate knowledge of pertinent scientific information;

IV.A.2.b).(2)  should have education in the entire venous and lymphatic system. Instruction in each area should be associated with relevant patient exposure. If this is not possible, instructional materials must be provided to ensure adequate education for unusual conditions, such as congenital disorders.

IV.A.2.b).(3)  must have instruction and become knowledgeable in the fundamental sciences, including anatomy, embryology, microbiology, physiology, and pathology as they relate to the pathophysiology, diagnosis, and treatment of venous and lymphatic diseases, as delineated in the “Core content for training in venous and lymphatic medicine” document ¹ ;

IV.A.2.b).(4)  must have instruction in critical thinking, design of clinical trials, evaluation of data, as well as in the technological advances that relate to the care of patients with venous and lymphatic diseases. The program should encourage the participation of fellows in clinical and/or laboratory research and make appropriate facilities available including the ability to submit abstracts, presenting original work, and publications; and,

IV.A.2.b).(5)  will have educational conferences that are adequate in quality and quantity to provide a review of venous and lymphatic diseases as well as recent advances. The conferences should be scheduled to permit the fellows to attend on a regular basis. Participation by fellows and faculty must be documented. Active participation by venous and lymphatic fellows in the planning and production of these conferences is essential. The following types of conferences must exist within a program:

IV.A.2.b).(5).(a)  a review, held at least quarterly, of all significant complications, including radiological and pathological correlation.

IV.A.2.b).(5).(b)   a course or a structured series of conferences to ensure coverage of the basic and clinical sciences fundamental to venous and lymphatic diseases (a sole reliance on textbook review is inadequate);

IV.A.2.b).(5).(c)   regular organized clinical teaching, such as ward rounds and clinical conferences; and,

IV.A.2.b).(5).(d)   a regular review of recent literature, such as a journal club format.

IV.A.2.c) Practice-based Learning and Improvement

Fellows are expected to develop skills and habits to be able to meet the following goals:

IV.A.2.c).(1)  systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement, and

IV.A.2.c).(2)  locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems;

IV.A.2.c).(3)  critique personal practice outcomes;

IV.A.2.c).(4)  demonstrate a recognition of the importance of and process for lifelong learning in practice.

IV.A.2.d) Interpersonal and Communication Skills

Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals, including the ability to:

IV.A.2.d).(1)  counsel and educate patients and families; and

IV.A.2.d).(2)  effectively document practice activities.

IV.A.2.e) Professionalism

Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles, and display:

IV.A.2.e).(1)  high standards of ethical behavior;

IV.A.2.e).(2)  a commitment to continuity of patient care; and

IV.A.2.e).(3)  sensitivity to age, gender, and culture of other health care professionals.

IV.A.2.f) Systems-based Practice

Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care, and:

IV.A.2.f).(1)  practice high quality, cost effective patient care;

IV.A.2.f).(2)  demonstrate a knowledge of risk-benefit analysis; and,

IV.A.2.f).(3)  demonstrate an understanding of the role of different specialists and other health care professionals in overall patient management.

IV.B. Fellows’ Scholarly Activities

IV.B.1. The curriculum must advance fellows’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.

IV.B.2. Fellows should participate in scholarly activity and include submission of abstracts, presentations, and publishing in peer-reviewed journals.

IV.B.3. The sponsoring institution and program should allocate adequate educational resources to facilitate fellow involvement in scholarly activities.

V.A. Fellow Evaluation

V.A.1. The program director must appoint the Clinical Competency Committee.

V.A.1.a)  At a minimum the Clinical Competency Committee must be composed of three members of the program faculty.

V.A.1.a).(1)   The program director may appoint additional members of the Clinical Competency Committee.

V.A.1.a).(1).(a)     These additional members must be physician faculty members from the same program or other programs, or other health professionals who have extensive contact and experience with the program’s fellows in patient care and other health care settings.

V.A.1.a).(1).(b)     Chief residents who have completed core residency programs in their specialty and are eligible for specialty board certification may be members of the Clinical Competency Committee.

V.A.1.b) There must be a written description of the responsibilities of the Clinical Competency Committee.

V.A.1.b).(1)  The Clinical Competency Committee should:

V.A.1.b).(1).(a)   review all fellow evaluations semi-annually;

V.A.1.b).(1).(b)   prepare and assure the reporting of Milestones evaluations of each fellow semi-annually; and,

V.A.1.b).(1).(c)   advise the program director regarding fellow progress, including promotion, remediation, and dismissal.

V.A.2. Formative Evaluation

V.A.2.a) The faculty must evaluate fellow performance in a timely manner.

This evaluation should be made for each rotation or similar educational assignment and written documentation should be provided at completion of the assignment.

V.A.2.b) The program must:

V.A.2.b).(1)   provide objective assessments of competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice based on the specialty-specific Milestones (see supplementary online material for Venous and Lymphatic Medicine Fellowship Milestones, available online with this article, http://phl.sagepub.com);

V.A.2.b).(2)   use multiple evaluators (e.g., faculty, peers, patients, self, and other professional staff); and,

V.A.2.b).(3)   provide each fellow with documented semiannual evaluation of performance with feedback.

V.A.2.c)  The evaluations of fellow performance must be accessible for review by the fellow, in accordance with institutional policy.

V.A.3. Summative Evaluation

V.A.3.a) The specialty-specific Milestones must be used as one of the tools to ensure fellows are able to practice core professional activities without supervision upon completion of the program.

V.A.3.b) The program director must provide a summative evaluation for each fellow upon completion of the program.

 This evaluation must:

V.A.3.b).(1)  become part of the fellow’s permanent record maintained by the institution and must be accessible for review by the fellow in accordance with institutional policy.

V.A.3.b).(2)  document the fellow’s performance during their education; and,

V.A.3.b).(3)  verify that the fellow has demonstrated sufficient competence to enter practice without direct supervision.

V.B. Faculty Evaluation

V.B.1. At least annually, the program will evaluate faculty performance as it relates to the educational program.

V.B.2. These evaluations should include a review of the faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities.

 These evaluations must include at least semiannual written confidential evaluations by the fellows of the faculty and program overall.

V.C. Program Evaluation and Improvement

V.C.1. The program director must appoint the Program Evaluation Committee (PEC).

V.C.1.a) The Program Evaluation Committee:

V.C.1.a).(1) must be composed of at least two program faculty members and should include at least one fellow;

V.C.1.a).(2) must have a written description of its responsibilities; and,

V.C.1.a).(3) should participate actively in:

V.C.1.a).(3).(a)  planning, developing, implementing, and evaluating educational activities of the program;

V.C.1.a).(3).(b)  reviewing and making recommendations for revision of competency-based curriculum goals and objectives;

V.C.1.a).(3).(c)  addressing areas of non-compliance with ACGME standards; and,

V.C.1.a).(3).(d)  reviewing the program annually using evaluations of faculty, fellows, and others, as specified below.

V.C.2. The program, through the PEC, must document formal, systematic evaluation of the curriculum at least annually, and is responsible for rendering a written and Annual Program Evaluation (APE).

The program must monitor and track each of the following areas:

V.C.2.a)  fellow performance;

V.C.2.b)  faculty development; and,

V.C.2.c)  progress on the previous year’s action plan(s).

V.C.3. The PEC must prepare a written plan of action to document initiatives to improve performance in one or more of the areas listed in section V.C.2., as well as delineate how they will be measured and monitored.

V.C.3.a) The action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes.

VI.A. Professionalism, Personal Responsibility, and Patient Safety

VI.A.1.  Programs and sponsoring institutions must educate fellows and faculty members concerning the professional responsibilities of physicians to appear for duty appropriately rested and fit to provide the services required by their patients.

VI.A.2.  The program must be committed to and responsible for promoting patient safety and fellow well-being in a supportive educational environment.

VI.A.3.  The program director must ensure that fellows are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.

VI.A.4.  The learning objectives of the program must:

VI.A.4.a)   be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events, and

VI.A.4.b)   not be compromised by excessive reliance on fellows to fulfill non-physician service obligations.

VI.A.5. The program director and sponsoring institution must ensure a culture of professionalism that supports patient safety and personal responsibility.

VI.A.6. Fellows and faculty members must demonstrate an understanding and acceptance of their personal role in the following:

VI.A.6.a)   assurance of the safety and welfare of patients entrusted to their care;

VI.A.6.b)  provision of patient- and family centered care;

VI.A.6.c)  assurance of their fitness for duty;

VI.A.6.d)  management of their time before, during, and after clinical assignments;

VI.A.6.e)  recognition of impairment, including illness and fatigue, in themselves and in their peers;

VI.A.6.f)  attention to lifelong learning;

VI.A.6.g)  the monitoring of their patient care performance improvement indicators; and,

VI.A.6.h)  honest and accurate reporting of duty hours, patient outcomes, and clinical experience data.

VI.A.7. All fellows and faculty members must demonstrate responsiveness to patient needs that supersedes self-interest. Physicians must recognize 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. Programs must design clinical assignments to minimize the number of transitions in patient care.

VI.B.2. Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety.

VI.B.3. Programs must ensure that fellows are competent in communicating with team members in the hand-over process.

VI.B.4. The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and fellows currently responsible for each patient’s care.

VI.C. Alertness Management/Fatigue Mitigation

VI.C.1. The program must:

VI.C.1.a)  educate all faculty members and fellows to recognize the signs of fatigue and sleep deprivation;

VI.C.1.b)  educate all faculty members and fellows in alertness management and fatigue mitigation processes; and,

VI.C.1.c)  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.

VI.C.2. Each program must have a process to ensure continuity of patient care in the event that a fellow may be unable to perform his/her patient care duties.

VI.C.3. The sponsoring institution must provide adequate sleep facilities and/or safe transportation options for fellows who may be too fatigued to safely return home.

VI.D. Supervision of Fellows

VI.D.1. In the clinical learning environment, each patient must have an identifiable, appropriately credentialed, and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient’s care.

VI.D.1.a)  This information should be available to fellows, faculty members, and patients.

VI.D.1.b)  Fellows and faculty members should inform patients of their respective roles in each patient’s care.

VI.D.2. The program must demonstrate that the appropriate level of supervision is in place for all fellows who care for patients.

Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervising faculty member. For many aspects of patient care, the supervising physician may be a more advanced fellow. Other portions of care provided by the fellow can be adequately supervised by the immediate availability of the supervising faculty member or fellow physician, either in the institution, or by means of telephonic and/or electronic modalities. In some circumstances, supervision may include post-hoc review of fellow-delivered care with feedback as to the appropriateness of that care.

VI.D.3. Levels of Supervision

To ensure oversight of fellow supervision and graded authority and responsibility, the program must use the following classification of supervision:

VI.D.3.a) Direct Supervision – the supervising physician is physically present with the fellow and patient.

VI.D.3.b) Indirect Supervision:

VI.D.3.b).(1)  with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care and is immediately available to provide Direct Supervision.

VI.D.3.b).(2)  with direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision.

VI.D.3.c)  Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

VI.D.4. The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each fellow must be assigned by the program director and faculty members.

VI.D.4.a) The program director must evaluate each fellow’s abilities based on specific criteria. When available, evaluation should be guided by specific national standards-based criteria.

VI.D.4.b) Faculty members functioning as supervising physicians should delegate portions of care to fellows, based on the needs of the patient and the skills of the fellows.

VI.D.4.c) Fellows should serve in a supervisory role of residents or junior fellows in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual fellow.

VI.D.5. Programs must set guidelines for circumstances and events in which fellows must communicate with appropriate supervising faculty members, such as the transfer of a patient to an intensive care unit, or end-of-life decisions.

VI.D.5.a) Each fellow must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence.

VI.D.6. Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each fellow and delegate to him/her the appropriate level of patient care authority and responsibility.

VI.E. Clinical Responsibilities

The clinical responsibilities for each fellow must be based on PGY-level, patient safety, fellow education, severity, and complexity of patient illness/condition and available support services.

VI.E.1. An optimal clinical workload allows fellows to develop the required competencies in patient care with a focus on learning over meeting service obligations.

VI.E.2. The work of the caregiver team should be assigned to team members based on each member’s level of education, experience, and competence.

VI.E.3. As fellows progress through levels of increasing competence and responsibility, it is expected that work assignments will keep pace with their advancement.

VI.F. Teamwork

Fellows must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty.

VI.F.1. Effective practices entail the involvement of members with a mix of complementary skills and attributes (physicians, nurses, and other staff). Success requires both an unwavering mutual respect for those skills and contributions, and a shared commitment to the process of patient care.

VI.F.2. Fellows must collaborate with fellow residents, and especially with faculty, other physicians outside of their specialty, and non-traditional health care providers, to best formulate treatment plans for an increasingly diverse patient population.

VI.F.3. Fellows must assume personal responsibility to complete all tasks to which they are assigned (or which they voluntarily assume) in a timely fashion. These tasks must be completed in the hours assigned, or, if that is not possible, fellows must learn and utilize the established methods for handing off remaining tasks to another member of the caregiver team so that patient care is not compromised.

VI.F.4. Lines of authority should be defined by the programs, and all fellows must have a working knowledge of these expected reporting relationships to maximize quality care and patient safety.

VI.G. Fellow Duty Hours

VI.G.1. Maximum Hours of Work per Week

Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities and all moonlighting.

VI.G.1.a) Duty Hour Exceptions

A Review Committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs based on a sound educational rationale.

VI.G.1.a).(1) In preparing a request for an exception the program director must follow the duty hour exception policy from the ACGME Manual on Policies and Procedures.

VI.G.1.a).(2) Prior to submitting the request to the Review Committee, the program director must obtain approval of the institution’s GMEC and DIO.

VI.G.2. Moonlighting

VI.G.2.a) Moonlighting must not interfere with the ability of the fellow to achieve the goals and objectives of the educational program.

VI.G.2.b) Time spent by fellows in Internal and External Moonlighting (as defined in the ACGME Glossary of Terms) must be counted towards the 80-hour Maximum Weekly Hour Limit.

VI.G.3. Mandatory Time Free of Duty

Fellows must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). At-home call cannot be assigned on these free days.

VI.G.4. Maximum Duty Period Length

Duty periods of fellows may be scheduled to a maximum of 24 hours of continuous duty in the hospital.

VI.G.4.a) Programs must encourage fellows to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested.

VI.G.4.b) It is essential for patient safety and fellow education that effective transitions in care occur. Fellows may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours.

VI.G.4.c) Fellows must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.

VI.G.4.d) In unusual circumstances, fellows, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family.

VI.G.4.d).(1) Under those circumstances, the fellow must:

VI.G.4.d).(1).(a) appropriately hand over the care of all other patients to the team responsible for their continuing care, and

VI.G.4.d).(1).(b) document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director.

VI.G.4.d).(2) The program director must review each submission of additional service, and track both individual fellow and program-wide episodes of additional duty.

VI.G.5. Minimum Time Off between Scheduled Duty Periods

VI.G.5.a) Fellows PGY4 and above must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods.

VI.G.5.a).(1) This preparation must occur within the context of the 80-hour, maximum duty period length, and one-day-off-in-seven standards. While it is desirable that fellows have eight hours free of duty between scheduled duty periods, there may be circumstances when these fellows must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty. The Review Committee defines such circumstances as: required continuity of care for a severely ill or unstable patient, or a complex patient with whom the fellow has been involved; events of exceptional educational value; or, humanistic attention to the needs of a patient or family.

VI.G.5.a).(1).(a) Circumstances of return-to-hospital activities with fewer than eight hours away from the hospital by fellows must be monitored by the program director.

VI.G.6. Maximum Frequency of In-House Night Float

Fellows must not be scheduled for more than six consecutive nights of night float.

VI.G.6.a) Any rotation that requires fellows to work nights in succession, is considered a night float rotation, and the total time on nights is counted toward the maximum allowable time for each resident over the one-year fellowship.

VI.G.6.b) Night float rotations must not exceed two months.

VI.G.6.c) There must be at least two months between each night float rotation.

VI.G.7. Maximum In-House On-Call Frequency

Fellows must be scheduled for in-house call no more frequently than every-third-night (when averaged over a four-week period).

VI.G.8. At-Home Call

VI.G.8.a) Time spent in the hospital by fellows on at-home call must count towards the 80-hour maximum weekly hour limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one-day-in-seven free of duty, when averaged over four weeks.

VI.G.8.a).(1) At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each fellow.

VI.G.8.b) Fellows are permitted to return to the hospital while on at-home call to care for new or established patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period.”