ࡱ> [Z g2ɀ\p Philip Kogan Ba==hKxKx-8X@"1Arial1Arial1Arial1Arial1.Times New Roman1.Times New Roman1.Times New Roman1 Arial1Arial1.Times New Roman1Arial1Verdana1.Times New Roman1.Times New Roman1.Times New Roman1.Times New Roman1Arial1Calibri1 Calibri1Calibri14Calibri1 Calibri1Calibri1Calibri1,8Calibri18Calibri18Calibri1>141<Calibri1?Calibri1h8Cambria1Calibri1 Calibri"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)"Yes";"Yes";"No""True";"True";"False""On";"On";"Off"],[$ -2]\ #,##0.00_);[Red]\([$ -2]\ #,##0.00\)                                                                      ff + ) , *     P  P        `           ! a> "  @ @ "x@ @ !8@ @ !8@ @ ! 8@ @  (@ @  0@ @   8@ @   (@ @ ||G}-} 00_)}-} 00_)}-} 00_)}-} 00_)}A} 00_)ef[$ -}A} 00_)ef [$ -}A} 00_)L[$ -}A} 00_)L[$ -}-} 00_)}A} 00_)L[$ -}A} 00_)L[$ -}A} 00_)L [$ -}A} 00_)23[$ -}A} 00_)23[$ -}-} 00_)}-} 00_)}A}  00_)23[$ -}-}! 00_)}A}" 00_)[$ -}A}# 00_)[$ -}A}$ 00_)[$ -}A}% 00_)[$ -}A}& 00_)[$ -}A}' 00_) [$ -}A}( 00_)[$ -}}) }00_)[$ -##0.  }}* 00_)[$ -???##0.??? ??? ???}-}/ 00_)}A}0 a00_)[$ -}A}1 00_)[$ -}A}2 00_)?[$ -}A}3 00_)23[$ -}-}4 00_)}}5 ??v00_)̙[$ -##0.  }A}6 }00_)[$ -}A}7 e00_)[$ -}x}800_)[$##  }}9 ???00_)[$???## ???  ??? ???}-}; 00_)}U}< 00_)[$## }-}= 00_) 20% - Accent1A 20% - Accent1 % 20% - Accent2A" 20% - Accent2 % 20% - Accent3A& 20% - Accent3 % 20% - Accent4A* 20% - Accent4 % 20% - Accent5M. 20% - Accent5 ef % 20% - Accent6M2 20% - Accent6  ef % 40% - Accent1M 40% - Accent1 L % 40% - Accent2M# 40% - Accent2 L渷 % 40% - Accent3A' 40% - Accent3 % 40% - Accent4M+ 40% - Accent4 L % 40% - Accent5M/ 40% - Accent5 L % 40% - Accent6M3 40% - Accent6  Lմ % 60% - Accent1M 60% - Accent1 23 % 60% - Accent2M$ 60% - Accent2 23ږ % 60% - Accent3A( 60% - Accent3 % 60% - Accent4A, 60% - Accent4 % 60% - Accent5M0 60% - Accent5 23 %! 60% - Accent6A4 60% - Accent6 % "Accent1AAccent1 O % #Accent2A!Accent2 PM % $Accent3A%Accent3 Y % %Accent4A)Accent4 d % &Accent5A-Accent5 K % 'Accent6A1Accent6  F %(Bad9Bad  %) Calculation Calculation  }% * Check Cell Check Cell  %????????? ???+ Comma,( Comma [0]-&Currency.. Currency [0]/Explanatory TextG5Explanatory Text % 0Good;Good  a%1 Heading 1G Heading 1 I}%O2 Heading 2G Heading 2 I}%?3 Heading 3G Heading 3 I}%234 Heading 49 Heading 4 I}% 5InputuInput ̙ ??v% 6 Linked CellK Linked Cell }% 7NeutralANeutral  e%"Normal 8Noteb Note   9OutputwOutput  ???%????????? ???:$Percent ;Title1Title I}% <TotalMTotal %OO= Warning Text? Warning Text %XTableStyleMedium9PivotStyleLight16`MSheet1" a`U i. Patient safety?AGY ii. Quality improvement=@FY iii. Transitions of care<@FO iv. Supervision;>Dh v. Duty hours and working environment =?El vi. Culture of professional responsibilities;>DProgram:Program Director:Date of Review: S/M/U;Answer Key: S- satisfactory, M- marginal, U- unsatisfactory %Please include any additonal commentsAttachments: Citations  g Plan for Improvement - Reviewer must complete the "Areas for Improvement" column 1. Accreditation status (LON) -2. Recurrent citations (0, 1, >1) (LON, ADS)# D3. New citations (process, detail, outcome)(0-2, 3-4, >4) (LON, ADS): b4. Effective resolution of prior citations from RRC (all, some, few/none, resolved) (ADS, AR, PR)V N5. Effective resolution of recommendation from internal or special review (AR)K #6. IR and CPR compliance (IR & CPR) `7. Program director or chair attendance at GMEC (75-100%, 50-75%, <50%) (GMEC Attendance Record)I 18. Effectiveness and Program Director effort (AR). <9. Effectiveness and Associate Program Directors effort (AR)9 410. Effectiveness and Program Coordinator effort AR)1 |11. Availability of all necessary professional, technical, clerical and support staff (AR,Downstate Prg.Eval.Ann. Survey-NI)W s 12. Presence of other learners interfere with appointed residents education (AR,Downstate Prg.Eval.Ann. Survey-NI)M m13. Appropriateness, effectiveness and quality of participating sites (AR,Downstate Prg.Eval.Ann. Survey-NI)G ?14. Aggregated milestones progression (APE, ADS when available)& O15. NRMP outcomes (improved, stable, declined) (AR, APE, NRMP Outcomes Report)0 8: x16. Aggregated program evaluation by residents (mostly: very pos./pos, pos/neut, neut/neg) (NI, Annual Survey- Resident)[ J17. Aggregated program evaluation by faculty (NI, Annual Survey - Faculty- T18. ACGME Resident Survey noncompliance (below national: 0, 1-2, >2 categories) (RS)Q T19. ACGME Faculty Survey noncompliance (below national: 0, 1-2, >2 categories) (FS) P SS20. Compliance with resident completion of evaluations (90-100%, 70-89%, <70%) (NI)O S21. Compliance with faculty completion of evaluations (90-100%, 70-89%, <70%) (NI)O `22. Does program conduct annual program evaluation and generate plan for improvement (Y/N) (APE)[ Z23. Does program demonstrate improvement in areas identified by previous APEs (Y/N) (APE)P24. Compliance with semiannual meetings of appropriately configured CCC (AR, DA)H X25. Compliance with semiannual meetings of PD (or designee) with each resident (AR, DA)U26. Evaluation of program didactics and organized teaching (AR, APE, NI Prog. Eval)= R27. Faculty participating in scholarly activity (80-100%, 60-79%, <60%) (AR, ADS)I S28. Resident participation in scholarly activity (80-100%, 60-79%, <60%) (AR, ADS)J |29. Aggregated scores of residents on most recent in-training exams (70-100%tile, 40-70%tile, <40%tile) (APE, req .from PD)i jy{ |30. Aggregated data on clinical experience/case logs (0 areas deficient, 1-2 categories deficient, >2 deficient) (APE, ADS)s F31. Residents actively participate in patient safety activities (APE)J33. Residents actively participate in quality improvement activities (APE)F X32. Residents participate in risk reduction initiatives and adverse events review (APE)S \34. Residents review data on personal clinical effectiveness and engage in PI (AR, APE, DA)P a35. Aggregate data on resident progression through the program (AR, APE, ADS, Milestones Report)@ T37. Duty hours violations reported or discovered (0, 1-3, >3) (APE, AR, DH Surveys)? S38. Issues related to alertness management and fatigue mitigation (APE, AR, RS, DHq39. Resident participate in standardized transitions of care in all settings (90-100%, 70-89%, <70%) (APE<< AR)g Z40. Program documents resident competence in hand-offs (90-100%, 70-89%, <70%) (APE, AR, Q YD41. Reports or discovery of supervision issues (0, 1, >1) (APE, RS)< Cr42. Reports or discovery of residents exceeding conditional independence in care or procedures (0, 1-2, >2) (APE)m `43. Resident participation and interaction in interdisciplinary health care teams (AR, APE, RS)S n44. Program use of 360 evaluations of resident competence by other care providers and patients (APE, ADS, DA)` z45. Complaints regarding professionalism, personal responsibility and honesty on the part of either resident or faculty) z46. Appropriate balance between education and service demands (>90%, 80-89%, <80% compliance) (RS, NI Prog. Eval sSurvey)_ d}47. Faculty participating in faculty development activities (>80%, 60-79%, <60%) (APE, FS, DA, NI Prg. Eval Survey- Faculty)R `y48. Faculty attendance in program organized didactics (>70%, 40-69%, <40%) (APE, FS, DA, NI Prg. Eval Survey- Faculty)N |49. Faculty participation in program meetings related to education or teaching (APE, FS, DA, NI Prg. Eval Survey- Faculty)Q 50. Faculty qualification (e.g. maintenance of certification) (all certified, 1-2 uncertified, >2 uncertified) (APE, ADS -Fac. List)p y51. Spectrum of faculty expertise in required specialties areas (all areas, missing 1, missing >1) (APE, ADS -Fac. List)d l52. Aggregated program board certification first time all parts pass rate (85-100%, 70-85%, <70%) (APE, AR)c M53. Program graduation/completion rate (100%, 90-99%, <90%) (APE, AR, ADS,)> 55. Aggregated data on program evaluation by recent graduates (APE- availableonly if program surveys grads as does exit surveys)? DM(56. Active Citations (ADS, APE, LON, AR) 9u. Attributes of the CLE (APE (categories of citations) {LON- Letter of Notification, ADS - Accred. Data System, AR- Annual report, PR - Progress Report, APE - Annual Progr. Eval, wNI_ New Innovations, RS - Resident Survey, FS - Faculty Survey, IR - Institutional Requirements, CPR, Common Prog. Req.,DA - Document Audit, DH - Duty Hours Survey.{Comment on overall assessment of program compliance with Institutional Common Program requirements and Specialty Prog. Req.b36. Program aggregate compliance with duty hours monitoring (80-100%, 60-79%, <60%) (APE, AR, DA)^54. Effective placement of program graduates into fellowship or practice positions (APE, AR)V 9a. Case/procedures #s ( none = S, one = M, multiple = U)Cb. Faculty scholarly activities ( none = S, one = M, multiple = U)Lc. Resident/fellow scholarly activities ( none = S, one = M, multiple = U);d. Qualification of PD ( none = S, one = M, multiple = U)=e. Responsibilities of PD ( none = S, one = M, multiple = U)@f. Qualifications of Faculty ( none = S, one = M, multiple = U)Ag. Responsibilities of Faculty ( none = S, one = M, multiple = U)>h. Other program personnel ( none = S, one = M, multiple = U)0i. Resources ( none = S, one = M, multiple = U)Ij. Progressive resident responsibility ( none = S, one = M, multiple = U)9k. ACGME competencies ( none = S, one = M, multiple = U)=l. Patient care experience ( none = S, one = M, multiple = U)<m. Procedural experience ( none = S, one = M, multiple = U)En. Service to education imbalance ( none = S, one = M, multiple = U)0o. Oversight ( none = S, one = M, multiple = U)>p. Evaluation of residents ( none = S, one = M, multiple = U)<q. Evaluatio<n of faculty ( none = S, one = M, multiple = U)<r. Evaluation of program ( none = S, one = M, multiple = U)Hs. Performance on board examinations ( none = S, one = M, multiple = U)Et. 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