ACGME Program Requirements for Graduate Medical Education in Obstetric Anesthesiology

Transcription

1 ACGME Program Requirements for Graduate Medical Education in ACGME-approved: October 1, 2011; effective: October 1, 2011 Revised Common Program Requirements effective: July 1, 2013 ACGME approved focused revision with categorization: September 29, 2013; effective: July 1, 2014 Revised Common Program Requirements effective: July 1, 2015 Revised Common Program Requirements effective: July 1, 2016 At its May 28, 2015 meeting, the Review Committee for Anesthesiology voted to allow exceptions to the Eligibility Requirements for Fellowship Programs in Section III.A. Thus, Requirement III.A.3. has been revised. Revised Common Program Requirements effective: July 1, 2017

2 Program Requirements for Graduate Medical Education in One-year Common Program Requirements are in BOLD Where applicable, text in italics describes the underlying philosophy of the requirements in that section. These philosophic statements are not program requirements and are therefore not citable. Introduction Int.A. Residency and fellowship programs are essential dimensions of the transformation of the medical student to the independent practitioner along the continuum of medical education. They are physically, emotionally, and intellectually demanding, and require longitudinally-concentrated effort on the part of the resident or fellow. The specialty education of physicians to practice independently is experiential, and necessarily occurs within the context of the health care delivery system. Developing the skills, knowledge, and attitudes leading to proficiency in all the domains of clinical competency requires the resident and fellow physician to assume personal responsibility for the care of individual patients. For the resident and fellow, the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context, and meaning to those interactions. As residents and fellows gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater independence. This concept-- graded and progressive responsibility--is one of the core tenets of American graduate medical education. Supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care to the individual patient; assuring each resident s and fellow s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishing a foundation for continued professional growth. Int.B. Int.C. Obstetric anesthesiology is the subspecialty of anesthesiology devoted to the comprehensive anesthetic management of women during pregnancy and the puerperium. The educational program in obstetric anesthesiology must be 12 months in length. (Core) * I. Institutions 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. (Core) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 1 of 32

3 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. (Core) I.A.1. I.A.2. I.B. I.B.1. The sponsoring institution must also sponsor ACGME-accredited residency programs in anesthesiology and obstetrics and gynecology. (Core) There must be interaction between the anesthesiology residency and the fellowship which results in coordination of educational, clinical, and investigative activities. (Detail) Participating Sites 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. (Core) The PLA should: I.B.1.a) I.B.1.b) I.B.1.c) I.B.1.d) I.B.2. identify the faculty who will assume both educational and supervisory responsibilities for fellows; (Detail) specify their responsibilities for teaching, supervision, and formal evaluation of fellows, as specified later in this document; (Detail) specify the duration and content of the educational experience; and, (Detail) state the policies and procedures that will govern fellow education during the assignment. (Detail) 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) or more through the Accreditation Council for Graduate Medical Education (ACGME) Accreditation Data System (ADS). (Core) II. II.A. II.A.1. Program Personnel and Resources Program Director 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. (Core) II.A.1.a) II.A.2. The program director must submit this change to the ACGME via the ADS. (Core) Qualifications of the program director must include: 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 2 of 32

4 II.A.2.a) II.A.2.b) II.A.2.c) II.A.2.d) II.A.2.e) II.A.2.f) II.A.2.g) II.A.2.h) II.A.3. requisite specialty expertise and documented educational and administrative experience acceptable to the Review Committee; (Core) current certification in the subspecialty by the American Board of Anesthesiology, or subspecialty qualifications that are acceptable to the Review Committee; and, (Core) current medical licensure and appropriate medical staff appointment. (Core) current certification in Anesthesiology by the American Board of Anesthesiology; (Core) completion of an obstetric anesthesiology fellowship, or at least three years participation in a clinical obstetric anesthesiology fellowship as a faculty member; (Core) at least three years of post-residency experience in clinical obstetric anesthesiology; (Detail) current appointment as a member of the anesthesiology faculty; and, (Core) demonstrated ongoing academic achievements appropriate to the subspecialty, including at least one of the following: publications, the development of educational programs, or the conduct of research. (Core) The program director must administer and maintain an educational environment conducive to educating the fellows in each of the ACGME competency areas. (Core) The program director must: II.A.3.a) II.A.3.b) II.A.3.c) II.A.3.c).(1) II.A.3.c).(2) prepare and submit all information required and requested by the ACGME; (Core) be familiar with and oversee compliance with ACGME and Review Committee policies and procedures as outlined in the ACGME Manual of Policies and Procedures; (Detail) obtain review and approval of the sponsoring institution s GMEC/DIO before submitting information or requests to the ACGME, including: (Core) all applications for ACGME accreditation of new programs; (Detail) changes in fellow complement; (Detail) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 3 of 32

5 II.A.3.c).(3) II.A.3.c).(4) II.A.3.c).(5) II.A.3.c).(6) II.A.3.c).(7) II.A.3.c).(8) II.A.3.d) II.A.3.d).(1) II.A.3.d).(2) II.A.3.e) II.A.3.f) II.A.3.g) II.A.4. II.B. II.B.1. II.B.2. II.B.3. Faculty major changes in program structure or length of training; (Detail) progress reports requested by the Review Committee; (Detail) requests for increases or any change to fellow duty hours; (Detail) voluntary withdrawals of ACGME-accredited programs; (Detail) requests for appeal of an adverse action; and, (Detail) appeal presentations to a Board of Appeal or the ACGME. (Detail) obtain DIO review and co-signature on all program application forms, as well as any correspondence or document submitted to the ACGME that addresses: (Detail) program citations, and/or, (Detail) request for changes in the program that would have significant impact, including financial, on the program or institution. (Detail) devote at least 50 percent of his or her professional effort to the anesthetic care of pregnant women; (Core) devote at least 20 percent of his or her professional effort to the, academic, educational, and administrative (non-clinical), aspects of the fellowship program; and, (Core) together with the core program director, prepare and implement a supervision policy that specifies the lines of responsibility for the anesthesiology core residents and the fellows. (Core) The program director must be based at the primary clinical site. (Detail) There must be a sufficient number of faculty with documented qualifications to instruct and supervise all fellows. (Core) 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. (Core) The physician faculty must have current certification in the 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 4 of 32

6 subspecialty by the American Board of Anesthesiology, or possess qualifications judged acceptable to the Review Committee. (Core) II.B.3.a) II.B.4. II.B.5. II.B.6. II.B.7. II.C. Physician faculty members must have fellowship education or post-residency experience in clinical obstetric anesthesiology. (Core) The physician faculty must possess current medical licensure and appropriate medical staff appointment. (Core) Physician faculty members must demonstrate ongoing academic achievements appropriate to the subspecialty, including at least one of the following: publications, the development of educational programs, or the conduct of research. (Core) Faculty members, including those certified in obstetrics and gynecology, maternal-fetal medicine, and neonatology, must be available for consultations and the collaborative management of peripartum patients, as well as instruction and supervision of fellows. (Core) Faculty members certified in adult critical care must be available for consultation and collaborative management of peripartum women with critical care needs. (Core) 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. (Core) II.C.1. II.C.2. II.D. Resources There must be specialized nursing staff for the care of the critically-ill newborn. (Core) There must be allied health staff and other support personnel necessary for the comprehensive care of women during pregnancy. (Detail) The institution and the program must jointly ensure the availability of adequate resources for fellow education, as defined in the specialty program requirements. (Core) II.D.1. II.D.1.a) II.D.1.b) II.D.1.c) Clinical facilities must include: a designated area for labor and delivery which includes labor rooms, and cesarean/operative delivery rooms; (Core) maternal and fetal monitoring and advanced life-support equipment; (Core) a post-anesthesia care unit (PACU) or Labor-Delivery-Postpartum rooms designed and equipped for the collaborative management 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 5 of 32

7 of post-operative obstetric patients by anesthesiologists and obstetrician-gynecologists; and, (Core) II.D.1.d) II.D.2. II.D.3. II.D.4. II.E. a clinical laboratory that provides prompt and readily available diagnostic and laboratory measurements pertinent to the care of obstetric patients. (Core) The patient population must include high-risk obstetric patients. (Core) There must be an active maternal fetal medicine and neonatology service that is regularly involved in multidisciplinary care. (Core) There must be facilities and space for the education of fellows, including meeting space, conference space, space for academic activities, and access to computers. (Core) 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. (Detail) III. III.A. Fellow Appointments Eligibility Requirements Fellowship Programs All required clinical education for entry into ACGME-accredited fellowship programs must be completed in an ACGME-accredited residency program, or in an RCPSC-accredited or CFPC-accredited residency program located in Canada. (Core) Prior to appointment in the program, fellows must have successfully completed an ACGME- or RCPSC-accredited program in anesthesiology. (Core) III.A.1. III.A.2. Fellowship programs must receive verification of each entering fellow s level of competency in the required field using ACGME or CanMEDS Milestones assessments from the core residency program. (Core) Fellow Eligibility Exception A Review Committee may grant the following exception to the fellowship eligibility requirements: An ACGME-accredited fellowship program may accept an exceptionally qualified applicant**, who does not satisfy the eligibility requirements listed in Sections III.A. and III.A.1., but who does meet all of the following additional qualifications and conditions: (Core) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 6 of 32

8 III.A.2.a) III.A.2.b) III.A.2.c) III.A.2.d) III.A.2.e) III.A.2.e).(1) Assessment by the program director and fellowship selection committee of the applicant s suitability to enter the program, based on prior training and review of the summative evaluations of training in the core specialty; and (Core) Review and approval of the applicant s exceptional qualifications by the GMEC or a subcommittee of the GMEC; and (Core) Satisfactory completion of the United States Medical Licensing Examination (USMLE) Steps 1, 2, and, if the applicant is eligible, 3, and; (Core) For an international graduate, verification of Educational Commission for Foreign Medical Graduates (ECFMG) certification; and, (Core) Applicants accepted by this exception must complete fellowship Milestones evaluation (for the purposes of establishment of baseline performance by the Clinical Competency Committee), conducted by the receiving fellowship program within six weeks of matriculation. This evaluation may be waived for an applicant who has completed an ACGME International-accredited residency based on the applicant s Milestones evaluation conducted at the conclusion of the residency program. (Core) If the trainee does not meet the expected level of Milestones competency following entry into the fellowship program, the trainee must undergo a period of remediation, overseen by the Clinical Competency Committee and monitored by the GMEC or a subcommittee of the GMEC. This period of remediation must not count toward time in fellowship training. (Core) ** An exceptionally qualified applicant has (1) completed a non- ACGME-accredited residency program in the core specialty, and (2) demonstrated clinical excellence, in comparison to peers, throughout training. Additional evidence of exceptional qualifications is required, which may include one of the following: (a) participation in additional clinical or research training in the specialty or subspecialty; (b) demonstrated scholarship in the specialty or subspecialty; (c) demonstrated leadership during or after residency training; (d) completion of an ACGME-Internationalaccredited residency program. III.A.3. III.B. The Review Committee for Anesthesiology does allow exceptions to the Eligibility Requirements for Fellowship Programs in Section III.A. (Core) Number of Fellows 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 7 of 32

9 The program s educational resources must be adequate to support the number of fellows appointed to the program. (Core) III.B.1. IV. IV.A. IV.A.1. IV.A.2. Educational Program The program director may not appoint more fellows than approved by the Review Committee, unless otherwise stated in the specialtyspecific requirements. (Core) The curriculum must contain the following educational components: 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 at least annually, in either written or electronic form. (Core) ACGME Competencies The program must integrate the following ACGME competencies into the curriculum: (Core) IV.A.2.a) IV.A.2.a).(1) IV.A.2.a).(1).(a) IV.A.2.a).(1).(a).(i) IV.A.2.a).(1).(a).(i).(a) IV.A.2.a).(1).(a).(ii) IV.A.2.a).(1).(a).(ii).(a) Patient Care and Procedural Skills 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: (Outcome) must demonstrate competence in the comprehensive analgesic/anesthetic management of deliveries, including: (Outcome) planned vaginal deliveries with a high-risk maternal co-morbidity; (Outcome) This must include obtaining the appropriate diagnostic testing and consultation and communication with the multi-disciplinary team. (Outcome) planned vaginal deliveries with high-risk fetal conditions; (Outcome) This must include appropriate interpretation of fetal surveillance and consultation with maternal-fetal medicine specialists and neonatologists as to the appropriate obstetric interventions and their timing. (Outcome) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 8 of 32

10 IV.A.2.a).(1).(a).(iii) IV.A.2.a).(1).(a).(iii).(a) IV.A.2.a).(1).(a).(iii).(b) IV.A.2.a).(1).(a).(iv) IV.A.2.a).(1).(a).(iv).(a) IV.A.2.a).(1).(b) IV.A.2.a).(1).(b).(i) IV.A.2.a).(1).(c) Cesarean deliveries with a high-risk maternal co-morbidity; and, (Outcome) This must include application of broad anesthetic principles and techniques in creating a comprehensive anesthetic care plan. (Outcome) This must include collaborative management between anesthesiologists and obstetricians of women with abnormal placentation. (Outcome) Cesarean deliveries with a high-risk fetal condition. (Outcome) This must include interpretation of fetal surveillance and consultation with maternal-fetal medicine specialists and neonatologists as to the appropriate obstetric interventions and their timing. (Outcome) must demonstrate competence to manage anesthetics during the first, second, or third trimesters, other than for Cesarean delivery, including antepartum procedures involving prenatal diagnosis and fetal treatment, maternal cardioversion, or electroconvulsive therapy (Outcome) This must include: assessment of fetal status and possible maternal co-morbidity; development of an anesthetic care plan that is integrated with the surgical and obstetric care plan and that includes provision for peri-operative fetal monitoring; development of a plan for possible emergency Cesarean delivery if appropriate; provision for postoperative analgesia; and collaboration between anesthesiologists and obstetricians in the development of a plan to prevent preterm birth. (Outcome) must demonstrate competence to manage general anesthetics for Cesarean or vaginal delivery; (Outcome) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 9 of 32

11 IV.A.2.a).(1).(c).(i) IV.A.2.a).(1).(d) IV.A.2.a).(1).(e) IV.A.2.a).(1).(f) IV.A.2.a).(2) This must include: recognizing indications for general anesthesia; efficiently and quickly allaying the anxiety of the mother and communicating the anesthetic care plan; appropriately assessing the airway; and rapidly assessing the clinical scenario and its urgency in concert with the obstetric specialist and making the clinical judgment to initiate general anesthesia after considering the maternal and fetal risks. (Outcome) must demonstrate proficiency and skill preparing for and providing care, including developing a care plan, which acknowledges the patient s birth plan goals; (Outcome) must demonstrate proficiency in the anesthesia critical care of women during the puerperium; and, (Outcome) must have completed a course in neonatal resuscitation through the American Academy of Pediatrics/American Heart Association (AAP/AHA) Neonatal Resuscitation Program, and must have received a course completion certificate prior to completion of the fellowship. (Outcome) Fellows must be able to competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice. Fellows: (Outcome) must demonstrate competency in management of: IV.A.2.a).(2).(a) IV.A.2.a).(2).(a).(i) IV.A.2.a).(2).(b) IV.A.2.a).(2).(b).(i) IV.A.2.a).(2).(c) IV.A.2.a).(2).(c).(i) high-risk maternal co-morbidity vaginal deliveries; (Outcome) This experience must include management of 30 deliveries of this type. (Core) high-risk fetal condition vaginal deliveries; (Outcome) This experience must include management of 30 deliveries of this type. (Core) high-risk maternal co-morbidity cesarean deliveries; (Outcome) This experience must include management of 30 deliveries of this type. (Core) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 10 of 32

12 IV.A.2.a).(2).(d) IV.A.2.a).(2).(d).(i) IV.A.2.a).(2).(e) IV.A.2.a).(2).(e).(i) IV.A.2.a).(2).(e).(ii) IV.A.2.b) Medical Knowledge high-risk fetal condition cesarean deliveries; and, (Outcome) This experience must include management of 20 deliveries of this type. (Core) antenatal procedures. (Outcome) This experience must include management of 10 procedures. (Core) This experience must be limited to no more than five cases accrued from cervical cerclage placement or removal. (Core) Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and socialbehavioral sciences, as well as the application of this knowledge to patient care. Fellows: (Outcome) IV.A.2.b).(1) IV.A.2.b).(1).(a) IV.A.2.b).(1).(b) IV.A.2.b).(1).(c) IV.A.2.b).(1).(d) IV.A.2.b).(1).(e) must demonstrate competence in their knowledge, with specific emphasis on the anesthetic implications of the altered maternal physiologic state, the impact of interventions on the mother and fetus/neonate, and the care of the high-risk pregnant patient, of the following areas: (Outcome) advanced maternal physiology, biochemistry (nitric oxide, prostaglandins), genetic predispositions, and polymorphisms; (Outcome) embryology and teratogenicity, including laboratory models and use of databases; (Outcome) fetal and placental physiology and pathophysiology, models of uteroplacental perfusion, and pharmacokinetics of placental transfer; (Outcome) neonatal physiology and advanced neonatal resuscitation; (Outcome) medical disease and pregnancy, including hypertensive disorders, morbid obesity, respiratory disorders, cardiac disorders, gastrointestinal diseases, endocrine disorders, autoimmune disorders, hematologic and coagulation disorders, neurologic disorders, substance abuse, HIV infection, AIDS, and psychiatric diseases; (Outcome) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 11 of 32

13 IV.A.2.b).(1).(f) IV.A.2.b).(1).(g) IV.A.2.b).(1).(h) IV.A.2.b).(1).(i) IV.A.2.b).(1).(j) IV.A.2.b).(1).(k) IV.A.2.b).(1).(l) IV.A.2.b).(1).(m) IV.A.2.b).(1).(n) obstetric management of abnormal labor, management of urgent and emergent delivery, and trial of labor; (Outcome) tocolytic therapy, the effects of genetics on preterm labor and response to tocolytics, and methods of tocolysis; (Outcome) labor pain, including pain pathways, experimental models for studying pain of labor, biochemical mechanisms of labor pain, and modalities for treating labor pain; (Outcome) local anesthetic use in obstetrics, including pregnancy-related effects on pharmacodynamics and pharmacokinetics; recognition and treatment of complications; lipid rescue of local anesthetic cardiotoxicity; effects on the fetus in different settings, including prematurity, asphyxia, fetal cardiovascular and neurological effects; and fetal drug disposition; (Outcome) neuraxial opioid use in obstetrics, including prevention, recognition, and treatment of complications; effects on the fetus; and fetal/neonatal drug disposition; (Outcome) regional anesthetic techniques, including recognition and treatment of complications, effect of genetic variations, and polymorphisms; (Outcome) general anesthesia use in obstetrics, including recognition and treatment of complications, alternatives for securing the airway in pregnant women (anticipated/unanticipated difficult airway), consequences on utero-placental perfusion, and opposing maternal-fetal considerations regarding the use of general anesthesia; (Outcome) anesthetic and obstetric management of obstetric complications and emergencies, including placental abruption, placenta previa, placenta accrete, vasa previa, uterine rupture, uterine atony, amniotic fluid embolism, and umbilical cord prolapse; (Outcome) anesthetic and obstetric management of preeclampsia, including laboratory models for study of preeclampsia; etiology and epidemiology; pathophysiology; biomolecular and genetic changes; and postpartum care; (Outcome) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 12 of 32

14 IV.A.2.b).(1).(o) IV.A.2.b).(1).(p) IV.A.2.b).(1).(q) IV.A.2.b).(1).(r) IV.A.2.b).(1).(s) IV.A.2.b).(1).(t) IV.A.2.b).(1).(u) IV.A.2.b).(1).(v) IV.A.2.b).(1).(w) IV.A.2.b).(1).(x) IV.A.2.b).(1).(y) IV.A.2.b).(1).(z) cardiopulmonary resuscitation (CPR) and advanced cardiac life support of the pregnant woman; (Outcome) postpartum tubal ligation and timing, including global policies to ensure availability, regulatory and consent issues, ethics, obstetric considerations, counseling, and alternatives; (Outcome) postpartum pain management in the parturient, including consequences of post-cesarean delivery pain; (Outcome) non-obstetric surgery during pregnancy, including laparoscopy and cardiorespiratory effects on the mother and fetus; (Outcome) effects of maternal medications on breastfeeding, particularly effects of labor analgesia and postpartum analgesia; (Outcome) antepartum and intrapartum fetal monitoring, including the application of ultrasonography, biophysical profile, electronic fetal heart monitoring, assessment of uterine contraction pattern and labor, and acid-base status of the fetus; (Outcome) effects of general anesthesia on the mother and fetus, and the effects of fetal circulation and placental transfer on newborn adaptation; (Outcome) related disciplines, particularly involving obstetrics, maternal and fetal medicine, and neonatology; (Outcome) anesthetic management of ex-utero intrapartum treatment (EXIT) procedures with and without neonatal transfer to extracorporeal membrane oxygenation (ECMO) and anesthesia for fetal surgery; (Outcome) transport and monitoring of critically-ill pregnant women within one hospital and between hospitals; (Outcome) organization and management of an obstetric anesthesia service, including health care delivery models, reimbursement, building a service, and regulatory agencies with jurisdiction; (Outcome) legal and ethical issues during pregnancy; (Outcome) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 13 of 32

15 IV.A.2.b).(1).(aa) IV.A.2.b).(1).(bb) IV.A.2.b).(1).(cc) IV.A.2.b).(1).(dd) IV.A.2.b).(1).(ee) IV.A.2.b).(1).(ff) IV.A.2.b).(1).(gg) IV.A.2.b).(1).(gg).(i) IV.A.2.b).(1).(gg).(ii) IV.A.2.b).(1).(gg).(iii) IV.A.2.c) social issues, including domestic violence; discrimination; substance abuse; homelessness; and cultural, ethnic and economic barriers to safe anesthesia care, including strategies to mobilize system resources for disadvantaged women in those situations; (Outcome) medical economics and public health issues of women during reproductive years as it applies to obstetric anesthesiology, including availability of obstetric analgesia, and Cesarean delivery rates; (Outcome) maternal morbidity and mortality; (Outcome) policies and procedures governing the labor and delivery unit, obstetric operating rooms, and the obstetric PACU, including the potential effects of societal, institutional, and governmental factors; (Outcome) principles and ethics of research in pregnant women, their fetuses, and neonates; (Outcome) processes involved in designing and implementing clinical trials; and, (Outcome) research funding, including: (Outcome) applicable funding agencies; (Outcome) components of a research budget, including direct and indirect costs; and, (Outcome) funding procurement mechanisms. (Outcome) 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) IV.A.2.c).(2) systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement; and, (Outcome) locate, appraise, and assimilate evidence from scientific studies related to their patients health problems. (Outcome) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 14 of 32

16 IV.A.2.c).(2).(a) IV.A.2.c).(3) IV.A.2.c).(4) IV.A.2.c).(4).(a) IV.A.2.c).(4).(b) IV.A.2.d) Studies must include literature from perinatal medicine and pediatrics in addition to anesthesiology. (Detail) demonstrate the ability to be an educator in obstetric anesthesiology; and, (Outcome) demonstrate competence in practice-based improvement by completing a project with at least one of the following goals: (Outcome) enhancing the fellow s engagement in multidisciplinary care of obstetric patients; or, (Outcome) improving patient safety as it applies to the fellow s practice of obstetric anesthesiology. (Outcome) 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. (Outcome) IV.A.2.d).(1) IV.A.2.d).(1).(a) IV.A.2.d).(1).(b) IV.A.2.d).(1).(c) IV.A.2.d).(1).(d) IV.A.2.e) Fellows must demonstrate the following communication skills in a multidisciplinary setting: (Outcome) Professionalism effectively communicating with the perinatal health care team; (Outcome) effectively collaborating with all health care providers in all settings relevant to the comprehensive care of the pregnant woman, including the outpatient clinic, antepartum consultation, labor and delivery, operating rooms, the PACU, intensive care units, and the emergency department; (Outcome) effectively leading the anesthesia care team; and, (Outcome) effectively supervising clinical trainees, including medical students and residents, and providing constructive feedback. (Outcome) Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. (Outcome) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 15 of 32

17 IV.A.2.e).(1) IV.A.2.f) Fellows must demonstrate the ability to work in a multidisciplinary environment, particularly the ability to have collegial and effective interactions with other members of the perinatal care team. (Outcome) 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. (Outcome) Fellows must: IV.A.2.f).(1) IV.A.2.f).(2) IV.A.2.f).(3) IV.A.2.f).(4) IV.A.3. IV.A.3.a) IV.A.3.a).(1) IV.A.3.a).(2) IV.A.3.a).(3) IV.A.3.a).(4) demonstrate competence in recognizing barriers and limitations in access to care for some patient populations, including Medicaid reimbursement for postpartum sterilization, and developing strategies to meet patient needs; (Outcome) demonstrate the ability to provide cost-effective care that incorporates best practices; (Outcome) demonstrate competence in developing policies, guidelines, standards, practice parameters, and quality management tools to ensure the public health of pregnant women; and, (Outcome) participate in a system improvement based on the literature, quality improvement data, and patient and family satisfaction data. (Outcome) Curriculum Organization and Fellow Experiences The curriculum must be structured to include: interpretation of fetal heart rate monitoring and demonstrated competency in the first three months of the program; (Core) a minimum of seven months of operating room and labor and delivery clinical activity; (Detail) at least one contiguous two-week rotation in maternal-fetal medicine that includes experience in antepartum fetal testing and high-risk antepartum care; (Core) at least one contiguous two-week rotation in neonatology during which fellows provide routine neonatal evaluation and care; and, (Core) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 16 of 32

18 IV.A.3.a).(5) IV.A.3.b) IV.A.3.b).(1) IV.A.3.b).(2) IV.A.3.b).(3) IV.A.3.b).(3).(a) IV.A.3.b).(3).(b) at least three months designated for research or other welldefined scholarly activity, leading to new knowledge related to the required rotations. (Core) The didactic curriculum should be provided through lectures, conferences, facilitated self-learning, workshops, or simulation, and should supplement clinical experience. (Core) Faculty members should be conference leaders in the majority of the sessions. (Core) The didactic curriculum should include all topics listed as expected medical knowledge outcomes. (Core) Additional didactic topics must include: the impact of different anesthetic and analgesic techniques on health care resources, including room allocation; staffing; and patient throughput; and, (Core) sound business practices and the direct and indirect costs of different obstetric analgesic and anesthetic techniques. (Core) IV.B. IV.B.1. IV.B.1.a) Fellows Scholarly Activities Each fellow should conduct or be substantially involved in a scholarly project related to the subspecialty which leads to both presentation at a national meeting, and publication. (Outcome) Fellows must have a faculty mentor overseeing the project. (Core) V. Evaluation V.A. V.A.1. V.A.1.a) V.A.1.a).(1) Fellow Evaluation The program director must appoint the Clinical Competency Committee. (Core) At a minimum the Clinical Competency Committee must be composed of three members of the program faculty. (Core) 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 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 17 of 32

19 with the program s fellows in patient care and other health care settings. (Core) V.A.1.a).(1).(b) V.A.1.b) V.A.1.b).(1) V.A.1.b).(1).(a) V.A.1.b).(1).(b) V.A.1.b).(1).(c) V.A.2. V.A.2.a) V.A.2.a).(1) V.A.2.b) V.A.2.b).(1) V.A.2.b).(2) V.A.2.b).(3) V.A.2.c) 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. (Core) There must be a written description of the responsibilities of the Clinical Competency Committee. (Core) Formative Evaluation The Clinical Competency Committee should: review all fellow evaluations semi-annually; (Core) prepare and ensure the reporting of Milestones evaluations of each fellow semi-annually to ACGME; and, (Core) advise the program director regarding fellow progress, including promotion, remediation, and dismissal. (Detail) The faculty must evaluate fellow performance in a timely manner. (Core) Faculty members must provide evaluations of each fellow s progress and competency to the program director at the end of three, six, and nine months of education. (Core) The program must: 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; (Core) use multiple evaluators (e.g., faculty, peers, patients, self, and other professional staff); and, (Detail) provide each fellow with documented semiannual evaluation of performance with feedback. (Core) The evaluations of fellow performance must be accessible for review by the fellow, in accordance with institutional policy. (Detail) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 18 of 32

20 V.A.3. V.A.3.a) V.A.3.b) Summative Evaluation 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. (Core) The program director must provide a summative evaluation for each fellow upon completion of the program. (Core) This evaluation must: V.A.3.b).(1) V.A.3.b).(2) V.A.3.b).(3) 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; (Detail) document the fellow s performance during their education; and, (Detail) verify that the fellow has demonstrated sufficient competence to enter practice without direct supervision. (Detail) V.B. V.B.1. V.B.2. V.B.2.a) V.C. V.C.1. V.C.1.a) V.C.1.a).(1) V.C.1.a).(2) V.C.1.a).(3) Faculty Evaluation At least annually, the program must evaluate faculty performance as it relates to the educational program. (Core) These evaluations should include a review of the faculty s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities. (Detail) These evaluations must include annual written confidential evaluations of faculty members by the fellows. (Core) Program Evaluation and Improvement The program director must appoint the Program Evaluation Committee (PEC). (Core) The Program Evaluation Committee: must be composed of at least two program faculty members and should include at least one fellow; (Core) must have a written description of its responsibilities; and, (Core) should participate actively in: 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 19 of 32

21 V.C.1.a).(3).(a) V.C.1.a).(3).(b) V.C.1.a).(3).(c) V.C.1.a).(3).(d) V.C.2. planning, developing, implementing, and evaluating educational activities of the program; (Detail) reviewing and making recommendations for revision of competency-based curriculum goals and objectives; (Detail) addressing areas of non-compliance with ACGME standards; and, (Detail) reviewing the program annually using evaluations of faculty, fellows, and others, as specified below. (Detail) The program, through the PEC, must document formal, systematic evaluation of the curriculum at least annually, and is responsible for rendering a written, annual program evaluation. (Core) The program must monitor and track each of the following areas: V.C.2.a) V.C.2.b) V.C.2.c) V.C.3. V.C.3.a) fellow performance; (Core) faculty development; and, (Core) progress on the previous year s action plan(s). (Core) 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. (Core) The action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes. (Detail) VI. The Learning and Working Environment Fellowship education must occur in the context of a learning and working environment that emphasizes the following principles: Excellence in the safety and quality of care rendered to patients by fellows today Excellence in the safety and quality of care rendered to patients by today s fellows in their future practice Excellence in professionalism through faculty modeling of: o the effacement of self-interest in a humanistic environment that supports the professional development of physicians 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 20 of 32

22 o the joy of curiosity, problem-solving, intellectual rigor, and discovery Commitment to the well-being of the students, residents/fellows, faculty members, and all members of the health care team VI.A. VI.A.1. Patient Safety, Quality Improvement, Supervision, and Accountability Patient Safety and Quality Improvement All physicians share responsibility for promoting patient safety and enhancing quality of patient care. Graduate medical education must prepare fellows to provide the highest level of clinical care with continuous focus on the safety, individual needs, and humanity of their patients. It is the right of each patient to be cared for by fellows who are appropriately supervised; possess the requisite knowledge, skills, and abilities; understand the limits of their knowledge and experience; and seek assistance as required to provide optimal patient care. Fellows must demonstrate the ability to analyze the care they provide, understand their roles within health care teams, and play an active role in system improvement processes. Graduating fellows will apply these skills to critique their future unsupervised practice and effect quality improvement measures. It is necessary for fellows and faculty members to consistently work in a well-coordinated manner with other health care professionals to achieve organizational patient safety goals. VI.A.1.a) VI.A.1.a).(1) Patient Safety Culture of Safety A culture of safety requires continuous identification of vulnerabilities and a willingness to transparently deal with them. An effective organization has formal mechanisms to assess the knowledge, skills, and attitudes of its personnel toward safety in order to identify areas for improvement. VI.A.1.a).(1).(a) VI.A.1.a).(1).(b) VI.A.1.a).(2) The program, its faculty, residents, and fellows must actively participate in patient safety systems and contribute to a culture of safety. (Core) The program must have a structure that promotes safe, interprofessional, team-based care. (Core) Education on Patient Safety 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 21 of 32

23 Programs must provide formal educational activities that promote patient safety-related goals, tools, and techniques. (Core) VI.A.1.a).(3) Patient Safety Events Reporting, investigation, and follow-up of adverse events, near misses, and unsafe conditions are pivotal mechanisms for improving patient safety, and are essential for the success of any patient safety program. Feedback and experiential learning are essential to developing true competence in the ability to identify causes and institute sustainable systemsbased changes to ameliorate patient safety vulnerabilities. VI.A.1.a).(3).(a) VI.A.1.a).(3).(a).(i) VI.A.1.a).(3).(a).(ii) VI.A.1.a).(3).(a).(iii) VI.A.1.a).(3).(b) VI.A.1.a).(4) Residents, fellows, faculty members, and other clinical staff members must: know their responsibilities in reporting patient safety events at the clinical site; (Core) know how to report patient safety events, including near misses, at the clinical site; and, (Core) be provided with summary information of their institution s patient safety reports. (Core) Fellows must participate as team members in real and/or simulated interprofessional clinical patient safety activities, such as root cause analyses or other activities that include analysis, as well as formulation and implementation of actions. (Core) Fellow Education and Experience in Disclosure of Adverse Events Patient-centered care requires patients, and when appropriate families, to be apprised of clinical situations that affect them, including adverse events. This is an important skill for faculty physicians to model, and for fellows to develop and apply. VI.A.1.a).(4).(a) All fellows must receive training in how to disclose adverse events to patients and families. (Core) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 22 of 32

24 VI.A.1.a).(4).(b) VI.A.1.b) VI.A.1.b).(1) Quality Improvement Fellows should have the opportunity to participate in the disclosure of patient safety events, real or simulated. (Detail) Education in Quality Improvement A cohesive model of health care includes qualityrelated goals, tools, and techniques that are necessary in order for health care professionals to achieve quality improvement goals. VI.A.1.b).(1).(a) VI.A.1.b).(2) Fellows must receive training and experience in quality improvement processes, including an understanding of health care disparities. (Core) Quality Metrics Access to data is essential to prioritizing activities for care improvement and evaluating success of improvement efforts. VI.A.1.b).(2).(a) VI.A.1.b).(3) Fellows and faculty members must receive data on quality metrics and benchmarks related to their patient populations. (Core) Engagement in Quality Improvement Activities Experiential learning is essential to developing the ability to identify and institute sustainable systemsbased changes to improve patient care. VI.A.1.b).(3).(a) VI.A.1.b).(3).(a).(i) VI.A.2. VI.A.2.a) Supervision and Accountability Fellows must have the opportunity to participate in interprofessional quality improvement activities. (Core) This should include activities aimed at reducing health care disparities. (Detail) Although the attending physician is ultimately responsible for the care of the patient, every physician shares in the responsibility and accountability for their efforts in the provision of care. Effective programs, in partnership with their Sponsoring Institutions, define, widely communicate, and monitor a structured chain of responsibility and accountability as it relates to the supervision of all patient care Accreditation Council for Graduate Medical Education (ACGME) Page 23 of 32

25 Supervision in the setting of graduate medical education provides safe and effective care to patients; ensures each fellow s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishes a foundation for continued professional growth. VI.A.2.a).(1) VI.A.2.a).(1).(a) VI.A.2.a).(1).(b) VI.A.2.b) VI.A.2.b).(1) VI.A.2.c) Each patient must have an identifiable and appropriately-credentialed and privileged attending physician (or licensed independent practitioner as specified by the applicable Review Committee) who is responsible and accountable for the patient s care. (Core) This information must be available to fellows, faculty members, other members of the health care team, and patients. (Core) Fellows and faculty members must inform each patient of their respective roles in that patient s care when providing direct patient care. (Core) Supervision may be exercised through a variety of methods. 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 on site or by means of telephonic and/or electronic modalities. Some activities require the physical presence of the supervising faculty member. In some circumstances, supervision may include post-hoc review of fellow-delivered care with feedback. The program must demonstrate that the appropriate level of supervision in place for all fellows is based on each fellow s level of training and ability, as well as patient complexity and acuity. Supervision may be exercised through a variety of methods, as appropriate to the situation. (Core) Levels of Supervision To promote oversight of fellow supervision while providing for graded authority and responsibility, the program must use the following classification of supervision: (Core) VI.A.2.c).(1) VI.A.2.c).(2) Direct Supervision the supervising physician is physically present with the fellow and patient. (Core) Indirect Supervision: 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 24 of 32

26 VI.A.2.c).(2).(a) 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. (Core) VI.A.2.c).(2).(b) VI.A.2.c).(3) VI.A.2.d) VI.A.2.d).(1) VI.A.2.d).(2) VI.A.2.d).(3) VI.A.2.e) VI.A.2.e).(1) VI.A.2.f) 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. (Core) Oversight the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered. (Core) 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. (Core) The program director must evaluate each fellow s abilities based on specific criteria, guided by the Milestones. (Core) Faculty members functioning as supervising physicians must delegate portions of care to fellows based on the needs of the patient and the skills of each fellow. (Core) Fellows should serve in a supervisory role to residents or junior fellows in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow. (Detail) Programs must set guidelines for circumstances and events in which fellows must communicate with the supervising faculty member(s). (Core) Each fellow must know the limits of their scope of authority, and the circumstances under which the fellow is permitted to act with conditional independence. (Outcome) Faculty supervision assignments must be of sufficient duration to assess the knowledge and skills of each fellow and to delegate to the fellow the appropriate level of patient care authority and responsibility. (Core) 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 25 of 32