Application Form
David C. Leach Award
Please note that the form is in a table format and the boxes will expand as text is entered.
Team Leader Contact Information
Name:
Name:
Nominator Contact Information
Address:
Address:
City, State, Zip:
City, State, Zip:
Telephone:
Telephone:
E-mail:
E-mail:
Name of Institution:
Name of Institution:
Name and address of residency/fellowship
Program number and specialty:
program:
Current accreditation status:
Name(s) and position(s) of rest of team in program, e.g., resident, faculty member, nurse,
residency coordinator, etc.:
1.
2.
3.
4.
5.
The resident* (or resident team**) will have demonstrated excellence in GME in at least
one of the following five areas:
1. fostering innovation and improvement in the learning environment
2. increasing the program’s emphasis on educational outcomes
3. increasing efficiency and reducing non-educational burden in the program
4. improving communication and collaboration in education and patient care within the
program and/or institution
5. advancing humanism*** in the patient care environment and among caregivers
Name the area (above) and describe the project, test, or activity that was targeted to
improve graduate medical education and/or patient care:
Did the project, test, or activity improve education or patient care? If so, describe how:
Describe how the project, test, or activity was carried out:
Describe the role of the resident(s) in this project:
Why was the project, test, activity significant for the program/institution, and, if
applicable, to patient care?
Describe how the project was evaluated and measured. What were the results? What did
the resident(s) and/or resident team learn? What were the resident(s) and/or team able to
predict?
Updated December 2015
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Is the improvement something that other programs/institutions could learn from and
adopt?
Describe current status and whether the improvement was sustainable:
Any reflections that the resident or resident team wish(es) to share?
*fellows are also eligible
**resident team may include: resident(s), fellow(s), faculty member(s), nurse(s), social worker(s),
residency coordinator(s), etc. (each team must include at least one resident or fellow)
***a program or activity designed to celebrate and refresh the spirit of physicians, reconnect
physicians, and renew the connections between the spirit and daily work, thus improving patient care
Please scan the support letters and application and send in one PDF file,
via e-mail, to DeLonda Dowling: ddowling@acgme.org.
All nominations must be e-mailed before Friday, March 18, 2016, 5:00 pm
CDT. Nominations received after the deadline will not be considered.
Checklist for Nomination Materials
Examples of qualifying demonstrations of excellence, as relate to the five
required areas noted above, include:

a house officer and residency coordinator who have designed an
innovative method to improve the program’s evaluation system

a program director and chief resident with extraordinary vision for
curriculum design and teaching

a house officer who has developed and implemented an improved system
of communicating within the program

a team of faculty members, residents, and others collaborating to identify
and assess educational outcomes for the program

programs that promote resident well-being

a team that improves patient care processes and implements sustainable
patient-centered care changes

a house officer or resident team that uses poems, music, or art to teach
the skills of the heart (courage, honesty, humility) and self-reflection to
improve patient care and resident well-being
Application Instructions
Two components are required for application:
1. A completed application form
2. Three letters of support (each letter must be 500 words or less)
Note: If applying as a team, a team leader must be designated. This individual is
responsible for the project and for receiving the award on behalf of the team.
About the Letters of Support

Letters should be addressed to “ACGME Awards Committee.”

The letters may be from faculty members, department chairs, program
directors, designated institutional officials (DIOs) or other institutional
representatives, Review Committee members, residency coordinators,
nurses, patients, etc.
Updated December 2015
©2015 Accreditation Council for Graduate Medical Education (ACGME)


Comments from a group (e.g., members of the faculty, residents, etc.)
should be compiled into one “group letter.” We will not accept more than
three letters of support for each nominee/team.
The letters should show how the nominee/team has made a positive
impact in at least one of the five criteria areas of excellence outlined
above.
Updated December 2015
©2015 Accreditation Council for Graduate Medical Education (ACGME)