The Johns Hopkins School of Medicine
GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Application for ACGME-equivalent
Fellowship Programs
Effective Date
Page
Supersedes
12/10/14
1 of 12
09/01/13
ACGME-Equivalency for Non-Accredited Fellowships
In order for a trainee in a non-accredited fellowship to qualify for ECFMG sponsorship and/or
UMP (Unlicensed Medical Practitioner) registration with the Maryland Board of Physicians, the
fellowship must be determined, by the GME Office, to be ACGME-Equivalent. A fellowship
that has not received and maintained that status may not enroll FMGs on J-1 visas and their
fellows must obtain a Maryland State Physicians License before commencing training.
To obtain the designation of ACGME-Equivalent, a fellowship must have a defined educational
purpose, with a structured didactic program, graded goals and objectives for the trainee over the
course of the fellowship and an evaluation system for the fellow, faculty and program. The
program may include both clinical training and research.
Application may be made for equivalency determination by completing this application which
will be reviewed by the Executive Committee of the Graduate Medical Education Committee.
That committee shall approve the equivalency, return the application for additional data or reject
an equivalency designation. If equivalency is granted, the program shall be listed as such on the
GMEC website.
To maintain the equivalency designation, the program needs to comply with the GMEC
requirements, including submission of the Annual Program Evaluation Report. The fellowship is
expected to maintain a reasonable level of activity; if 3 years lapse without a trainee, the
equivalency designation will terminate and reapplication will be required for future enrollees.
The Johns Hopkins School of Medicine
GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Application for ACGME-equivalent
Fellowship Programs
Effective Date
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NON-ACCREDITED, ACGME-equivalent PROGRAM APPLICATION
INSTRUCTIONS:
This document is not only for data collection, but also designed to educate the Program Director in the specific
requirements for equivalency. Therefore, it must be completed and signed by the Program Director.
This is a Word form; you can only type into the grey text boxes or check boxes. You can move from box to box with the
tab key, the navigation arrows or the mouse.
Fill in the requested information; in the boxed areas which present the standards, check whether you are compliant or not;
if not compliant, explain in the text box at the bottom of the section, as illustrated here.
Compliant or N/A
Noncompliant
A standard
Another standard
Explain here, if not compliant
SECTION I: PROGRAM IDENTIFICATION
Name of Program:
Program Director:
Program Coordinator:
Division or Department Director:
Length of Program:
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 fellow
physician to assume personal responsibility for the care of individual patients. For the 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 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 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.
The Johns Hopkins School of Medicine
GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Effective Date
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Fellowship Programs
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What percentage of the training in this fellowship is clinical, not research?
One sponsoring institution must assume ultimate responsibility for the program and this responsibility extends to fellow
assignments at all participating sites. (Core)*
Where is the Program primarily based?
Do trainees rotate to any other institutions or clinic sites?
If no, skip the rest of this section and proceed to Section II.
Compliant or N/A
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)
What other institutions participate in the Program, and what is the length of each rotation?
Attach copies of the letter(s) of agreement for outside rotations as Appendix 1.
Noncompliant
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GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Effective Date
Application for ACGME-equivalent
Fellowship Programs
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SECTION II. Program Personnel and Resources
Compliant or N/A
Noncompliant
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)
The program director must administer and maintain an educational environment
conducive to educating the fellows in each of the ACGME competency areas.
(Core)
Adequate lengths of appointment for both the program director and faculty are
essential to maintaining such an appropriate continuity of leadership
Qualifications of the program director are as follows:
a) The program director must possess the requisite specialty expertise, as well
as documented educational and administrative abilities.
b) The program director must be certified in the specialty by the appropriate
American Board, or possess qualifications judged to be acceptable by the
department chair.
c) The program director must be appointed in good standing and based at the
primary teaching site.
Briefly describe the Program Director’s qualifications, including Board certifications.
List core faculty members with their board status and certification dates.
Responsibilities of the program director are as follows:
a) The program director must oversee and organize the activities of the
educational program in all institutions that participate in the program. This
includes selecting and supervising the faculty and other program personnel at
each participating institution, appointing a local site director, and monitoring
appropriate trainee supervision at all participating institutions.
How does the Program Director oversee the educational program and monitor trainee supervision at each
rotation site?
The Johns Hopkins School of Medicine
GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Application for ACGME-equivalent
Fellowship Programs
Effective Date
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09/01/13
b) The program director must ensure the implementation of fair policies,
grievance procedures, and due process, as established by the sponsoring
institution.
What is the Program Director’s time commitment to the program (administrative and teaching activities)?
What is the Program Director’s non-program (eg: research) commitment?
Compliant or N/A
Faculty
1. At each participating institution, there must be a sufficient number of faculty
with documented qualifications to instruct and supervise adequately all trainees
in the program.
2. The faculty, furthermore, must devote sufficient time to the educational
program to fulfill their supervisory and teaching responsibilities. They must
demonstrate a strong interest in the education of trainees, and must support the
goals and objectives of the educational program of which they are a member.
3. Qualifications of the physician faculty are as follows:
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 experience in their field.
The faculty must regularly participate in organized clinical discussions, rounds,
journal clubs, and conferences.
List non-physician faculty and specify their roles
Other Program Personnel
Additional necessary professional, technical, and clerical personnel must be
provided to support the program.
Resources
The program must ensure that adequate resources (e.g., sufficient laboratory
space and equipment, computer and statistical consultation services) are
available.
Noncompliant
The Johns Hopkins School of Medicine
GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Effective Date
Application for ACGME-equivalent
Fellowship Programs
Page
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SECTION III. Fellow Appointments
Compliant or N/A
Noncompliant
What are your eligibility criteria for applicants?
How do you, or how will you, select your trainees?
Candidates (applicants who are invited for an interview) must be informed, in
writing or by electronic means, of the terms, conditions, and benefits of
appointment, including financial support; vacations; parental, sick, and other
leaves of absence; professional liability, hospitalization, health, disability and
other insurance provided for the trainees and their families; and the conditions
under which living quarters, meals, laundry services, or their equivalents are to
be provided.
How do you ensure that interviewees are informed of the conditions of appointment?
Appointment of Fellows and Other Students
The appointment of fellows and other specialty trainees or students must not
dilute or detract from the educational opportunities available to regularly
appointed trainees and fellows.
How do you ensure that the training and education of other trainees is not adversely affected by trainees in this program?
How will this fellowship affect other training programs in related areas?
Have the Program Directors of accredited programs within your department approved of this fellowship?
Describe your plans for fellow involvement in Quality Improvement and Patient Safety activities.
The Johns Hopkins School of Medicine
GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Application for ACGME-equivalent
Fellowship Programs
Effective Date
Page
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09/01/13
SECTION IV. Educational Program
Compliant or N/A
Noncompliant
The curriculum must contain the following educational components:
Overall educational goals for the program, which the program must make
available to fellows and faculty; (Core)
Competency-based goals and objectives for each assignment at each educational
level, which the program must distribute to fellows and faculty at least annually,
in either written or electronic form; (Core)
Regularly scheduled didactic sessions; (Core)
Delineation of fellow responsibilities for patient care, progressive responsibility
for patient management, and supervision of fellows over the continuum of the
program
Attach, as Appendix 2, a block diagram of assignments and a description of each major assignment or
rotation, with separate description if repeated at different levels of training.
Attach, as Appendix 3, the goals and objectives for each major assignment categorized according to the
ACGME’s 6 core competencies.
Attach, as Appendix 4, a description of the evaluations for each major assignment, including evaluations
of the trainee, the faculty and the assignment itself.
Attach, as Appendix 5, the mechanisms of supervision on each assignment (see section VI A, below).
How do you assure that the goals and objectives are reviewed with each trainee at the start of each rotation?
Attach, as Appendix 6, a list of major conferences and didactic activities, indicating whether each is
required or optional. Include the topic list for your major teaching conference(s); if this is a new program,
list the anticipated conference schedule.
Core Competencies
The residency program must require its trainees to obtain competence in the six
areas listed below to the level expected of a new practitioner. Programs must
define the specific knowledge, skills, behaviors, and attitudes required, and
provide educational experiences as needed in order for their trainees to
demonstrate the following:
1. Patient care that is compassionate, appropriate, and effective for the
treatment of health problems and the promotion of health;
2. Medical knowledge about established and evolving biomedical, clinical, and
cognate sciences, as well as the application of this knowledge to patient care;
3. Practice-based learning and improvement that involves the investigation and
evaluation of care for their patients, the appraisal and assimilation of scientific
evidence, and improvements in patient care;
4. Interpersonal and communication skills that result in the effective exchange
of information and collaboration with patients, their families, and other health
professionals;
The Johns Hopkins School of Medicine
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5. Professionalism, as manifested through a commitment to carrying out
professional responsibilities, adherence to ethical principles, and sensitivity to
patients of diverse backgrounds;
6. Systems-based practice, as manifested by actions that 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.
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The Johns Hopkins School of Medicine
GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Application for ACGME-equivalent
Fellowship Programs
Effective Date
Page
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12/10/14
9 of 12
09/01/13
SECTION V. Evaluation
Fellow Evaluation
The program director must appoint a Clinical Competency Committee.
At a minimum the Clinical Competency Committee must be composed of three
members of the program faculty. (Core)
There must be a written description of the responsibilities of the Clinical
Competency Committee. (Core)
The Clinical Competency Committee should review all fellow evaluations semiannually; (Core)
Compliant or N/A
Noncompliant
List the members of your
Clinical Competency
Committee
Formative Evaluation
The faculty must evaluate fellow performance in a timely manner during each
rotation or similar educational assignment, and document this evaluation at
completion of the assignment. (Core)
The program must:
1) 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
2) use multiple evaluators (e.g., faculty, peers, patients, self, and other
professional staff)
3) provide each fellow with documented semiannual evaluation of performance
with feedback
Describe how you use, or will use, evaluation tools developed to assess a trainee's level of competence in
each of the six competencies.
Documented Evaluations used:
Faculty
Nursing
Social Worker
Patient
Self
Other Evaluation Methods Used:
In-Service Exam
Formal Oral Exam
OSCE
Peers
Medical Students
Residents from Outside Program
Other(specify)
Other(specify)
Portfolio
Record Review
Patient Survey
The Johns Hopkins School of Medicine
GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Application for ACGME-equivalent
Fellowship Programs
Simulation/Models
Patient Safety Data
Other(specify)
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Case Logs
Evaluation of Presentations
Other(specify)
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.
How do (or will) trainees evaluate faculty?
How do (or will) trainees evaluate their educational experiences?
Program Evaluation and Improvement
The program director must appoint the Program Evaluation Committee (PEC).
The Program Evaluation Committee:
1) must be composed of at least two program faculty members and should
include at least one fellow;
2) must have a written description of its responsibilities
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.
List the members of your
Program Evaluation
Committee
Effective Date
The Johns Hopkins School of Medicine
GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Application for ACGME-equivalent
Fellowship Programs
Effective Date
12/10/14
Page
11 of 12
Supersedes
09/01/13
SECTION VI: Fellow Duty Hours in the Learning and Working Environment
Compliant or N/A
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.
The program director must ensure that fellows are integrated and actively
participate in interdisciplinary clinical quality improvement and patient safety
programs.
The learning objectives of the program must be accomplished through an
appropriate blend of supervised patient care responsibilities, clinical teaching,
and didactic educational events;
In the clinical learning environment, each patient must have an identifiable,
appropriately-credentialed and privileged attending physician who is ultimately
responsible for that patient’s care.
The program must demonstrate that the appropriate level of supervision is in
place for all fellows who care for patients.
Duty Hours
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.
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.
Adequate time for rest and personal activities must be provided. This should
consist of an 8-hour time period provided between all daily duty periods and
after in-house call.
In- house call must occur no more frequently than every third night, averaged
over a 4-week period.
Continuous on-site duty, including in-house call, must not exceed 24
consecutive hours. Trainees may remain on duty for up to 4 additional hours to
participate in didactic activities, transfer care of patients, conduct outpatient
clinics, and maintain continuity of medical and surgical care.
The program director and the faculty must monitor the demands of at-home call
in their programs, and make scheduling adjustments as necessary to mitigate
excessive service demands and/or fatigue.
Extracurricular Activities
1. Because residency education is a full-time endeavor, the program director
must ensure that moonlighting does not interfere with the ability of the trainee
to achieve the goals and objectives of the educational program.
2. The program director must comply with the sponsoring institution’s written
policies and procedures regarding extracurricular activity.
3. Any hours a trainee works for compensation at the sponsoring institution or
any of the sponsor’s primary clinical sites must be considered part of the 80hour weekly limit on duty hours.
Noncompliant
The Johns Hopkins School of Medicine
GRADUATE MEDICAL EDUCATION COMMITTEE POLICY
Application for ACGME-equivalent
Fellowship Programs
Effective Date
12/10/14
Page
12 of 12
Supersedes
09/01/13
How do you, or will you monitor duty hours?
Complete if you have current trainees:
How compliant are your trainees in recording their hours?
If you currently have trainees, complete for the last 28-day period:
Hours worked per week:
Maximum for any trainee:
Average for all trainees:
Continuous hours on duty:
Average for all trainees:
Maximum for any trainee:
Minimum number of days off:
Maximum number of days of in-house call per week:
IX: APPENDICES
1.
2.
3.
4.
5.
6.
Letters of agreement for outside rotations
Block diagram and rotation descriptions, with competency-based goals and objectives, assessment
mechanisms and supervision strategies
Competency-based goals and objectives for each major assignment
Evaluation techniques for each major assignment
Mechanism of supervision for each major assignment
Major conferences and didactic activities
Signed:
Printed:
Program Director