New Application: Pediatric Nephrology
Review Committee for Pediatrics
ACGME
515 North State Street, Suite 2000, Chicago, Illinois 60654  312.755.5000  www.acgme.org
COMMON SUBSPECIALTY SECTION
FACULTY RESEARCH
1. Complete the table below regarding the involvement of faculty in research. Add rows as necessary.
[PR II.B.5.b)]
# of current
IRB approved
research
Name
projects
Program Director:
Total # of
current
funded
research
projects
# of current
research
projects with
peer review
funding
(subset of
total # in
previous
column)
#
presentations
at national
scientific
# publications
meetings in in peer review
the last 5
journals in the
years
last 5 years
Key Faculty:
Research Mentors Who Are Not Key Faculty:
2. List active research projects in the subspecialty. Add additional rows as necessary.
Project title
Funding
source
Put an “X for
funding
awarded by
peer review
process
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Years of
funding
(dates)
Faculty investigator and
role in grant (i.e. PI, Co-PI,
Co-investigator)
Updated 4/2015
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RESEARCH RESOURCES
1. Does the program provide research laboratory space and equipment? (if appropriate) [PR II.D.]
.................................................................................................................................... ☐ YES ☐ NO
2. Does the program provide financial support for research? ........................................... ☐ YES ☐ NO
3. Does the program provide computer and statistical consultation services? .................. ☐ YES ☐ NO
PROGRAM CURRICULUM
Goals and Objectives
Place an ‘X” in the box before the applicable response. [PR IV.A.2.]
Are there goals and objectives for all training
☐ YES ☐ NO
experiences?
Are they rotation and level specific?
☐ YES ☐ NO
How are they distributed?
☐ Hard Copy ☐ Electronic or web-based
If not web-based, when are they distributed to
☐ Prior to Each Rotation
☐ Annually
fellows?
☐ Once in Handbook
☐ Other
If not web-based, when are they distributed to
☐ Prior to Each Rotation
faculty?
☐ Annually
☐ Other
If web-based, do you send out reminders to access ☐ YES ☐ NO
them?
If yes, when do you send them?
Click here to enter text.
Collaboration between Programs
Are there meetings among the core Program
Director and subspecialty Program Directors?
How often do these meetings occur?
Who is typically involved in these meetings?
(check all that apply)
☐ YES ☐ NO
Click here to enter text.
☐ Core program director
☐ Subspecialty program director for this specialty
☐ Program directors from other subspecialties
General Subspecialty Curriculum
Topic
e.g., Biostatistics
Basic science as
related to the
Participants (place and X in the
appropriate column)
Where Taught in
Number of
Fellows in
Curriculum?
Structured
this
All
Residents &
(Name should Teaching Hours Discipline Subspecialty Subspecialty
match name in
Dedicated to
Will
Fellows
Fellows
conference list)
Topic Area?
Attend
Attend
Attend
Research
Course
14
X
Click here to
#
☐
☐
☐
enter text.
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 2 of 11
Participants (place and X in the
appropriate column)
Where Taught in
Number of
Fellows in
Curriculum?
Structured
this
All
Residents &
(Name should Teaching Hours Discipline Subspecialty Subspecialty
match name in
Dedicated to
Will
Fellows
Fellows
conference list)
Topic Area?
Attend
Attend
Attend
Topic
application in clinical
subspecialty practice
Clinical subspecialty
Click here to
#
☐
☐
☐
content
enter text.
For the topics below, if the topic is not appropriate for your discipline (i.e., lab research for
fellows in developmental and behavioral pediatrics), enter N/A into column 1.
Biostatistics
Click here to
#
☐
☐
☐
enter text.
Lab research
Click here to
#
☐
☐
☐
methodology (if
enter text.
appropriate)
Clinical research
Click here to
#
☐
☐
☐
methodology
enter text.
Study design
Click here to
#
☐
☐
☐
enter text.
Grant preparation
Click here to
#
☐
☐
☐
enter text.
Preparation of
Click here to
#
☐
☐
☐
protocols for
enter text.
institutional review
board
Principles of evidenceClick here to
#
☐
☐
☐
based medicine/
enter text.
Critical literature
review
Quality Improvement
Click here to
#
☐
☐
☐
enter text.
Teaching skills
Click here to
#
☐
☐
☐
enter text.
Professionalism/Ethics
Click here to
#
☐
☐
☐
enter text.
Cultural Diversity
Click here to
#
☐
☐
☐
enter text.
Systems-based
Click here to
#
☐
☐
☐
practice (economics of
enter text.
healthcare, practice
management, clinical
outcomes, etc.)
Conferences
1. List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the
subspecialty training program. Identify the "SITE" by using the corresponding number as appears
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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on the first and second pages of this form. Indicate the frequency, e.g., weekly, monthly, etc., and
whether conference attendance is required (R) or optional (0). List the planned role of the fellow in
this activity (e.g., conducts conference, presents case and participates in discussion, case
presentation only, participation limited to Q&A component, etc.). Add rows as necessary.
Conference
Site #
Frequency
R/O
Role of the Fellow
2. Describe the mechanism that will be used to ensure fellow attendance at required conferences.
State the degree to which faculty attendance is expected, and how this will be monitored.
Limit the response to 50 words
Click here to enter text.
Scholarship Oversight Committee
1. Will there be a scholarship oversight committee for every fellow? ................................ ☐ YES ☐ NO
2. How often will the committee meet with the fellow? ................................................... # times per year
Fellow Research Activities
1. Describe how the program will ensure a meaningful supervised research experience for the fellows,
beginning in their first year and extending throughout their training.
Click here to enter text.
2. If faculty outside the division will be actively involved in mentoring the fellows, identify the mentors
and describe how liaisons will be created between these mentors and the fellows that allows for
meaningful accomplishment of research.
Click here to enter text.
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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SPECIALTY-SPECIFIC SECTION
PROGRAM PERSONNEL AND RESOURCES
Other Professional Personnel
1. Indicate with a check mark the personnel who will interact regularly with fellows at each
participating site. [PR II.C.; VII.A.2.; VII.B.3.)
Team Members
Nutrition
Psychology
Social Work
Dialysis Support Staff
Site #1
☐
☐
☐
☐
Site #2
☐
☐
☐
☐
Site #3
☐
☐
☐
☐
2. For categories of personnel that are unavailable, describe how that function will be addressed in the
program.
Click here to enter text.
Facilities [PR VII.B.1.]
1. Indicate the availability of the following (for inpatient services, indicate the number of available
beds):
Facility/Service
CRRT facilities
Dialysis unit
Space in an ambulatory setting for evaluation
and care of patients
PICU (indicate total number of beds)
NICU (indicate total number of beds)
Site #1
(Yes/No)
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item.
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item.
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item.
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item.
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item.
Site #2
(Yes/No)
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item.
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item.
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item.
Site #3
(Yes/No)
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item.
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item.
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item.
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item.
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item.
2. If “NO” is indicated for any of the service/experiences across all sites, explain how the
service/experience is provided below.
Click here to enter text.
Services [PR VII.B.]
Site #1
(Yes/No)
Pathology Service: [PR VII.B.1.]
Are there pathologists with experience/training in
Choose an
pediatric renal pathology?
item.
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Site #2
(Yes/No)
Site #3
(Yes/No)
Choose an
item.
Choose an
item.
Updated 4/2015
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Do the fellows have an opportunity to participate in
review and interpretation of renal biopsy specimens?
Diagnostic Services: [PR VII.B.2.]
Comprehensive diagnostic imaging
Electron microscopy
Immunology
Immunopathology
Histocompatibility
Radionuclide laboratory
Site #1
(Yes/No)
Choose an
item.
Site #2
(Yes/No)
Choose an
item.
Site #3
(Yes/No)
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item.
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If “NO” is indicated for any of the service/experiences across all sites, explain how the
service/experience will be provided below:
Click here to enter text.
Patient Population [PR VII.B.4.]
1. Provide the following information for the most recent 12-month academic or calendar year for each
site that fellows rotate on the pediatric nephrology service. Note the same timeframe should be
used throughout the forms.
Inclusive Dates:
From: Click here to enter a date.
Total number of admissions to the Pediatric
Nephrology service
Number of new patients admitted each year
(“new” refers to those who are seen by members
of the Pediatric Nephrology service for the first
time.)
Average length of stay of patients on the
Pediatric Nephrology service
Total number of consultations by Pediatric
Nephrologists on other inpatients
Number of consultations provided to the
NICU
Number of consultations provided to the
PICU
Average daily census of patients on the Pediatric
Nephrology service, including consultations
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
To: Click here to enter a date.
Site #1
#
Site #2
#
Site #3
#
#
#
#
Length
Length
Length
#
#
#
#
#
#
#
#
#
#
#
#
Updated 4/2015
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Site #1
#
Number of patients requiring follow-up care by
Pediatric Nephrology service as outpatients
during 12-month period reported
Site #2
#
Site #3
#
2. Provide the following information for the most recent 12-month academic or calendar year for each
site used to provide a specific required experience, such as transplant, cardiology, intensive care,
etc. Duplicate this table as necessary. Note the same timeframe should be used throughout the
forms.
Inclusive Dates:
From: Click here to enter a date.
To: Click here to enter a date.
Site #1
Site #2
Site #3
Name of service:
Total number of fellows and residents on the
service
Total number of admissions to the service
Number of new patients admitted each year
(“new” refers to those who are seen by members
of the service for the first time.)
Average length of stay of patients on the service
Average daily census of patients on the service,
including consultations
3. Ambulatory Pediatric Nephrology Experience for All Years of Training
Add rows as necessary.
Name of Experience
Site/Other Setting Identifier
Estimated Estimated Estimated
Number of Number of Average
Planned
New
Return
Number
Number of Patients
Patients
Teaching
Duration of Sessions Per Fellow Per Fellow Attendings
Experience Per Week
Per
Per
Per
(in wks/yr) Per Fellow Session
Session
Session
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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Name of Experience
Site/Other Setting Identifier
Estimated Estimated Estimated
Number of Number of Average
Planned
New
Return
Number
Number of Patients
Patients
Teaching
Duration of Sessions Per Fellow Per Fellow Attendings
Experience Per Week
Per
Per
Per
(in wks/yr) Per Fellow Session
Session
Session
If the experience is in a private office, provide full details, including name and credentials of
supervisor, numbers and types of patients, degree of fellow responsibility for their care, frequency
of attendance at office, how director will monitor the experience and fellow performance.
Click here to enter text.
4. 12-Month Summary - Inpatient Services
Summarize how many pediatric patients with the following nephrology problems were admitted to or
consulted on by the Nephrology service at the primary site. This should cover the same 12-month
period used in previous sections.
Site Name:
Inclusive Dates:
Name
From: Click here to enter a date.
Primary Renal Disorders
Perinatal and neonatal conditions including
congenital anomalies of the kidneys and
genitourinary tract
[PR VIII.A.1.a)]
Hypertension
[PR VIII.A.1.b)]
Acute kidney injury
[PR VIII.A.1.c)]
Chronic kidney disease and end-stage renal
disease
[PR VIII.A.1.d)]
Urinary tract infections, voiding dysfunction,
nephrolithiasis, and urologic disorders
[PR VIII.A.1.e)]
Renal transplantation
[PR VIII.A.1.f)]
Fluid and electrolyte and acid base disorders
[PR VIII.A.1.g)]
Acute and chronic glomerular diseases
[PR VIII.A.1.h)]
To: Click here to enter a date.
Total # of patients on Total # of patients on
Nephrology service
Nephrology service
#
#
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
#
#
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Primary Renal Disorders
Inherited renal disorders
[PR VIII.A.1.i)]:
 genetic syndromes
 tubular disorders
 cystic diseases
Total # of patients on Total # of patients on
Nephrology service
Nephrology service
#
#
#
#
#
#
5. 36 Month Summary: Patient Procedures
Provide patient data for the most recent 36 month period for which records can be obtained.
Indicate the number available of the following at each participating site.
Inclusive Dates:
From: Click here to enter a date.
Dialysis:
Total number of new and chronic dialysis
patients cared for by the pediatric service in the
past 3 years [PR VIII.A.3.a)]:
 Hemodialysis [PR VIII.A.3.a).(2)]
 Peritoneal dialysis [PR VIII.A.3.a).(2)]
Total number of acute dialysis treatments
performed in the past 3 years [PR
VIII.A.3.a).(4)]:
 Acute renal injury
 Toxin removal
Total number of patients that fellows are
exposed to that utilize home dialysis treatment
modalities:
Renal Transplantation:
Total number of patients who have undergone
transplantation in the past 3 years [PR VIII.A.2):
New Renal Transplantation
 Living related donor
 Deceased donor
Other Procedures:
Patients started on Continuous Renal
Replacement Therapy [PR VIII.A.3.a).(1)]
Percutaneous Renal Biopsy [PR VIII.A.3.b)]
To: Click here to enter a date.
Site #1
Site #2
Site #3
#
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#
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6. List of Diagnoses
List 150 CONSECUTIVE admissions and/or consultations to the Pediatric Nephrology service.
Identify the time period during which these admissions/consultations occurred. The date range
should occur within the same 12-month period used in previous sections. The dates must begin on
the date the first patient on the list was admitted and end with the date the 150th patient was
admitted, (e.g., July 1, 2014 through October 20, 2014). Submit a separate list for each site that
provides required rotations. Duplicate tables as necessary.
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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Site Name:
Give inclusive dates
during which these
admissions/consultations
occurred:
Patient ID
Number
Age
Name
From: Click here to enter a date.
Number of days in
hospital
To: Click here to enter a date.
Nephrology Diagnosis
(may include secondary diagnosis if relevant)
EDUCATIONAL PROGRAM [PR: VIII.]
Core Curriculum: Specialty Experiences
Identify the learning activities (clinical experience, conference series, journal club, etc.) and training
sites (Site #) which will be used to address the required core knowledge area.
List the Learning Activities
Used to Address the Core
Core Knowledge Area
Knowledge/Skill
Other Core Curricular Areas
Congenital anomalies of Click here to enter text.
the kidneys and
genitourinary tract
[PR VIII.A.1.a)]
Hypertension
Click here to enter text.
[PR VIII.A.1.b)]
Acute kidney injury
Click here to enter text.
[PR VIII.A.1.c)]
Chronic kidney disease
Click here to enter text.
and end-stage renal
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
List the Corresponding
Setting in Which These
Year(s) of
Learning Activities Take Place Training
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#
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#
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#
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#
Updated 4/2015
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Core Knowledge Area
disease
[PR VIII.A.1.d)]
Urinary tract infections
[PR VIII.A.1.e)]
Voiding dysfunction
Nephrolithiasis
Urologic disorders
Fluid and electrolyte and
acid base disorders
[PR VIII.A.1.g)]
Acute and chronic
glomerular diseases
[PR VIII.A.1.h)]
Renal Development
Renal physiology and
pathophysiology
Renal immunopathology
Renal cell and molecular
biology and genetics
List the Learning Activities
List the Corresponding
Used to Address the Core
Setting in Which These
Year(s) of
Knowledge/Skill
Learning Activities Take Place Training
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#
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Inpatient Experiences
What responsibilities will the fellows have for inpatients and how and by whom will they be
supervised when assigned to inpatient services?
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Outpatient Experiences
1. What responsibilities will the fellows have for outpatients and how and by whom will they be
supervised during the provision of outpatient care?
Click here to enter text.
2. Describe how the program will ensures that fellows provide continuity of care for a panel of patients
throughout training and to what extent will fellows have the opportunity to provide outpatient care for
patients whom they treated on the inpatient service?
Click here to enter text.
IF THERE ARE ANY UNIQUE SCENARIOS OCCURRING IN THE PROGRAM THAT DO NOT FIT WITHIN THE CONFINES
OF THIS FORM, PLEASE EXPLAIN.
Click here to enter text.
Pediatric Nephrology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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