New Application: Neonatal-Perinatal Medicine
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 rows as necessary.
Project title
Funding
source
Put an “X for
funding
awarded by
peer review
process
Neonatal-Perinatal Medicine
©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
Page 1 of 11
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?
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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.
Neonatal-Perinatal Medicine
©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
Neonatal-Perinatal Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 3 of 11
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.
Neonatal-Perinatal Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 4 of 11
SPECIALTY-SPECIFIC SECTION
PROGRAM PERSONNEL AND RESOURCES
Other Professional Personnel [PR VIII.B.]
1. Indicate with a check mark the personnel who will interact regularly with fellows at each
participating site. [PR: VIII.B.]
Team Members
Respiratory therapists assigned to NICU
Pathologists skilled in placental and perinatal
pathology
Mid-level providers (NNPs, PAs, etc)
Nutritionists skilled in the management of enteral
and parenteral nutrition
Physical and occupational therapists skilled in
developmentally appropriate care and feeding
problems
Specialists in the assessment of hearing in
infants
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 and Resources [PR VIII.C.]
Indicate whether the following services are available:
Available 24 hours a day
Portable x-ray
[PR VIII.C.1.a).(1)]
Ultrasound imaging
[PR VIII.C.1.a).(1)]
ECG
[PR VIII.C.1.a).(1)]
Neonatal echocardiography
[PR VIII.C.1.a).(1)]
EEG and interpretive services
[PR VIII.C.1.a).(1)]
Microchemistry and hematology laboratories
[PR VIII.C.3.a)]
Blood gas analysis
[PR VIII.C.3.b)]
Diagnostic bacteriology and virology laboratories
[PR VIII.C.3.e)]
Site #1
(Yes/No)
Site #2
(Yes/No)
Site #3
(Yes/No)
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Neonatal-Perinatal Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 5 of 11
Blood Bank
[PR VIII.C.3.f)]
Accessible CT and/or MRI facilities
[PR VIII.C.3.g)]
Available in a reasonable time
Screening laboratory for inborn errors of metabolism
[PR VIII.C.4.a)]
Clinical toxicology laboratory
[PR VIII.C.4.b)]
Nuclear medicine facilities
[PR VIII.C.4.c)]
Cytogenetics laboratory
[PR VIII.C.4.d)]
Audiology services
[PR VIII.C.4.e)]
Pathology services, including those for evaluation of
placental pathology
[PR VIII.C.3.d)]
Site #1
(Yes/No)
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(Yes/No)
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(Yes/No)
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Neonatal Intensive Care Unit (NICU) Data
Provide patient data for the most recent 12-month period for which records can be obtained. 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.
1. Indicate the availability of the following at each of the sites participating in the program. Use the
appropriate response (i.e., a number or yes/no answer):
1. Number of births per year
2. Number of neonatal ICU admissions per year
a) Number of admissions in NICU. Of these,
how many had a birth weight< 1500
grams
b) Number of admissions in NICU. Of these,
how many had a birth weight < 1000
grams
c) Number of admissions inborn
d) Number of patients outborn/transported
3. Average daily census in NICU:
4. Average Length of Stay in NICU
5. Number of patients requiring ventilatory
support:
a) CPAP only (without mechanical
ventilation)
b) Ventilator
Neonatal-Perinatal Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Site #1
#
#
#
Site #2
#
#
#
Site #3
#
#
#
#
#
#
#
#
#
Length
#
#
#
#
Length
#
#
#
#
Length
#
#
#
#
#
#
#
Updated 4/2015
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c) Extra corporeal membrane oxygenation
(ECMO)
6. Number of neonatal surgical cases
a) cardiac
b) general
7. Total number of residents in NICU (excluding
neonatology fellows) during a block rotation
a) Number of pediatric residents
b) Number of other residents
c) Number of primary, non-resident
providers
Site #1
#
Site #2
#
Site #3
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
2. If all or most admissions are outborn/transported, explain how fellows will obtain sufficient
experience in resuscitation and stabilization for deliveries.
Click here to enter text.
3
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.
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
Site #1
Site #2
Click here to enter text.
#
#
Site #3
#
#
#
#
#
#
#
Length
#
Length
#
Length
#
List of Diagnoses
List 100 consecutive admissions. Identify the time period during which these admissions 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 100th 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.
Site Name:
Total number of patients admitted in most recent 12-month period
#
Inclusive Dates: From: Click here to enter a date.
To: Click here to enter a date.
Number
Patient ID
Gestational
Age
Birth
Weight
Number of
days in
Hospital
Neonatal-Perinatal Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Up to three most significant Discharge
Diagnoses
Updated 4/2015
Page 7 of 11
Number
Patient ID
Gestational
Age
Birth
Weight
Number of
days in
Hospital
Up to three most significant Discharge
Diagnoses
Outpatient Experiences [PR VIII.C.6.]
Provide the following information for the same 12-month period. The date range should occur within the
same 12-month period used in previous sections.
Inclusive Dates:
From: Click here to enter a date.
To: Click here to enter a date.
1. Indicate the following at each of the sites participating in the program. Use the appropriate
response, (i.e., a number or yes/no answer)
Clinic Data
Is there a NICU follow-up clinic for patients discharged from the
NICU? Yes or No
Number of NICU follow up clinic sessions per week:
Number of NICU follow up visits per year:
Number of NICU high-risk follow-up clinics a subspecialty fellow
attends while in the program:
Average number of NICU follow up patients per fellow per
session:
Choose an item.
Year 1
#
#
#
Year 2
#
Year 3
#
#
#
#
2. If there is no separate NICU follow up clinic, explain below where the NICU follow up patients are
seen (e.g., offices, clinics)? 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 and how the director will monitor the experience and fellow performance.
Neonatal-Perinatal Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 8 of 11
Limit response to 250 words
Click here to enter text.
3. Describe how and by whom the fellows will be supervised during the provision of outpatient care,
and identify the way in which the program ensures that the NICU follow up clinic has staff with
expertise in performing developmental assessments and skilled neonatal or pediatric faculty as
teachers.
Limit response to 250 words
Click here to enter text.
Inpatient Experiences
1. Describe the responsibilities the fellows will have for inpatients when assigned to inpatient services.
Click here to enter text.
2. Describe how and by whom the fellows will be supervised in the inpatient setting.
Click here to enter text.
3. Explain how fellows will be directly involved in the care of critically ill surgical patients to acquire the
requisite knowledge and skills to attain competence in evaluation, diagnosis and pre/post operative
management of such patients. Also describe the coordination of care between the pediatric
surgeons and the neonatologists concerning the management of medical problems in these
patients. [PR IX.A.1.]
Click here to enter text.
4. Explain how fellows will be directly involved in the care of critically ill cardiac and cardiothoracic
surgical patients to acquire the requisite knowledge and skills to attain competence in evaluation,
diagnosis and pre/post operative management of such patients. Also describe the coordination of
care between the cardiothoracic surgeons and the neonatologists concerning the management of
medical problems in these patients.
Click here to enter text.
Procedural Competence
1. Explain how fellows will learn the indications, contraindications, techniques and complications of
procedures in the management of critically ill newborn infants, including the technique of neonatal
resuscitation, venous and arterial access, evacuation of air leaks, endotracheal intubation,
preparation for transport, ventilatory support, continuous monitoring, temperature control and
nutritional support. [PR IX.A.2.a)]
Limit response to 200 words
Click here to enter text.
2. How will the program director document and monitor the procedural competence of fellows?
Click here to enter text.
Neonatal-Perinatal Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 9 of 11
EDUCATIONAL PROGRAM - CORE CURRICULUM [PR: IX.]
Identify the training sites (e.g., clinics, sites, etc.) and learning activities (e.g., clinical experience,
conference series, self-directed learning modules, small group discussions, journal club, workshops)
which will be used to address the required core knowledge areas
List the learning activities
used to address the core
Core Knowledge Area
knowledge area
Methods to evaluate fetal well- Click here to enter text.
being and maturation
[PR IX.A.4.]
Factors that compromise the
Click here to enter text.
fetus during the intrapartum
period and recognition of fetal
distress [PR IX.A.4.a)]
Maternal physiological,
Click here to enter text.
biochemical, and
pharmacological influences on
the fetus [PR IX.B.1.a).(1)]
Fetal physiology
Click here to enter text.
[PR IX.B.1.a).(1)]
Fetal development
Click here to enter text.
[PR IX.B.1.a).(1)]
Placental function (circulation, Click here to enter text.
gas exchange, growth)
[PR IX.B.1.a).(1)]
Physiological and biochemical Click here to enter text.
adaptation to birth
[PR IX.B.1.a).(1)]
Cellular, molecular, and
Click here to enter text.
developmental biology an
pathology relevant to diseases
of the neonate
[PR IX.B.1.a).(1)]
Psychology of pregnancy and Click here to enter text.
maternal-infant interaction
[PR IX.B.1.a).(1)]
Growth and nutrition
Click here to enter text.
[PR IX.B.1.a).(1)]
Breastfeeding and lactation
Click here to enter text.
[PR IX.B.1.a).(1)]
Genetics [PR IX.B.1.a).(1)]
Click here to enter text.
Stabilization for Neonatal
Click here to enter text.
Transport [PR IX.A.2.a)]
Use and interpretation of a
Click here to enter text.
neonatal database [PR IX.A.7.]
List the corresponding
Year(s)
setting in which these
of
learning activities take place Training
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IF THERE ARE ANY UNIQUE SCENARIOS OCCURRING IN THE PROGRAM THAT DO NOT FIT WITHIN THE CONFINES
OF THIS FORM, PLEASE EXPLAIN.
Neonatal-Perinatal Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 10 of 11
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Neonatal-Perinatal Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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