This document is a "form". To enter your responses, use the mouse to click ON or IN the check- and text - boxes.
Notes:
1. If you have not already done so, discuss this proposed program with the core residency or fellowship program director (and other program directors in related subspecialties, as applicable) prior to submission of this application.
2. A copy of this application, when completed, will be sent to the director of the core residency or fellowship program in your department/division, with the request that s/he a. discuss the anticipated impact of this program on the residency and/or other GME program(s) b. provide his/her assessment of the educational value and opportunities the program would provide, and c. state whether and why s/he supports this new program.
3. You must provide, as separate attachments: a. your CV or biosketch b. a letter of nomination/support from the Department Chair/Service Chief, for you as program director and for the program itself.
4. When completing this form:
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 do spell out any acronyms that may not be familiar to those outside your specialty do write responses specific to each of the questions below do not leave any questions unanswered or merely refer to some attachment do not insert multi-page documents or lists you may “copy and paste” from existing resources (e.g., brochures, websites, accreditation applications) as applicable, editing as needed to update and/or provide succinct responses.
Program name:
Program director:
Sponsoring Hospital and Department:
Associate program director (if any):
Division Chief:
Program coordinator:
If this is a new program, when do you intend the first fellow/s to start?
Have both the core residency program director
(RPD) and your Department Chair agreed to sponsor this program?
Maximum no. of training years offered:
Total number of fellow/s, and by program year, if more than one year of training:
Prerequisite training: e.g., has completed 2 years of a core residency pro gram in……; is a graduate of a U.S. pro gram in….., post-fellowship, etc.
Is national accreditation currently available for this
(sub)specialty? (see below)
If yes, state the name of the body: (e.g., ABMS, specialty society, ACGME)
Hospital ( not HMS) appointment (to be) given: e.g., Clinical Fellow, At tending in…..)
*Will you use the standard Partners contract for non-ACGME fellows?
If no, attach a copy of the contract you will issue to the fellow/s (e.g., standard departmental contract).
RPD: Yes No Not yet
Chair: Yes No Not yet
Total, maximum number of fellows:
Year 1: Year 2:
Yes No
Yes No
N/A Attached Pending

*Will fellow/s be paid according to Partners Resident Salary Scale?
If yes, state PGY level/s:
If no, state amount, by program year:
List (proposed) funding source/s:
Will this program or fellow/s be supported by a gift from industry?
Yes
Yes
No
No
Date:
**The Partners Resident Salary Scale and the contract template for non-ACGME fellows can be found at http://www.partners.org/Graduate-Medical-Education/Current-Residents-And-Fellows/Benefits-Contract-Templates-
Salary-Scale.aspx
ACCREDITATION:
If national accreditation IS available for this subspecialty, and:
1. you do not plan to apply for accreditation, check here and explain this decision below:
Not applying for accreditation for the following reason/s:
2. you are applying for national accreditation a. provide a copy of the (sub)specialty requirements from the accrediting body b. describe any areas of potential non-compliance with specialty requirements.
Non-compliance:
Additional notes regarding accreditation applications:
(i) If you have already completed or are currently writing an application for national accreditation, you may
"copy and paste" relevant portions from it into this document, editing as needed to provide succinct, specific responses to the questions below (i.e., abbreviated versions of the generally fuller text that is required in an accreditation application).
(ii) If you intend to apply for ACGME or other national accreditation after you have obtained Partners sponsorship, please note that the accreditation application form must be co-signed by the (Associate) Director of GME prior to submission. Submit the final application form to the GME Office at least four weeks prior to the date it is due to the ACGME/ accrediting body.
CURRICULUM:
You are required to submit a formal, detailed written curriculum as a separate document . (Note: be sure to review both documents in the Criteria for Program Approval section of the GME webpage http://www.partners.org/Graduate-Medical-Education/Program-Directors/Starting-A-GME-
Program.aspx
for more information regarding required program description and curricular elements.
A curriculum "template" and sample curricula are located here: http://www.partners.org/Graduate-
Medical-Education/Curricular-Materials-And-Educational-Resources/Guidelines-and-
Templates.aspx
Notes:
1.
The comprehensive written curriculum will be reviewed by the (Associate) Director of GME on
2. behalf of the Committee. The Committee will review only the text you provide below .
If the curriculum has not yet been fully developed, check here and insert the date it will be sent to the GME Office . Please note: must be no later than four weeks prior to PEC meeting.
PROGRAM DESCRIPTION:
Briefly summarize the content of the training program and the specific educational goals and objectives, as well as the overall plan to accomplish these(ideally to include overarching goals/objectives and goals/objectives described by rotation).
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Goals and objectives:
Discuss anticipated strengths and weaknesses of the program, and how you might address the latter.
Strengths and weaknesses:
Describe the expected interactions between your fellows and other trainees; describe any potential impact on the core residency program and other fellowship/s (e.g., reduced clinical material available to residents; increased medical student teaching or resident supervision, expanded didactic conferences open to trainees in other programs, etc.)
Interactions/impact (core residency, other GME programs):
Describe how the program can or will be integrated across the Partners teaching hospitals. Note:
Please list the colleagues with whom you have discussed the proposed program and the content of your discussions.
Integration:
Describe the plan for program leadership and governance (e.g., composition of training program committee).
Program governance/leadership:
List the key faculty who will be/are involved in the program; where applicable, state how much time each will devote to teach ing in “hours-per-week” format.
Faculty; time commitment:
Describe the fellow recruitment (e.g., national advertisement, internal candidates) and selection processes (NRMP or other specialty matching program; list the members of program’s selection committee, etc.). Discuss the selection criteria and overall recruitment timetable.
Fellow selection process, criteria and timetable:
Discuss the opportunities for which the program will prepare trainees, and how it will enhance their career development overall. Describe the anticipated career path/s for program graduates (may be expressed as a percentage, such as “75% expected to become private practitioners, 25% academic clinicians”).
Career preparation:
List the rotations and estimate fellow time (to be) spent in various educational activities; describe (as percentages) inpatient vs. ambulatory patient care, research, conferences, etc. Specify which rotations are required or elective; define the amount of pure elective time and how it may be used. If external rotations, name the institutions and identify the benefits expected from (proposed) affiliations with other sites. Include a block diagram, if applicable.
Rotation descriptions; affiliates:
Describe the schedule, length, format and content of lectures, conferences and other didactic program components specifically designed for your fellow/s, List other didactics the fellow/s may attend; state who will deliver the lectures/conferences, and who else will attend.
Didactics:
Describe the basic science and/or clinical research requirements, and/or opportunities available to the fellow/s; note whether (and how much) protected time will be provided for research.
Research:
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Describe the regular clinical duty hours and overall fellow/s’ schedule, including call. And, specify if any of the following will not be met: workweek no more than 80 hours; at least one day off per week, with no beeper call; consecutive work hours no greater than 24; in-house call no more often than every third night; minimum of 10 hours between shifts
Duty hours:
Discuss assigned coverage responsibilities (e.g., fellow covers private patients, takes call from home every other weekend, etc.).
Patient coverage:
State how much vacation time and sick leave will be given.
Leave:
Will moonlighting be either permitted or “required”?
Moonlighting:
Describe how the fellow/s will be supervised by the faculty in all patient care settings, and throughout the program, even if the fellow/s will be given a staff appointment.
Fellow supervision:
Describe planned practices/procedures for evaluation of and feedback to the fellow/s (verbal/written, frequency, by faculty and by program director). Also discuss how career counseling and mentoring will be provided.
Evaluation and feedback; career counseling and mentoring:
Describe the plan for the fellow/s to evaluate the faculty, the program director and the program overall; define the mechanism for program leaders(hip) to review the fellow/s’ feedback and implement appropriate changes.
Evaluation by the fellow/s; program improvement process:
Provide as separate attachments the evaluation forms (to be) used for
(i) faculty evaluations of the fellow/s
(ii) fellow evaluations of the faculty, and
(iii) fellow evaluations of the program.
Please return the completed application and all requested documents via email to Diane Sheehan dsheehan@partners.org
no later than FOUR WEEKS prior to the date you intend to present the program to PEC. If you are unable to submit all required documents* on a timely basis, review of your program will be postponed until a subsequent meeting.
*Required attachments:
1. Program Director CV or biosketch
2. Letter of nomination/support for Program Director from Department Chair/Division Chief
3. Curriculum
4. Evaluation tools
*Please do NOT submit this completed application form as a PDF. This form is a WORD document, and should be filled out and returned as a WORD document. Thank you.
Revised 5-12
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