Accreditation Evaluation

AGP Fellowship Project: Accreditation Evaluation



1= does not meet requirement       2=needs improvement       3=meets requirement
These items are absolute requirements for accreditation

I. General Requirements

1.1. _____ An accredited AGP program must exist in conjunction with and be an integral part of a core pediatric residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME).
1.2. _____ Interaction of the academic general pediatric fellows and faculty with the residents in the core pediatrics residency program is required.
1.3. _____ Lines of responsibility for the pediatric residents and the academic general pediatric fellows must be clearly defined.

Institutional Organization

2.1 Sponsoring Organization
2.1.1. _____ The AGP fellowship program must be sponsored by the same institution that sponsors the related core pediatrics residency program.
2.1.2 _____ The institution must provide sufficient support to the Program Director, support staff and trainees to show an ongoing commitment to fellowship education.

2.2 Appointment of AGP Fellows
2.2.1 _____ Prerequisite training for entry into a pediatric fellowship program should include the satisfactory completion of an ACGME-accredited pediatric residency or other training judged suitable by the program director (e.g. internal medicine – pediatrics or international pediatrics residency training).

Duration and Scope of Training

3.1 _____ AGP fellowship programs must provide at least two years of training.
3.2 _____ The program must provide the AGP fellow with instruction and opportunities to ensure effective interaction with patients, patients’ families, professional associates, and others in carrying out their responsibilities as physicians in the field.
3.3 _____ Clinical work should range from 15% time at a minimum to a 50% at a maximum, averaged over the course of the fellowship. Programs with a heavy clinical load should consider a three-year training cycle.
3.4 _____ The fellowship program also must develop in its fellows a commitment to lifelong learning and must emphasize scholarship, self-evaluation and self- directed learning, planning for continuous learning, evidenced based medicine, critical analysis of clinical problems, clinical decision making, quality improvement, and understanding of the health care system.
3.5 _____ Each fellow should formulate a focus of clinical and scholarly activity that will serve as a base for future career development.

Program Personnel

Program Director
4.1.1 _____ There must be a single program director based at the primary teaching site who is fully committed to the program and devotes sufficient time to ensure achievement of the educational goals and objectives.
4.1.2 _____ The director must possess the requisite educational, investigative, and administrative abilities and experience and have an appointment in good standing to an academic institution participating in the program.
4.1.3 _____ The program director must have a written curriculum that outlines the educational goals of the program with respect to knowledge, skills, and other attributes that the AGP fellows must achieve by the end of training. The curriculum must also include a list of teaching activities and evaluation methods that are linked to the goals and objectives.
4.1.4 _____ This curriculum must be distributed to AGP fellows when they enter the program, as well as to faculty. It should be reviewed and modified over time, based on periodic program evaluations.
4.1.5 _____ The program director oversees selection of AGPs fellows for appointment to the program in accordance with institutional and departmental policies and procedures.
4.1.6 _____ The program director oversees the selection and supervision of the teaching staff and other program personnel at each institution participating in the program.
4.1.7 _____ The program director supervises AGP fellows through explicit written guidelines describing supervisory lines of responsibility for the care of patients. Such guidelines must be communicated to all members of the program staff. Academic general pediatric fellows must be provided with prompt, reliable systems for communication and interaction with supervisory physicians.
4.1.8 _____ The program director oversees implementation of fair procedures, as established by the sponsoring institution, regarding academic discipline and AGP fellows’ complaints or grievances.
4.1.9 _____ The program director monitors and documents the procedural skills of the fellows where appropriate.
4.1.10_____ The program director monitors stress in AGP fellows, including mental or emotional conditions inhibiting performance or learning and drug- or alcohol- related dysfunction. Training situations that consistently produce unhealthy stress for fellows must be evaluated and modified.

4.2 Mentor
4.2.1 _____ Each trainee must have at least one faculty member who will guide the fellow's career decisions through the training period. The mentor must supervise the academic advancement of the fellow, be certain that the Scholarship Oversight Committee is active and effective, and oversee the professional well being of the trainee.

4.3 Teaching Staff
4.3.1 _____ There must be sufficient numbers of teaching staff who devote adequate time to the educational program to enable it to meet its educational goals and objectives. In addition to the AGP program director, there must be at least one other qualified member of the teaching staff.
4.3.2 _____ If the program is conducted at more than one institution, a member of the teaching staff of each participating institution must be designed to assume responsibility for the day-to-day activities of the program at that institution, with overall coordination by the program director.
4.3.3 _____ The teaching staff must provide evidence of a commitment to and productivity in the disciplines that are central to the program’s core curriculum, including research and education, and ongoing pursuit of scholarship. The APA will consider the following as indicative of the commitment of the teaching staff to scholarly activity:

  • Projects funded by agencies requiring peer review
  • Publications in peer-reviewed journals
  • Presentations at national, regional, or international scientific meetings
  • Research protocols approved by the local Institutional Review Board and implemented.
  • Leadership in research networks or regional/national educational organizations.

4.3.4 _____ All members of the teaching staff must demonstrate a strong interest in the education of AGP fellows, sound clinical and teaching abilities, support of the goals and objectives of the program, a commitment to their own continuing education, and participation in scholarly activities.

4.4 Other Professional Personnel
_____ Consultants should be available, including biostatisticians, methodologists, programmers, medical education specialists, economists and others as needed.

Scholarship Oversight Committee
4.4.1 _____ Each fellow must have a Scholarship Oversight Committee. The Scholarship Oversight Committee should consist of three or more individuals, at least one of whom is based outside the academic general pediatric discipline. The fellowship program director may serve as a trainee’s mentor and participate in the activities of the oversight committee, but should not be a standing member.
4.4.2 _____ The Scholarship Oversight Committee performs the following:
Determine whether a specific activity is appropriate to meet the APA guidelines for scholarly activity

  • Determine whether a specific activity is appropriate to meet the APA guidelines for scholarly activity
  • Determine a course of preparation beyond the core fellowship curriculum to ensure successful completion of the project
  • Evaluate the fellow's progress as related to scholarly activity
  • Meet with the fellow early in the training period and regularly thereafter
  • Require the fellow to present/defend the project related to his/her scholarly activity
  • Advise the program director on the fellow's progress and assess whether the fellow has satisfactorily met the guidelines associated with the requirement for active participation in scholarly activities.

5. Facilities and Resources
5.1 _____ Fellows must have access to appropriate patient populations and clinical facilities needed for the clinical experience.
5.2 _____ AGP fellows must have access to an on-site library or collection of appropriate texts or journals in each participating institution or must have access to electronic databases and other data processing applications.
5.2_____ There must be adequate resources for scholarly activity, research and critical analysis. These must include adequate laboratory space, equipment, teaching facilities and access to learning, financial support, and computer services.

6. Educational Program

6.1 Program Design
6.1.1 _____ Every program must develop written educational goals and objectives (Curriculum Requirement A), learner needs assessment and progress tracking (Curriculum Requirement B), learning activities (Curriculum Requirement C), and evaluation methods (Curriculum Requirement D), all of which should be linked to the program’s goals and objectives.
6.1.2 _____ The AGP fellowship program must provide advanced clinical training to allow fellows to acquire expertise as a provider, consultant, and care coordinator in the field (general pediatrics, child protection, environmental health, etc.)..
6.1.3 _____ Education must be provided in three academic competency domains: 1) Academic Development and Leadership, 2) Research and 3) Education.
6.1.4 _____ Program goals are sufficiently comprehensive within domains (cover important curricular topics)
6.1.5 _____Program objectives are appropriate in length and detail and prioritization of objectives is realistic for program implementation.
6.1.6 _____ The fellowship program must address the competency of professionalism and evaluate trainees in this area.
6.1.7 _____ The fellowship program must teach and demonstrate a commitment to continued learning and improvement.
6.1.8 _____ The fellows must learn the important skills of time management and balancing multiple priorities.

6.2. Clinical Skills (NOTE: The quality of the clinical program is not the focus of this fellowship review.)
6.2.1 _____ The fellows’ clinical and academic experiences should be integrated and complementary.
6.2.2 _____ Fellows should participate in quality improvement activities in a clinical setting.

6.3. Educational Activities
6.3.1 _____ Teaching and learning activities in the program must be linked to the written goals and objectives of the curriculum.
6.3.2 _____ There must be a formally structured educational program in academic general pediatrics that uses an effective combination of didactic, interactive, and experiential activities. A reasonable diversity of learning activities is used (e.g., suitable for settings, adaptable to individual learning and teaching styles.)
6.3.3 _____ The AGP fellow should actively participate in the planning and implementation of these educational activities, including conferences, experiential projects, and teaching sessions with students and residents.
6.3.4 _____ At the time of entry into the program, each fellow should develop an individual learning plan that includes both required and self-directed educational activities that will prepare the fellow for his/her chosen career path. All learners must revisit and revise their learning plans annually.

6.4. Teaching Experience
6.4.1 _____ AGP fellows must be given the opportunity to teach using a variety of methods and settings, and to assume some departmental administrative responsibilities.
6.4.2 _____ Fellows should participate in clinical teaching.

6.5. Scholarly Activity
6.5.1 _____ Each program is expected to engage fellows in scholarly activities that relate to the core academic competency domains of Academic Development and Leadership, Research, and Education.
6.5.2 _____ The core experience of the fellowship curriculum should be a research or scholarly project. All fellows must engage in hypothesis-testing projects or in projects of substantive scholarly exploration and analysis that require critical thinking. Areas in which scholarly activity may be pursued include, but are not limited to: basic, clinical, or translational biological or behavioral medicine; health services; quality improvement; bioethics; education; community advocacy; and public policy.
6.5.3 _____ Fellows must acquire and analyze data, derive and defend conclusions, place conclusions in the context of what is known or not known about a specific area of inquiry, and present their work in oral and written form to their Scholarly Oversight Committee (see below) and elsewhere. These activities require active participation by the fellow and must be mentored.

7. Evaluation, Guidance, and Oversight
7.1 Evaluation of Fellows
7.1.1 _____ The program must have formal mechanisms by which the knowledge, skills, and professional growth of the AGP fellows, based on the program’s written educational goals and objectives, are evaluated at least annually.
7.1.2 _____ The fellow must be given a copy of the written educational goals and objectives at the start of training and are told in advance that they will be evaluated and that objectives must be met for successful completion of the program..
7.1.3 _____ A written record of these evaluations must be maintained, must be formally reviewed with the AGP fellow at least annually, and must be accessible to authorized personnel. More frequent, informal assessment and feedback sessions between the fellow and mentor and/or Scholarship Oversight Committee are strongly recommended.
7.1.4 _____ The program director, in consultation with the teaching staff and Scholarship Oversight Committee, must provide a written final evaluation for each AGP fellow who completes the program. This final evaluation should be part of the AGP fellow’s permanent record, which must be maintained by the institution.
7.1.5 ____ Remediation plans should be developed and monitored if needed for learners making unsatisfactory progress.
7.1.6 _____ Educationally appropriate evaluation methods are assigned to key objectives
7.1.7 _____ A reasonable diversity of evaluation methods and sources used
7.1.8 _____ Evaluation tools are well constructed and informative (focused, specific, reliable)
7.1.9 _____ Faculty are given instruction on how to conduct good evaluations

7.2 Evaluation of Faculty
7.2.1 _____ Teaching faculty must be evaluated at least annually. Documentation of faculty evaluation must include an assessment of their teaching ability and commitment to teaching, their clinical knowledge, and their active participation in scholarly activity.
7.2.2 _____ Faculty should receive formal feedback from these evaluations.
7.2.3 _____ Faculty evaluation tools are sound and informative.
7.2.4 _____ Faculty should discuss their teaching and other educational contributions with the program director.

7.3 Evaluation of the Program
7.3.1 _____ The teaching staff must be organized and have regular documented meetings to review program goals and objectives as well as program effectiveness in achieving them. They should annually review AGP fellows’ time allocations (to clinical care, teaching, and research) and evaluate the fellows’ academic performance in relation to their educational goals and objectives.
7.3.2 _____ Periodically, the program should evaluate the academic outcomes of program graduates. The evaluation should also review the quality of supervision of fellows, and teaching quality of faculty and the program’s use of available resources, e.g., financial and administrative support of the program, the volume and variety of patients available for educational purposes, and the contributions of the participating institutions. Information gained from these evaluations should be used to implement improvements in the program.
7.3.3 _____ Long term professional outcomes of fellows available suggest that the program is effective.
7.3.4 _____ Annual review and evaluation of the program in relation to the educational goals, the quality of the curriculum, the needs of the AGP fellows, and the clinical and research responsibilities of the faculty must be documented. At least one AGP fellow representative should participate in these annual reviews. Formal input should be provided from fellows, faculty and important stakeholders (e.g. department chair, funders)
7.3.5_____ Program responds to evaluation results in an appropriate and timely way
7.3.6 _____ Past program evaluations have contributed to continuous quality improvement (Appendix E).

Please attach a narrative assessment of the program’s strengths, weaknesses, challenges/barriers, and opportunities for growth and improvement.





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