Pediatric Otolaryngology

ACGME Program Requirements for

Graduate Medical Education

in Pediatric Otolaryngology

ACGME-approved focused revision: June 12, 2022; effective July 1, 2022

Pediatric Otolaryngology Tracked Changes Copy

Contents

Introduction .............................................................................................................................. 3

Int.A. Preamble ................................................................................................................ 3

Int.B. Definition of Subspecialty ..................................................................................... 3

Int.C. Length of Educational Program ............................................................................ 4

I. Oversight ............................................................................................................................ 4

I.A. Sponsoring Institution............................................................................................ 4

I.B. Participating Sites .................................................................................................. 4

I.C. Recruitment ............................................................................................................. 5

I.D. Resources ............................................................................................................... 6

I.E. Other Learners and Other Care Providers ............................................................ 7

II. Personnel ............................................................................................................................ 8

II.A. Program Director .................................................................................................... 8

II.B. Faculty ....................................................................................................................12

II.C. Program Coordinator ............................................................................................15

II.D. Other Program Personnel .....................................................................................15

III. Fellow Appointments ........................................................................................................15

III.A. Eligibility Criteria ...................................................................................................15

III.B. Number of Fellows .................................................................................................17

IV. Educational Program ........................................................................................................17

IV.A. Curriculum Components .......................................................................................17

IV.B. ACGME Competencies ..........................................................................................18

IV.C. Curriculum Organization and Fellow Experiences ..............................................21

IV.D. Scholarship ............................................................................................................22

IV.E. Independent Practice ............................................................................................23

V. Evaluation ..........................................................................................................................24

V.A. Fellow Evaluation ..................................................................................................24

V.B. Faculty Evaluation .................................................................................................27

V.C. Program Evaluation and Improvement ................................................................28

VI. The Learning and Working Environment .........................................................................29

VI.A. Patient Safety, Quality Improvement, Supervision, and Accountability ............30

VI.B. Professionalism .....................................................................................................35

VI.C. Well-Being ..............................................................................................................37

VI.D. Fatigue Mitigation ..................................................................................................40

VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care ...........................41

VI.F. Clinical Experience and Education.......................................................................43

Pediatric Otolaryngology

ACGME Program Requirements for Graduate Medical Education

in Pediatric Otolaryngology

Common Program Requirements (One-Year Fellowship) are in BOLD

Where applicable, text in italics describes the underlying philosophy of the requirements in that

section. These philosophic statements are not program requirements and are therefore not

citable.

Background and Intent: These fellowship requirements reflect the fact that these

learners have already completed the first phase of graduate medical education. Thus,

the Common Program Requirements (One-Year Fellowship) are intended to explain

the differences.

Introduction

Int.A. Fellowship is advanced graduate medical education beyond a core

residency program for physicians who desire to enter more specialized

practice. Fellowship-trained physicians serve the public by providing

subspecialty care, which may also include core medical care, acting as a

community resource for expertise in their field, creating and integrating

new knowledge into practice, and educating future generations of

physicians. Graduate medical education values the strength that a diverse

group of physicians brings to medical care.

Fellows who have completed residency are able to practice independently

in their core specialty. The prior medical experience and expertise of

fellows distinguish them from physicians entering into residency training.

The fellow’s care of patients within the subspecialty is undertaken with

appropriate faculty supervision and conditional independence. Faculty

members serve as role models of excellence, compassion,

professionalism, and scholarship. The fellow develops deep medical

knowledge, patient care skills, and expertise applicable to their focused

area of practice. Fellowship is an intensive program of subspecialty clinical

and didactic education that focuses on the multidisciplinary care of

patients. Fellowship education is often physically, emotionally, and

intellectually demanding, and occurs in a variety of clinical learning

environments committed to graduate medical education and the well-being

of patients, residents, fellows, faculty members, students, and all members

of the health care team.

In addition to clinical education, many fellowship programs advance

fellows’ skills as physician-scientists. While the ability to create new

knowledge within medicine is not exclusive to fellowship-educated

physicians, the fellowship experience expands a physician’s abilities to

pursue hypothesis-driven scientific inquiry that results in contributions to

the medical literature and patient care. Beyond the clinical subspecialty

expertise achieved, fellows develop mentored relationships built on an

infrastructure that promotes collaborative research.

Int.B. Definition of Subspecialty

Pediatric Otolaryngology

Pediatric otolaryngologists specialize in the medical and surgical management of

neonates, infants, children, and adolescents 18 years or younger, particularly

those with complex otolaryngologic problems and significant co-morbidities,

generally cared for in tertiary care pediatric institutions.

Int.C. Length of Educational Program

The educational program in pediatric otolaryngology must be 12 months in

length.

(Core)*

I. Oversight

I.A. Sponsoring Institution

The Sponsoring Institution is the organization or entity that assumes the

ultimate financial and academic responsibility for a program of graduate

medical education consistent with the ACGME Institutional Requirements.

When the Sponsoring Institution is not a rotation site for the program, the

most commonly utilized site of clinical activity for the program is the

primary clinical site.

Background and Intent: Participating sites will reflect the health care needs of the

community and the educational needs of the fellows. A wide variety of organizations

may provide a robust educational experience and, thus, Sponsoring Institutions and

participating sites may encompass inpatient and outpatient settings including, but not

limited to a university, a medical school, a teaching hospital, a nursing home, a

school of public health, a health department, a public health agency, an organized

health care delivery system, a medical examiner’s office, an educational consortium, a

teaching health center, a physician group practice, a federally qualified health center,

a surgery center, an academic and private single-specialty clinic, or an educational

foundation.

I.A.1. The program must be sponsored by one ACGME-accredited

Sponsoring Institution.

(Core)

I.B. Participating Sites

A participating site is an organization providing educational experiences or

educational assignments/rotations for fellows.

I.B.1. The program, with approval of its Sponsoring Institution, must

designate a primary clinical site.

(Core)

I.B.1.a) The program must be based in a tertiary care pediatric institution

where the care of neonates and children can be readily

coordinated with other subspecialists.

(Core)

I.B.1.b) The sponsoring institution must also sponsor an ACGME-

accredited otolaryngology – head and neck surgery program.

(Core)

Pediatric Otolaryngology

I.B.2. There must be a program letter of agreement (PLA) between the

program and each participating site that governs the relationship

between the program and the participating site providing a required

assignment.

(Core)

I.B.2.a) The PLA must:

I.B.2.a).(1) be renewed at least every 10 years; and,

(Core)

I.B.2.a).(2) be approved by the designated institutional official

(DIO).

(Core)

I.B.3. The program must monitor the clinical learning and working

environment at all participating sites.

(Core)

I.B.3.a) At each participating site there must be one faculty member,

designated by the program director, who is accountable for

fellow education for that site, in collaboration with the

program director.

(Core)

Background and Intent: While all fellowship programs must be sponsored by a single

ACGME-accredited Sponsoring Institution, many programs will utilize other clinical

settings to provide required or elective training experiences. At times it is appropriate

to utilize community sites that are not owned by or affiliated with the Sponsoring

Institution. Some of these sites may be remote for geographic, transportation, or

communication issues. When utilizing such sites, the program must designate a

faculty member responsible for ensuring the quality of the educational experience. In

some circumstances, the person charged with this responsibility may not be physically

present at the site, but remains responsible for fellow education occurring at the site.

The requirements under I.B.3. are intended to ensure that this will be the case.

Suggested elements to be considered in PLAs will be found in the ACGME Program

Director’s Guide to the Common Program Requirements. These include:

• Identifying the faculty members who will assume educational and supervisory

responsibility for fellows

• Specifying the responsibilities for teaching, supervision, and formal evaluation

of fellows

• Specifying the duration and content of the educational experience

• Stating the policies and procedures that will govern fellow education during the

assignment

I.B.4. The program director must submit any additions or deletions of

participating sites routinely providing an educational experience,

required for all fellows, of one month full time equivalent (FTE) or

more through the ACGME’s Accreditation Data System (ADS).

(Core)

I.C. The program, in partnership with its Sponsoring Institution, must engage in

practices that focus on mission-driven, ongoing, systematic recruitment

and retention of a diverse and inclusive workforce of residents (if present),

Pediatric Otolaryngology

fellows, faculty members, senior administrative staff members, and other

relevant members of its academic community.

(Core)

Background and Intent: It is expected that the Sponsoring Institution has, and programs

implement, policies and procedures related to recruitment and retention of minorities

underrepresented in medicine and medical leadership in accordance with the

Sponsoring Institution’s mission and aims. The program’s annual evaluation must

include an assessment of the program’s efforts to recruit and retain a diverse workforce,

as noted in V.C.1.c).(5).(c).

I.D. Resources

I.D.1. The program, in partnership with its Sponsoring Institution, must

ensure the availability of adequate resources for fellow education.

(Core)

I.D.1.a) Program resources must include:

I.D.1.a).(1) inpatient and outpatient facilities.

(Core)

I.D.1.a).(2) an emergency department;

(Core)

I.D.1.a).(3) neonatal and pediatric intensive care units;

(Core)

I.D.1.a).(4) facilities for the diagnostic assessment of infants and

children with otolaryngologic disorders, including

audiologic, voice, speech, language and developmental

assessments; and,

(Core)

I.D.1.a).(5) facilities to support clinical research.

(Core)

I.D.1.b) Fellows must be provided with prompt reliable systems for

communication and interaction with supervising physicians.

(Core)

I.D.2. The program, in partnership with its Sponsoring Institution, must

ensure healthy and safe learning and working environments that

promote fellow well-being and provide for:

(Core)

I.D.2.a) access to food while on duty;

(Core)

I.D.2.b) safe, quiet, clean, and private sleep/rest facilities available

and accessible for fellows with proximity appropriate for safe

patient care, if the fellows are assigned in-house call;

(Core)

Background and Intent: Care of patients within a hospital or health system occurs

continually through the day and night. Such care requires that fellows function at

their peak abilities, which requires the work environment to provide them with the

ability to meet their basic needs within proximity of their clinical responsibilities.

Access to food and rest are examples of these basic needs, which must be met while

fellows are working. Fellows should have access to refrigeration where food may be

stored. Food should be available when fellows are required to be in the hospital

Pediatric Otolaryngology

overnight. Rest facilities are necessary, even when overnight call is not required, to

accommodate the fatigued fellow.

I.D.2.c) clean and private facilities for lactation that have refrigeration

capabilities, with proximity appropriate for safe patient care;

(Core)

Background and Intent: Sites must provide private and clean locations where fellows

may lactate and store the milk within a refrigerator. These locations should be in close

proximity to clinical responsibilities. It would be helpful to have additional support

within these locations that may assist the fellow with the continued care of patients,

such as a computer and a phone. While space is important, the time required for

lactation is also critical for the well-being of the fellow and the fellow's family, as

outlined in VI.C.1.d).(1).

I.D.2.d) security and safety measures appropriate to the participating

site; and,

(Core)

I.D.2.e) accommodations for fellows with disabilities consistent with

the Sponsoring Institution’s policy.

(Core)

I.D.3. Fellows must have ready access to subspecialty-specific and other

appropriate reference material in print or electronic format. This

must include access to electronic medical literature databases with

full text capabilities.

(Core)

I.D.4. The program’s educational and clinical resources must be adequate

to support the number of fellows appointed to the program.

(Core)

I.E. A fellowship program usually occurs in the context of many learners and

other care providers and limited clinical resources. It should be structured

to optimize education for all learners present.

I.E.1. Fellows should contribute to the education of residents in core

programs, if present.

(Core)

I.E.1.a) The presence of other learners, including otolaryngology – head

and neck surgery residents, residents from other specialties,

unaccredited pediatric otolaryngology fellows, other subspecialty

fellows, PhD students, and nurse practitioners, must not interfere

with the appointed fellows’ education.

(Core)

Background and Intent: The clinical learning environment has become increasingly

complex and often includes care providers, students, and post-graduate residents and

fellows from multiple disciplines. The presence of these practitioners and their learners

enriches the learning environment. Programs have a responsibility to monitor the learning

environment to ensure that fellows’ education is not compromised by the presence of

other providers and learners, and that fellows’ education does not compromise core

residents’ education.

Pediatric Otolaryngology

II. Personnel

II.A. Program Director

II.A.1. There must be one faculty member appointed as program director

with authority and accountability for the overall program, including

compliance with all applicable program requirements.

(Core)

II.A.1.a) The Sponsoring Institution’s Graduate Medical Education

Committee (GMEC) must approve a change in program

director.

(Core)

II.A.1.b) Final approval of the program director resides with the

Review Committee.

(Core)

Background and Intent: While the ACGME recognizes the value of input from numerous

individuals in the management of a fellowship, a single individual must be designated as

program director and have overall responsibility for the program. The program director’s

nomination is reviewed and approved by the GMEC. Final approval of the program

director resides with the applicable ACGME Review Committee.

II.A.2. The program director and, as applicable, the program’s leadership

team, must be provided with support adequate for administration of

the program based upon its size and configuration.

(Core)

II.A.2.a) At a minimum, the program director must be provided with support

equal to a dedicated minimum of 10 percent FTE for

administration of the program.

(Core)

Background and Intent: To achieve successful graduate medical education, individuals

serving as education and administrative leaders of fellowship programs, as well as those

significantly engaged in the education, supervision, evaluation, and mentoring of fellows,

must have sufficient dedicated professional time to perform the vital activities required to

sustain an accredited program.

The ultimate outcome of graduate medical education is excellence in fellow education

and patient care.

The program director and, as applicable, the program leadership team, devote a portion

of their professional effort to the oversight and management of the fellowship program,

as defined in II.A.4.-II.A.4.a).(16). Both provision of support for the time required for the

leadership effort and flexibility regarding how this support is provided are important.

Programs, in partnership with their Sponsoring Institutions, may provide support for this

time in a variety of ways. Examples of support may include, but are not limited to, salary

support, supplemental compensation, educational value units, or relief of time from other

professional duties.

Program directors and, as applicable, members of the program leadership team, who are

new to the role may need to devote additional time to program oversight and

management initially as they learn and become proficient in administering the program. It

Pediatric Otolaryngology

is suggested that during this initial period the support described above be increased as

needed.

In addition, it is important to remember that the dedicated time and support requirement

for ACGME activities is a minimum, recognizing that, depending on the unique needs of

the program, additional support may be warranted.

II.A.3. Qualifications of the program director:

II.A.3.a) must include subspecialty expertise and qualifications

acceptable to the Review Committee; and,

(Core)

II.A.3.a).(1) The program director should have also completed a

pediatric otolaryngology fellowship.

(Core)

II.A.3.b) must include subspecialty qualifications that are acceptable

to the Review Committee.

(Core)

[Note that while the Common Program Requirements deem

certification by a member board of the American Board of Medical

Specialties (ABMS) or a certifying board of the American

Osteopathic Association (AOA) acceptable, there is no ABMS or

AOA board that offers certification in this subspecialty]

II.A.3.b).(1) The Review Committee only accepts American Board of

Otolaryngology – Head and Neck Surgery (ABOHNS) or

American Osteopathic Boards of Ophthalmology and

Otorhinolaryngology Head and Neck Surgery

(AOBOOHNS) certification in otolaryngology – head and

neck surgery.

(Core)

II.A.4. Program Director Responsibilities

The program director must have responsibility, authority, and

accountability for: administration and operations; teaching and

scholarly activity; fellow recruitment and selection, evaluation, and

promotion of fellows, and disciplinary action; supervision of fellows;

and fellow education in the context of patient care.

(Core)

II.A.4.a) The program director must:

II.A.4.a).(1) be a role model of professionalism;

(Core)

Background and Intent: The program director, as the leader of the program, must serve

as a role model to fellows in addition to fulfilling the technical aspects of the role. As

fellows are expected to demonstrate compassion, integrity, and respect for others, they

must be able to look to the program director as an exemplar. It is of utmost importance,

therefore, that the program director model outstanding professionalism, high quality

patient care, educational excellence, and a scholarly approach to work. The program

Pediatric Otolaryngology

director creates an environment where respectful discussion is welcome, with the goal

of continued improvement of the educational experience.

II.A.4.a).(2) design and conduct the program in a fashion

consistent with the needs of the community, the

mission(s) of the Sponsoring Institution, and the

mission(s) of the program;

(Core)

Background and Intent: The mission of institutions participating in graduate medical

education is to improve the health of the public. Each community has health needs that

vary based upon location and demographics. Programs must understand the social

determinants of health of the populations they serve and incorporate them in the design

and implementation of the program curriculum, with the ultimate goal of addressing

these needs and health disparities.

II.A.4.a).(3) administer and maintain a learning environment

conducive to educating the fellows in each of the

ACGME Competency domains;

(Core)

Background and Intent: The program director may establish a leadership team to assist

in the accomplishment of program goals. Fellowship programs can be highly complex.

In a complex organization the leader typically has the ability to delegate authority to

others, yet remains accountable. The leadership team may include physician and non-

physician personnel with varying levels of education, training, and experience.

II.A.4.a).(4) develop and oversee a process to evaluate candidates

prior to approval as program faculty members for

participation in the fellowship program education and

at least annually thereafter, as outlined in V.B.;

(Core)

II.A.4.a).(5) have the authority to approve program faculty

members for participation in the fellowship program

education at all sites;

(Core)

II.A.4.a).(6) have the authority to remove program faculty

members from participation in the fellowship program

education at all sites;

(Core)

II.A.4.a).(7) have the authority to remove fellows from supervising

interactions and/or learning environments that do not

meet the standards of the program;

(Core)

Background and Intent: The program director has the responsibility to ensure that all

who educate fellows effectively role model the Core Competencies. Working with a

fellow is a privilege that is earned through effective teaching and professional role

modeling. This privilege may be removed by the program director when the standards

of the clinical learning environment are not met.

There may be faculty in a department who are not part of the educational program, and

the program director controls who is teaching the residents.

Pediatric Otolaryngology

II.A.4.a).(8) submit accurate and complete information required

and requested by the DIO, GMEC, and ACGME;

(Core)

II.A.4.a).(9) provide applicants who are offered an interview with

information related to the applicant’s eligibility for the

relevant subspecialty board examination(s);

(Core)

II.A.4.a).(10) provide a learning and working environment in which

fellows have the opportunity to raise concerns and

provide feedback in a confidential manner as

appropriate, without fear of intimidation or retaliation;

(Core)

II.A.4.a).(11) ensure the program’s compliance with the Sponsoring

Institution’s policies and procedures related to

grievances and due process;

(Core)

II.A.4.a).(12) ensure the program’s compliance with the Sponsoring

Institution’s policies and procedures for due process

when action is taken to suspend or dismiss, not to

promote, or not to renew the appointment of a fellow;

(Core)

Background and Intent: A program does not operate independently of its Sponsoring

Institution. It is expected that the program director will be aware of the Sponsoring

Institution’s policies and procedures, and will ensure they are followed by the

program’s leadership, faculty members, support personnel, and fellows.

II.A.4.a).(13) ensure the program’s compliance with the Sponsoring

Institution’s policies and procedures on employment

and non-discrimination;

(Core)

II.A.4.a).(13).(a) Fellows must not be required to sign a non-

competition guarantee or restrictive covenant.

(Core)

II.A.4.a).(14) document verification of program completion for all

graduating fellows within 30 days;

(Core)

II.A.4.a).(15) provide verification of an individual fellow’s

completion upon the fellow’s request, within 30 days;

and,

(Core)

Background and Intent: Primary verification of graduate medical education is

important to credentialing of physicians for further training and practice. Such

verification must be accurate and timely. Sponsoring Institution and program policies

for record retention are important to facilitate timely documentation of fellows who

have previously completed the program. Fellows who leave the program prior to

completion also require timely documentation of their summative evaluation.

Pediatric Otolaryngology

II.A.4.a).(16) obtain review and approval of the Sponsoring

Institution’s DIO before submitting information or

requests to the ACGME, as required in the Institutional

Requirements and outlined in the ACGME Program

Director’s Guide to the Common Program

Requirements.

(Core)

II.B. Faculty

Faculty members are a foundational element of graduate medical education

– faculty members teach fellows how to care for patients. Faculty members

provide an important bridge allowing fellows to grow and become practice

ready, ensuring that patients receive the highest quality of care. They are

role models for future generations of physicians by demonstrating

compassion, commitment to excellence in teaching and patient care,

professionalism, and a dedication to lifelong learning. Faculty members

experience the pride and joy of fostering the growth and development of

future colleagues. The care they provide is enhanced by the opportunity to

teach. By employing a scholarly approach to patient care, faculty members,

through the graduate medical education system, improve the health of the

individual and the population.

Faculty members ensure that patients receive the level of care expected

from a specialist in the field. They recognize and respond to the needs of

the patients, fellows, community, and institution. Faculty members provide

appropriate levels of supervision to promote patient safety. Faculty

members create an effective learning environment by acting in a

professional manner and attending to the well-being of the fellows and

themselves.

Background and Intent: “Faculty” refers to the entire teaching force responsible for

educating fellows. The term “faculty,” including “core faculty,” does not imply or

require an academic appointment.

II.B.1. For each participating site, there must be a sufficient number of

faculty members with competence to instruct and supervise all

fellows at that location.

(Core)

II.B.1.a) To enhance fellows’ educational experience, there must be

participation from appropriately qualified faculty members from

other related pediatric disciplines, including:

(Core)

II.B.1.a).(1) anesthesiology;

(Core)

II.B.1.a).(2) audiology and speech pathology;

(Core)

II.B.1.a).(3) child and adolescent psychiatry;

(Core)

II.B.1.a).(4) gastroenterology;

(Core)

II.B.1.a).(5) medical genetics;

(Core)

Pediatric Otolaryngology

II.B.1.a).(6) neonatology;

(Core)

II.B.1.a).(7) neurology;

(Core)

II.B.1.a).(8) pathology;

(Core)

II.B.1.a).(9) plastic surgery;

(Core)

II.B.1.a).(10) prenatal and fetal medicine;

(Core)

II.B.1.a).(11) pulmonology;

(Core)

II.B.1.a).(12) radiology; and,

(Core)

II.B.1.a).(13) sleep medicine.

(Core)

II.B.2. Faculty members must:

II.B.2.a) be role models of professionalism;

(Core)

II.B.2.b) demonstrate commitment to the delivery of safe, quality,

cost-effective, patient-centered care;

(Core)

Background and Intent: Patients have the right to expect quality, cost-effective care

with patient safety at its core. The foundation for meeting this expectation is formed

during residency and fellowship. Faculty members model these goals and continually

strive for improvement in care and cost, embracing a commitment to the patient and

the community they serve.

II.B.2.c) demonstrate a strong interest in the education of fellows;

(Core)

II.B.2.d) devote sufficient time to the educational program to fulfill

their supervisory and teaching responsibilities;

(Core)

II.B.2.e) administer and maintain an educational environment

conducive to educating fellows;

(Core)

II.B.2.f) pursue faculty development designed to enhance their skills.

(Core)

II.B.3. Faculty Qualifications

II.B.3.a) Faculty members must have appropriate qualifications in

their field and hold appropriate institutional appointments.

(Core)

II.B.3.b) Subspecialty physician faculty members must:

II.B.3.b).(1) possess qualifications judged acceptable to the

Review Committee.

(Core)

Pediatric Otolaryngology

[Note that while the Common Program Requirements

deem certification by a member board of the American

Board of Medical Specialties (ABMS) or a certifying board

of the American Osteopathic Association (AOA)

acceptable, there is no ABMS or AOA board that offers

certification in this subspecialty]

II.B.3.b).(1).(a) The Review Committee only accepts ABOHNS or

AOBOOHNS certification in otolaryngology – head

and neck surgery.

(Core)

II.B.3.c) Any non-physician faculty members who participate in

fellowship program education must be approved by the

program director.

(Core)

Background and Intent: The provision of optimal and safe patient care requires a team

approach. The education of fellows by non-physician educators enables the fellows to

better manage patient care and provides valuable advancement of the fellows’

knowledge. Furthermore, other individuals contribute to the education of the fellow in

the basic science of the subspecialty or in research methodology. If the program

director determines that the contribution of a non-physician individual is significant to

the education of the fellow, the program director may designate the individual as a

program faculty member or a program core faculty member.

II.B.3.d) Any other specialty physician faculty members must have

current certification in their specialty by the appropriate

American Board of Medical Specialties (ABMS) member

board or American Osteopathic Association (AOA) certifying

board, or possess qualifications judged acceptable to the

Review Committee.

(Core)

II.B.4. Core Faculty

Core faculty members must have a significant role in the education

and supervision of fellows and must devote a significant portion of

their entire effort to fellow education and/or administration, and

must, as a component of their activities, teach, evaluate, and provide

formative feedback to fellows.

(Core)

Background and Intent: Core faculty members are critical to the success of fellow

education. They support the program leadership in developing, implementing, and

assessing curriculum, mentoring fellows, and assessing fellows’ progress toward

achievement of competence in and the independent practice of the specialty. Core

faculty members should be selected for their broad knowledge of and involvement in

the program, permitting them to effectively evaluate the program. Core faculty

members may also be selected for their specific expertise and unique contributions to

the program. Core faculty members are engaged in a broad range of activities, which

may vary across programs and specialties. Core faculty members provide clinical

teaching and supervision of fellows, and also participate in non-clinical activities

Pediatric Otolaryngology

related to fellow education and program administration. Examples of these non-clinical

activities include, but are not limited to, interviewing and selecting fellow applicants,

providing didactic instruction, mentoring fellows, simulation exercises, completing the

annual ACGME Faculty Survey, and participating on the program’s Clinical

Competency Committee, Program Evaluation Committee, and other GME committees.

II.B.4.a) Core faculty members must be designated by the program

director.

(Core)

II.B.4.b) Core faculty members must complete the annual ACGME

Faculty Survey.

(Core)

II.B.4.c) There must be at least three core faculty members who are

ABOHNS or AOBOOHNS certified in otolaryngology – head and

neck surgery and who have completed a pediatric otolaryngology

fellowship program.

(Core)

II.C. Program Coordinator

II.C.1. There must be administrative support for program coordination.

(Core)

II.C.1.a) The program coordinator must be provided with support equal to a

dedicated minimum of 20 percent FTE for administration of the

program.

(Core)

Background and Intent: The requirement does not address the source of funding

required to provide the specified salary support.

II.D. Other Program Personnel

The program, in partnership with its Sponsoring Institution, must jointly

ensure the availability of necessary personnel for the effective

administration of the program.

(Core)

Background and Intent: Multiple personnel may be required to effectively administer a

program. These may include staff members with clerical skills, project managers,

education experts, and staff members to maintain electronic communication for the

program. These personnel may support more than one program in more than one

discipline.

III. Fellow Appointments

III.A. Eligibility Criteria

III.A.1. Eligibility Requirements – Fellowship Programs

All required clinical education for entry into ACGME-accredited

fellowship programs must be completed in an ACGME-accredited

residency program, an AOA-approved residency program, a

program with ACGME International (ACGME-I) Advanced Specialty

Pediatric Otolaryngology

Accreditation, or a Royal College of Physicians and Surgeons of

Canada (RCPSC)-accredited or College of Family Physicians of

Canada (CFPC)-accredited residency program located in Canada.

(Core)

Background and Intent: Eligibility for ABMS or AOA Board certification may not be

satisfied by fellowship training. Applicants must be notified of this at the time of

application, as required in II.A.4.a).(9).

III.A.1.a) Fellowship programs must receive verification of each

entering fellow’s level of competence in the required field,

upon matriculation, using ACGME, ACGME-I, or CanMEDS

Milestones evaluations from the core residency program.

(Core)

III.A.1.b) Prior to appointment in the program, fellows must have

successfully completed an otolaryngology – head and neck

surgery residency in a program that satisfies the requirements in

III.A.1.

(Core)

III.A.1.c) Fellow Eligibility Exception

The Review Committee for Otolaryngology – Head and Neck

Surgery will allow the following exception to the fellowship

eligibility requirements:

III.A.1.c).(1) An ACGME-accredited fellowship program may accept

an exceptionally qualified international graduate

applicant who does not satisfy the eligibility

requirements listed in III.A.1., but who does meet all of

the following additional qualifications and conditions:

(Core)

III.A.1.c).(1).(a) evaluation by the program director and

fellowship selection committee of the

applicant’s suitability to enter the program,

based on prior training and review of the

summative evaluations of training in the core

specialty; and,

(Core)

III.A.1.c).(1).(b) review and approval of the applicant’s

exceptional qualifications by the GMEC; and,

(Core)

III.A.1.c).(1).(c) verification of Educational Commission for

Foreign Medical Graduates (ECFMG)

certification.

(Core)

III.A.1.c).(2) Applicants accepted through this exception must have

an evaluation of their performance by the Clinical

Competency Committee within 12 weeks of

matriculation.

(Core)

Pediatric Otolaryngology

Background and Intent: An exceptionally qualified international graduate applicant has

(1) completed a residency program in the core specialty outside the continental United

States that was not accredited by the ACGME, AOA, ACGME-I, RCPSC or CFPC, and

(2) demonstrated clinical excellence, in comparison to peers, throughout training.

Additional evidence of exceptional qualifications is required, which may include one of

the following: (a) participation in additional clinical or research training in the specialty

or subspecialty; (b) demonstrated scholarship in the specialty or subspecialty; and/or

these positions must be informed of the fact that their training may not lead to

certification by ABMS member boards or AOA certifying boards.

In recognition of the diversity of medical education and training around the world, this

early evaluation of clinical competence required for these applicants ensures they can

provide quality and safe patient care. Any gaps in competence should be addressed

as per policies for fellows already established by the program in partnership with the

Sponsoring Institution.

III.B. The program director must not appoint more fellows than approved by the

Review Committee.

(Core)

III.B.1. All complement increases must be approved by the Review

Committee.

(Core)

IV. Educational Program

The ACGME accreditation system is designed to encourage excellence and

innovation in graduate medical education regardless of the organizational

affiliation, size, or location of the program.

The educational program must support the development of knowledgeable, skillful

physicians who provide compassionate care.

In addition, the program is expected to define its specific program aims consistent

with the overall mission of its Sponsoring Institution, the needs of the community

it serves and that its graduates will serve, and the distinctive capabilities of

physicians it intends to graduate. While programs must demonstrate substantial

compliance with the Common and subspecialty-specific Program Requirements, it

is recognized that within this framework, programs may place different emphasis

on research, leadership, public health, etc. It is expected that the program aims

will reflect the nuanced program-specific goals for it and its graduates; for

example, it is expected that a program aiming to prepare physician-scientists will

have a different curriculum from one focusing on community health.

IV.A. The curriculum must contain the following educational components:

(Core)

IV.A.1. a set of program aims consistent with the Sponsoring Institution’s

mission, the needs of the community it serves, and the desired

distinctive capabilities of its graduates;

(Core)

Pediatric Otolaryngology

IV.A.1.a) The program’s aims must be made available to program

applicants, fellows, and faculty members.

(Core)

IV.A.2. competency-based goals and objectives for each educational

experience designed to promote progress on a trajectory to

autonomous practice in their subspecialty. These must be

distributed, reviewed, and available to fellows and faculty members;

(Core)

IV.A.3. delineation of fellow responsibilities for patient care, progressive

responsibility for patient management, and graded supervision in

their subspecialty;

(Core)

Background and Intent: These responsibilities may generally be described by PGY

level and specifically by Milestones progress as determined by the Clinical

Competency Committee. This approach encourages the transition to competency-

based education. An advanced learner may be granted more responsibility

independent of PGY level and a learner needing more time to accomplish a certain

task may do so in a focused rather than global manner.

IV.A.4. structured educational activities beyond direct patient care; and,

(Core)

Background and Intent: Patient care-related educational activities, such as morbidity

and mortality conferences, tumor boards, surgical planning conferences, case

discussions, etc., allow fellows to gain medical knowledge directly applicable to the

patients they serve. Programs should define those educational activities in which

fellows are expected to participate and for which time is protected. Further

specification can be found in IV.C.

IV.A.5. advancement of fellows’ knowledge of ethical principles

foundational to medical professionalism.

(Core)

IV.B. ACGME Competencies

Background and Intent: The Competencies provide a conceptual framework describing

the required domains for a trusted physician to enter autonomous practice. These

Competencies are core to the practice of all physicians, although the specifics are

further defined by each subspecialty. The developmental trajectories in each of the

Competencies are articulated through the Milestones for each subspecialty. The focus

in fellowship is on subspecialty-specific patient care and medical knowledge, as well

as refining the other competencies acquired in residency.

IV.B.1. The program must integrate the following ACGME Competencies

into the curriculum:

(Core)

IV.B.1.a) Professionalism

Fellows must demonstrate a commitment to professionalism

and an adherence to ethical principles.

(Core)

Pediatric Otolaryngology

IV.B.1.b) Patient Care and Procedural Skills

Background and Intent: Quality patient care is safe, effective, timely, efficient, patient-

centered, equitable, and designed to improve population health, while reducing per

capita costs. (See the Institute of Medicine [IOM]’s Crossing the Quality Chasm: A New

Health System for the 21st Century, 2001 and

Berwick D, Nolan T, Whittington J. The

Triple Aim: care, cost, and quality. Health Affairs. 2008; 27(3):759-769.). In addition, there

should be a focus on improving the clinician’s well-being as a means to improve patient

care and reduce burnout among residents, fellows, and practicing physicians.

These organizing principles inform the Common Program Requirements across all

Competency domains. Specific content is determined by the Review Committees with

input from the appropriate professional societies, certifying boards, and the community.

IV.B.1.b).(1) Fellows must be able to provide patient care that is

compassionate, appropriate, and effective for the

treatment of health problems and the promotion of

health.

(Core)

IV.B.1.b).(1).(a) Fellows must demonstrate competence in

advocating for quality patient care when facilitating

patient management in the home, school, or

institutional setting.

(Core)

IV.B.1.b).(1).(b) Fellows must demonstrate competence in care that

is:

(Core)

IV.B.1.b).(1).(b).(i) culturally sensitive;

(Core)

IV.B.1.b).(1).(b).(ii) situationally sensitive; and,

(Core)

IV.B.1.b).(1).(b).(iii) specific to the particular patient/family

needs.

(Core)

IV.B.1.b).(1).(c) Fellows must demonstrate competence in care that

is accurate in diagnosis and treatment care options,

and based on best practice and standards of

practice.

(Core)

IV.B.1.b).(2) Fellows must be able to perform all medical,

diagnostic, and surgical procedures considered

essential for the area of practice.

(Core)

IV.B.1.b).(2).(a) Fellows must demonstrate competence in:

IV.B.1.b).(2).(a).(i) evaluating neonates, infants, children, and

adolescents 18 years and younger with

congenital abnormalities, infectious and

inflammatory disorders, and inherited and

acquired conditions of the head and neck,

Pediatric Otolaryngology

including hearing loss and other

communication impairments;

(Core)

IV.B.1.b).(2).(a).(ii) diagnosing and managing the medical and

surgical treatment of the aerodigestive tract,

ear, nose, sinus, throat, voice and speech,

and head and neck and disorders of

neonates, infants, children, and adolescents

18 years and younger; and,

(Core)

IV.B.1.b).(2).(a).(iii) performing procedures in the following

domains with an emphasis on neonates,

infants, children younger than three years of

age, and children and adolescents with

significant co-morbidities as defined by

American Society of Anesthesiology (ASA)

status:

(Core)

IV.B.1.b).(2).(a).(iii).(a) closed and open airways;

(Core)

IV.B.1.b).(2).(a).(iii).(b) congenital anomalies;

((Core)

IV.B.1.b).(2).(a).(iii).(c) endoscopic airways;

(Core)

IV.B.1.b).(2).(a).(iii).(d) facial plastics;

(Core)

IV.B.1.b).(2).(a).(iii).(e) facial trauma;

(Core)

IV.B.1.b).(2).(a).(iii).(f) head and neck surgery;

(Core)

IV.B.1.b).(2).(a).(iii).(g) otology;

(Core)

IV.B.1.b).(2).(a).(iii).(h) rhinology; and,

(Core)

IV.B.1.b).(2).(a).(iii).(i) complex and uncommon pediatric

procedures infrequently encountered

in the general practice of

otolaryngology – head and neck

surgery.

(Core)

IV.B.1.b).(2).(b) Fellows must document surgical experience as

assistant surgeon, surgeon, and resident

supervisor in the ACGME Case Log System,

recording patient age and ASA classification for

each documented case.

(Core)

IV.B.1.c) Medical Knowledge

Fellows must demonstrate knowledge of established and

evolving biomedical, clinical, epidemiological and social-

Pediatric Otolaryngology

behavioral sciences, as well as the application of this

knowledge to patient care.

(Core)

IV.B.1.c).(1) Fellows must demonstrate competence in their knowledge

of medical and surgical management of neonatal, infant,

childhood, and adolescent diseases of the head and neck

to a level appropriate for unsupervised practice as defined

by the didactic curriculum.

(Core)

IV.B.1.d) Practice-based Learning and Improvement

Fellows must demonstrate the ability to investigate and

evaluate their care of patients, to appraise and assimilate

scientific evidence, and to continuously improve patient care

based on constant self-evaluation and lifelong learning.

(Core)

Background and Intent: Practice-based learning and improvement is one of the

defining characteristics of being a physician. It is the ability to investigate and

evaluate the care of patients, to appraise and assimilate scientific evidence, and to

continuously improve patient care based on constant self-evaluation and lifelong

learning.

The intention of this Competency is to help a fellow refine the habits of mind required

to continuously pursue quality improvement, well past the completion of fellowship.

IV.B.1.e) Interpersonal and Communication Skills

Fellows must demonstrate interpersonal and communication

skills that result in the effective exchange of information and

collaboration with patients, their families, and health

professionals.

(Core)

IV.B.1.f) Systems-based Practice

Fellows must demonstrate an awareness of and

responsiveness to the larger context and system of health

care, including the social determinants of health, as well as

the ability to call effectively on other resources to provide

optimal health care.

(Core)

IV.C. Curriculum Organization and Fellow Experiences

IV.C.1. The curriculum must be structured to optimize fellow educational

experiences, the length of these experiences, and supervisory

continuity.

(Core)

IV.C.1.a) Clinical rotations must be at least four weeks in length.

(Core)

IV.C.2. The program must provide instruction and experience in pain

management if applicable for the subspecialty, including recognition

of the signs of substance use disorder.

(Core)

Pediatric Otolaryngology

IV.C.3. The didactic curriculum must include basic science, clinical, and research

conferences and seminars, as well as journal club activities pertaining to

pediatric otolaryngology.

(Core)

IV.C.3.a) Didactic topics must include:

IV.C.3.a).(1) developmental anatomy and physiology, embryology,

microbiology, oncology, and psychology of the infant and

child as related to the head and neck;

(Core)

IV.C.3.a).(2) diagnosis and care of uncommon and complex congenital

and acquired conditions involving the aerodigestive tract,

nose and paranasal sinuses, and ear, as well as diseases

and disorders of the laryngotracheal complex and the head

and neck;

(Core)

IV.C.3.a).(3) diagnosis, treatment, and management of childhood

disorders of hearing, language, speech, and voice; and,

(Core)

IV.C.3.a).(4) genetics.

(Core)

IV.C.3.b) Quality improvement conferences must take place at least

quarterly.

(Core)

IV.C.3.c) Fellows must participate in planning and conducting conferences.

(Core)

IV.C.3.d) Both faculty members and fellows must attend and participate in

multidisciplinary conferences.

(Core)

IV.C.3.e) Faculty member and fellow attendance at conferences must be

documented.

(Core)

IV.C.4. Fellows’ clinical experiences must include:

IV.C.4.a) participation in a multispecialty, interdisciplinary team to manage

and treat conditions for at least three of the following: cochlear

implant, craniofacial disorders, tumors, or vascular anomalies;

and,

(Core)

IV.C.4.b) attendance at a minimum of four clinic sessions per month.

(Core)

IV.D. Scholarship

Medicine is both an art and a science. The physician is a humanistic

scientist who cares for patients. This requires the ability to think critically,

evaluate the literature, appropriately assimilate new knowledge, and

practice lifelong learning. The program and faculty must create an

environment that fosters the acquisition of such skills through fellow

Pediatric Otolaryngology

participation in scholarly activities as defined in the subspecialty-specific

Program Requirements. Scholarly activities may include discovery,

integration, application, and teaching.

The ACGME recognizes the diversity of fellowships and anticipates that

programs prepare physicians for a variety of roles, including clinicians,

scientists, and educators. It is expected that the program’s scholarship will

reflect its mission(s) and aims, and the needs of the community it serves.

For example, some programs may concentrate their scholarly activity on

quality improvement, population health, and/or teaching, while other

programs might choose to utilize more classic forms of biomedical

research as the focus for scholarship.

IV.D.1. Program Responsibilities

IV.D.1.a) The program must demonstrate evidence of scholarly

activities, consistent with its mission(s) and aims.

(Core)

IV.D.2. Faculty Scholarly Activity

IV.D.2.a) The faculty must establish and maintain an environment of inquiry

and scholarship with an active research component.

(Core)

IV.D.2.b) Scholarly activity of each core physician faculty member must

include at least one of the following:

(Core)

IV.D.2.b).(1) funded research grants;

(Detail)

IV.D.2.b).(2) peer-reviewed publications; or,

(Detail)

IV.D.2.b).(3) presentations in regional or national conferences.

(Detail)

IV.D.3. Fellow Scholarly Activity

IV.D.3.a) Fellows’ scholarly activity initiated or completed during the

program, including scientific study, production of review articles or

chapters, or creation of online educational activities, must be

documented.

(Outcome)‡

IV.E. Fellowship programs may assign fellows to engage in the independent

practice of their core specialty during their fellowship program.

IV.E.1. If programs permit their fellows to utilize the independent practice

option, it must not exceed 20 percent of their time per week or 10

weeks of an academic year.

(Core)

Background and Intent: Fellows who have previously completed residency programs

have demonstrated sufficient competence to enter autonomous practice within their

core specialty. This option is designed to enhance fellows’ maturation and competence

in their core specialty. This enables fellows to occupy a dual role in the health system:

as learners in their subspecialty, and as credentialed practitioners in their core

Pediatric Otolaryngology

specialty. Hours worked in independent practice during fellowship still fall under the

clinical and educational work hour limits. See Program Director Guide for more details.

V. Evaluation

V.A. Fellow Evaluation

V.A.1. Feedback and Evaluation

Background and Intent: Feedback is ongoing information provided regarding aspects

of one’s performance, knowledge, or understanding. The faculty empower fellows to

provide much of that feedback themselves in a spirit of continuous learning and self-

reflection. Feedback from faculty members in the context of routine clinical care

should be frequent, and need not always be formally documented.

Formative and summative evaluation have distinct definitions. Formative evaluation is

monitoring fellow learning and providing ongoing feedback that can be used by fellows

to improve their learning in the context of provision of patient care or other educational

opportunities. More specifically, formative evaluations help:

• fellows identify their strengths and weaknesses and target areas that need work

• program directors and faculty members recognize where fellows are struggling

and address problems immediately

Summative evaluation is evaluating a fellow’s learning by comparing the fellows

against the goals and objectives of the rotation and program, respectively. Summative

evaluation is utilized to make decisions about promotion to the next level of training, or

program completion.

End-of-rotation and end-of-year evaluations have both summative and formative

components. Information from a summative evaluation can be used formatively when

fellows or faculty members use it to guide their efforts and activities in subsequent

rotations and to successfully complete the fellowship program.

Feedback, formative evaluation, and summative evaluation compare intentions with

accomplishments, enabling the transformation of a new specialist to one with growing

subspecialty expertise.

V.A.1.a) Faculty members must directly observe, evaluate, and

frequently provide feedback on fellow performance during

each rotation or similar educational assignment.

(Core)

V.A.1.a).(1) This must include meeting with each fellow in person to

review his or her cumulative operative experience and

Case Log data at least semiannually to ensure balanced

progress towards achieving experience with a variety and

complexity of surgical procedures.

(Core)

Background and Intent: Faculty members should provide feedback frequently

throughout the course of each rotation. Fellows require feedback from faculty

members to reinforce well-performed duties and tasks, as well as to correct

Pediatric Otolaryngology

deficiencies. This feedback will allow for the development of the learner as they strive

to achieve the Milestones. More frequent feedback is strongly encouraged for fellows

who have deficiencies that may result in a poor final rotation evaluation.

V.A.1.b) Evaluation must be documented at the completion of the

assignment.

(Core)

V.A.1.b).(1) Evaluations must be completed at least every three

months.

(Core)

V.A.1.c) The program must provide an objective performance

evaluation based on the Competencies and the subspecialty-

specific Milestones, and must:

(Core)

V.A.1.c).(1) use multiple evaluators (e.g., faculty members, peers,

patients, self, and other professional staff members);

and,

(Core)

V.A.1.c).(2) provide that information to the Clinical Competency

Committee for its synthesis of progressive fellow

performance and improvement toward unsupervised

practice.

(Core)

Background and Intent: The trajectory to autonomous practice in a subspecialty is

documented by the subspecialty-specific Milestones evaluation during fellowship.

These Milestones detail the progress of a fellow in attaining skill in each competency

domain. It is expected that the most growth in fellowship education occurs in patient

care and medical knowledge, while the other four domains of competency must be

ensured in the context of the subspecialty. They are developed by a subspecialty

group and allow evaluation based on observable behaviors. The Milestones are

considered formative and should be used to identify learning needs. This may lead to

focused or general curricular revision in any given program or to individualized

learning plans for any specific fellow.

V.A.1.d) The program director or their designee, with input from the

Clinical Competency Committee, must:

V.A.1.d).(1) meet with and review with each fellow their

documented semi-annual evaluation of performance,

including progress along the subspecialty-specific

Milestones.

(Core)

V.A.1.d).(2) develop plans for fellows failing to progress, following

institutional policies and procedures.

(Core)

Background and Intent: Learning is an active process that requires effort from the

teacher and the learner. Faculty members evaluate a fellow's performance at least at

the end of each rotation. The program director or their designee will review those

evaluations, including their progress on the Milestones, at a minimum of every six

months. Fellows should be encouraged to reflect upon the evaluation, using the

Pediatric Otolaryngology

information to reinforce well-performed tasks or knowledge or to modify deficiencies in

knowledge or practice. Working together with the faculty members, fellows should

develop an individualized learning plan.

Fellows who are experiencing difficulties with achieving progress along the Milestones

may require intervention to address specific deficiencies. Such intervention,

documented in an individual remediation plan developed by the program director or a

faculty mentor and the fellow, will take a variety of forms based on the specific learning

needs of the fellow. However, the ACGME recognizes that there are situations which

require more significant intervention that may alter the time course of fellow

progression. To ensure due process, it is essential that the program director follow

institutional policies and procedures.

V.A.1.e) The evaluations of a fellow’s performance must be accessible

for review by the fellow.

(Core)

V.A.2. Final Evaluation

V.A.2.a) The program director must provide a final evaluation for each

fellow upon completion of the program.

(Core)

V.A.2.a).(1) The subspecialty-specific Milestones, and when

applicable the subspecialty-specific Case Logs, must

be used as tools to ensure fellows are able to engage

in autonomous practice upon completion of the

program.

(Core)

V.A.2.a).(2) The final evaluation must:

V.A.2.a).(2).(a) become part of the fellow’s permanent record

maintained by the institution, and must be

accessible for review by the fellow in

accordance with institutional policy;

(Core)

V.A.2.a).(2).(b) verify that the fellow has demonstrated the

knowledge, skills, and behaviors necessary to

enter autonomous practice;

(Core)

V.A.2.a).(2).(c) consider recommendations from the Clinical

Competency Committee; and,

(Core)

V.A.2.a).(2).(d) be shared with the fellow upon completion of

the program.

(Core)

V.A.3. A Clinical Competency Committee must be appointed by the

program director.

(Core)

V.A.3.a) At a minimum the Clinical Competency Committee must

include three members, at least one of whom is a core faculty

member. Members must be faculty members from the same

program or other programs, or other health professionals

Pediatric Otolaryngology

who have extensive contact and experience with the

program’s fellows.

(Core)

V.A.3.b) The Clinical Competency Committee must:

V.A.3.b).(1) review all fellow evaluations at least semi-annually;

(Core)

V.A.3.b).(2) determine each fellow’s progress on achievement of

the subspecialty-specific Milestones; and,

(Core)

V.A.3.b).(3) meet prior to the fellows’ semi-annual evaluations and

advise the program director regarding each fellow’s

progress.

(Core)

V.B. Faculty Evaluation

V.B.1. The program must have a process to evaluate each faculty

member’s performance as it relates to the educational program at

least annually.

(Core)

Background and Intent: The program director is responsible for the education program

and for whom delivers it. While the term faculty may be applied to physicians within a

given institution for other reasons, it is applied to fellowship program faculty members

only through approval by a program director. The development of the faculty improves

the education, clinical, and research aspects of a program. Faculty members have a

strong commitment to the fellow and desire to provide optimal education and work

opportunities. Faculty members must be provided feedback on their contribution to the

mission of the program. All faculty members who interact with fellows desire feedback

on their education, clinical care, and research. If a faculty member does not interact

with fellows, feedback is not required. With regard to the diverse operating

environments and configurations, the fellowship program director may need to work

with others to determine the effectiveness of the program’s faculty performance with

regard to their role in the educational program. All teaching faculty members should

have their educational efforts evaluated by the fellows in a confidential and

anonymous manner. Other aspects for the feedback may include research or clinical

productivity, review of patient outcomes, or peer review of scholarly activity. The

process should reflect the local environment and identify the necessary information.

The feedback from the various sources should be summarized and provided to the

faculty on an annual basis by a member of the leadership team of the program.

V.B.1.a) This evaluation must include a review of the faculty member’s

clinical teaching abilities, engagement with the educational

program, participation in faculty development related to their

skills as an educator, clinical performance, professionalism,

and scholarly activities.

(Core)

V.B.1.b) This evaluation must include written, confidential evaluations

by the fellows.

(Core)

Pediatric Otolaryngology

V.B.2. Faculty members must receive feedback on their evaluations at least

annually.

(Core)

Background and Intent: The quality of the faculty’s teaching and clinical care is a

determinant of the quality of the program and the quality of the fellows’ future clinical

care. Therefore, the program has the responsibility to evaluate and improve the

program faculty members’ teaching, scholarship, professionalism, and quality care.

This section mandates annual review of the program’s faculty members for this

purpose, and can be used as input into the Annual Program Evaluation.

V.C. Program Evaluation and Improvement

V.C.1. The program director must appoint the Program Evaluation

Committee to conduct and document the Annual Program

Evaluation as part of the program’s continuous improvement

process.

(Core)

V.C.1.a) The Program Evaluation Committee must be composed of at

least two program faculty members, at least one of whom is a

core faculty member, and at least one fellow.

(Core)

V.C.1.b) Program Evaluation Committee responsibilities must include:

V.C.1.b).(1) acting as an advisor to the program director, through

program oversight;

(Core)

V.C.1.b).(2) review of the program’s self-determined goals and

progress toward meeting them;

(Core)

V.C.1.b).(3) guiding ongoing program improvement, including

development of new goals, based upon outcomes;

and,

(Core)

V.C.1.b).(4) review of the current operating environment to identify

strengths, challenges, opportunities, and threats as

related to the program’s mission and aims.

(Core)

Background and Intent: In order to achieve its mission and train quality physicians, a

program must evaluate its performance and plan for improvement in the Annual

Program Evaluation. Performance of fellows and faculty members is a reflection of

program quality, and can use metrics that reflect the goals that a program has set for

itself. The Program Evaluation Committee utilizes outcome parameters and other data

to assess the program’s progress toward achievement of its goals and aims.

V.C.1.c) The Program Evaluation Committee should consider the

following elements in its assessment of the program:

V.C.1.c).(1) fellow performance;

(Core)

V.C.1.c).(2) faculty development; and,

(Core)

Pediatric Otolaryngology

V.C.1.c).(3) progress on the previous year’s action plan(s).

(Core)

V.C.1.d) The Program Evaluation Committee must evaluate the

program’s mission and aims, strengths, areas for

improvement, and threats.

(Core)

V.C.1.e) The annual review, including the action plan, must:

V.C.1.e).(1) be distributed to and discussed with the members of

the teaching faculty and the fellows; and,

(Core)

V.C.1.e).(2) be submitted to the DIO.

(Core)

V.C.2. The program must participate in a Self-Study prior to its 10-Year

Accreditation Site Visit.

(Core)

V.C.2.a) A summary of the Self-Study must be submitted to the DIO.

(Core)

Background and Intent: Outcomes of the documented Annual Program Evaluation can

be integrated into the 10-year Self-Study process. The Self-Study is an objective,

comprehensive evaluation of the fellowship program, with the aim of improving it.

Underlying the Self-Study is this longitudinal evaluation of the program and its

learning environment, facilitated through sequential Annual Program Evaluations that

focus on the required components, with an emphasis on program strengths and self-

identified areas for improvement. Details regarding the timing and expectations for the

Self-Study and the 10-Year Accreditation Site Visit are provided in the ACGME Manual

of Policies and Procedures. Additionally, a description of the

Self-Study process, as

well as information on how to prepare for the 10-Year Accreditation Site Visit, is

available on the ACGME website.

VI. The Learning and Working Environment

Fellowship education must occur in the context of a learning and working

environment that emphasizes the following principles:

• Excellence in the safety and quality of care rendered to patients by fellows

today

• Excellence in the safety and quality of care rendered to patients by today’s

fellows in their future practice

• Excellence in professionalism through faculty modeling of:

o the effacement of self-interest in a humanistic environment that supports

the professional development of physicians

o the joy of curiosity, problem-solving, intellectual rigor, and discovery

Pediatric Otolaryngology

• Commitment to the well-being of the students, residents, fellows, faculty

members, and all members of the health care team

Background and Intent: The revised requirements are intended to provide greater

flexibility within an established framework, allowing programs and fellows more

discretion to structure clinical education in a way that best supports the above

principles of professional development. With this increased flexibility comes the

responsibility for programs and fellows to adhere to the 80-hour maximum weekly limit

(unless a rotation-specific exception is granted by a Review Committee), and to utilize

flexibility in a manner that optimizes patient safety, fellow education, and fellow well-

being. The requirements are intended to support the development of a sense of

professionalism by encouraging fellows to make decisions based on patient needs and

their own well-being,

without fear of jeopardizing their program’s accreditation status. In

addition, the proposed requirements eliminate the burdensome documentation

requirement for fellows to justify clinical and educational work hour variations.

Clinical and educational work hours represent only one part of the larger issue of

conditions of the learning and working environment, and Section VI has now been

expanded to include greater attention to patient safety and fellow and faculty member

well-being. The requirements are intended to support programs and fellows as they

strive for excellence, while also ensuring ethical, humanistic training. Ensuring that

flexibility is used in an approp

riate manner is a shared responsibility of the program and

fellows. With this flexibility comes a responsibility for fellows and faculty members to

recognize the need to hand off care of a patient to another provider when a fellow is too

fatigued to provide safe, high quality care and for programs to ensure that fellows

remain within the 80-hour maximum weekly limit.

VI.A. Patient Safety, Quality Improvement, Supervision, and Accountability

VI.A.1. Patient Safety and Quality Improvement

All physicians share responsibility for promoting patient safety and

enhancing quality of patient care. Graduate medical education must

prepare fellows to provide the highest level of clinical care with

continuous focus on the safety, individual needs, and humanity of

their patients. It is the right of each patient to be cared for by fellows

who are appropriately supervised; possess the requisite knowledge,

skills, and abilities; understand the limits of their knowledge and

experience; and seek assistance as required to provide optimal

patient care.

Fellows must demonstrate the ability to analyze the care they

provide, understand their roles within health care teams, and play an

active role in system improvement processes. Graduating fellows

will apply these skills to critique their future unsupervised practice

and effect quality improvement measures.

It is necessary for fellows and faculty members to consistently work

in a well-coordinated manner with other health care professionals to

achieve organizational patient safety goals.

Pediatric Otolaryngology

VI.A.1.a) Patient Safety

VI.A.1.a).(1) Culture of Safety

A culture of safety requires continuous identification

of vulnerabilities and a willingness to transparently

deal with them. An effective organization has formal

mechanisms to assess the knowledge, skills, and

attitudes of its personnel toward safety in order to

identify areas for improvement.

VI.A.1.a).(1).(a) The program, its faculty, residents, and fellows

must actively participate in patient safety

systems and contribute to a culture of safety.

(Core)

VI.A.1.a).(1).(b) The program must have a structure that

promotes safe, interprofessional, team-based

care.

(Core)

VI.A.1.a).(2) Education on Patient Safety

Programs must provide formal educational activities

that promote patient safety-related goals, tools, and

techniques.

(Core)

Background and Intent: Optimal patient safety occurs in the setting of a coordinated

interprofessional learning and working environment.

VI.A.1.a).(3) Patient Safety Events

Reporting, investigation, and follow-up of adverse

events, near misses, and unsafe conditions are pivotal

mechanisms for improving patient safety, and are

essential for the success of any patient safety

program. Feedback and experiential learning are

essential to developing true competence in the ability

to identify causes and institute sustainable systems-

based changes to ameliorate patient safety

vulnerabilities.

VI.A.1.a).(3).(a) Residents, fellows, faculty members, and other

clinical staff members must:

VI.A.1.a).(3).(a).(i) know their responsibilities in reporting

patient safety events at the clinical site;

(Core)

Pediatric Otolaryngology

VI.A.1.a).(3).(a).(ii) know how to report patient safety

events, including near misses, at the

clinical site; and,

(Core)

VI.A.1.a).(3).(a).(iii) be provided with summary information

of their institution’s patient safety

reports.

(Core)

VI.A.1.a).(3).(b) Fellows must participate as team members in

real and/or simulated interprofessional clinical

patient safety activities, such as root cause

analyses or other activities that include

analysis, as well as formulation and

implementation of actions.

(Core)

VI.A.1.a).(4) Fellow Education and Experience in Disclosure of

Adverse Events

Patient-centered care requires patients, and when

appropriate families, to be apprised of clinical

situations that affect them, including adverse events.

This is an important skill for faculty physicians to

model, and for fellows to develop and apply.

VI.A.1.a).(4).(a) All fellows must receive training in how to

disclose adverse events to patients and

families.

(Core)

VI.A.1.a).(4).(b) Fellows should have the opportunity to

participate in the disclosure of patient safety

events, real or simulated.

(Detail)†

VI.A.1.b) Quality Improvement

VI.A.1.b).(1) Education in Quality Improvement

A cohesive model of health care includes quality-

related goals, tools, and techniques that are necessary

in order for health care professionals to achieve

quality improvement goals.

VI.A.1.b).(1).(a) Fellows must receive training and experience in

quality improvement processes, including an

understanding of health care disparities.

(Core)

VI.A.1.b).(2) Quality Metrics

Access to data is essential to prioritizing activities for

care improvement and evaluating success of

improvement efforts.

Pediatric Otolaryngology

VI.A.1.b).(2).(a) Fellows and faculty members must receive data

on quality metrics and benchmarks related to

their patient populations.

(Core)

VI.A.1.b).(3) Engagement in Quality Improvement Activities

Experiential learning is essential to developing the

ability to identify and institute sustainable systems-

based changes to improve patient care.

VI.A.1.b).(3).(a) Fellows must have the opportunity to

participate in interprofessional quality

improvement activities.

(Core)

VI.A.1.b).(3).(a).(i) This should include activities aimed at

reducing health care disparities.

(Detail)

VI.A.2. Supervision and Accountability

VI.A.2.a) Although the attending physician is ultimately responsible for

the care of the patient, every physician shares in the

responsibility and accountability for their efforts in the

provision of care. Effective programs, in partnership with

their Sponsoring Institutions, define, widely communicate,

and monitor a structured chain of responsibility and

accountability as it relates to the supervision of all patient

care.

Supervision in the setting of graduate medical education

provides safe and effective care to patients; ensures each

fellow’s development of the skills, knowledge, and attitudes

required to enter the unsupervised practice of medicine; and

establishes a foundation for continued professional growth.

VI.A.2.a).(1) Each patient must have an identifiable and

appropriately-credentialed and privileged attending

physician (or licensed independent practitioner as

specified by the applicable Review Committee) who is

responsible and accountable for the patient’s care.

(Core)

VI.A.2.a).(1).(a) This information must be available to fellows,

faculty members, other members of the health

care team, and patients.

(Core)

VI.A.2.a).(1).(b) Fellows and faculty members must inform each

patient of their respective roles in that patient’s

care when providing direct patient care.

(Core)

VI.A.2.b) Supervision may be exercised through a variety of methods.

For many aspects of patient care, the supervising physician

Pediatric Otolaryngology

may be a more advanced fellow. Other portions of care

provided by the fellow can be adequately supervised by the

appropriate availability of the supervising faculty member or

fellow, either on site or by means of telecommunication

technology. Some activities require the physical presence of

the supervising faculty member. In some circumstances,

supervision may include post-hoc review of fellow-delivered

care with feedback.

Background and Intent: Appropriate supervision is essential for patient safety and

high-quality teaching. Supervision is also contextual. There is tremendous diversity of

fellow patient interactions, education and training locations, and fellow skills and

abilities even at the same level of the educational program. The degree of supervision

is expected to evolve progressively as a fellow gains more experience, even with the

same patient condition or procedure. All fellows have a level of supervision

commensurate with their level of autonomy in practice; this level of supervision may

be enhanced based on factors such as patient safety, complexity, acuity, urgency, risk

of serious adverse events, or other pertinent variables.

VI.A.2.b).(1) The program must demonstrate that the appropriate

level of supervision in place for all fellows is based on

each fellow’s level of training and ability, as well as

patient complexity and acuity. Supervision may be

exercised through a variety of methods, as appropriate

to the situation.

(Core)

VI.A.2.b).(2) The program must define when physical presence of a

supervising physician is required.

(Core)

VI.A.2.c) Levels of Supervision

To promote appropriate fellow supervision while providing

for graded authority and responsibility, the program must use

the following classification of supervision:

(Core)

VI.A.2.c).(1) Direct Supervision:

VI.A.2.c).(1).(a) the supervising physician is physically present

with the fellow during the key portions of the

patient interaction.

(Core)

VI.A.2.c).(2) Indirect Supervision: the supervising physician is not

providing physical or concurrent visual or audio

supervision but is immediately available to the fellow

for guidance and is available to provide appropriate

direct supervision.

(Core)

VI.A.2.c).(3) Oversight – the supervising physician is available to

provide review of procedures/encounters with

feedback provided after care is delivered.

(Core)

Pediatric Otolaryngology

VI.A.2.d) The privilege of progressive authority and responsibility,

conditional independence, and a supervisory role in patient

care delegated to each fellow must be assigned by the

program director and faculty members.

(Core)

VI.A.2.d).(1) The program director must evaluate each fellow’s

abilities based on specific criteria, guided by the

Milestones.

(Core)

VI.A.2.d).(2) Faculty members functioning as supervising

physicians must delegate portions of care to fellows

based on the needs of the patient and the skills of

each fellow.

(Core)

VI.A.2.d).(3) Fellows should serve in a supervisory role to junior

fellows and residents in recognition of their progress

toward independence, based on the needs of each

patient and the skills of the individual resident or

fellow.

(Detail)

VI.A.2.e) Programs must set guidelines for circumstances and events

in which fellows must communicate with the supervising

faculty member(s).

(Core)

VI.A.2.e).(1) Each fellow must know the limits of their scope of

authority, and the circumstances under which the

fellow is permitted to act with conditional

independence.

(Outcome)

Background and Intent: The ACGME Glossary of Terms defines conditional

independence as: Graded, progressive responsibility for patient care with defined

oversight.

VI.A.2.f) Faculty supervision assignments must be of sufficient

duration to assess the knowledge and skills of each fellow

and to delegate to the fellow the appropriate level of patient

care authority and responsibility.

(Core)

VI.B. Professionalism

VI.B.1. Programs, in partnership with their Sponsoring Institutions, must

educate fellows and faculty members concerning the professional

responsibilities of physicians, including their obligation to be

appropriately rested and fit to provide the care required by their

patients.

(Core)

VI.B.2. The learning objectives of the program must:

VI.B.2.a) be accomplished through an appropriate blend of supervised

patient care responsibilities, clinical teaching, and didactic

educational events;

(Core)

Pediatric Otolaryngology

VI.B.2.b) be accomplished without excessive reliance on fellows to

fulfill non-physician obligations; and,

(Core)

Background and Intent: Routine reliance on fellows to fulfill non-physician obligations

increases work compression for fellows and does not provide an optimal educational

experience. Non-physician obligations are those duties which in most institutions are

performed by nursing and allied health professionals, transport services, or clerical

staff. Examples of such obligations include transport of patients from the wards or units

for procedures elsewhere in the hospital; routine blood drawing for laboratory tests;

routine monitoring of patients when off the ward; and clerical duties, such as

scheduling. While it is understood that fellows may be expected to do any of these

things on occasion when the need arises, these activities should not be performed by

fellows routinely and must be kept to a minimum to optimize fellow education.

VI.B.2.c) ensure manageable patient care responsibilities.

(Core)

Background and Intent: The Common Program Requirements do not define

“manageable patient care responsibilities” as this is variable by specialty and PGY

level. Review Committees will provide further detail regarding patient care

responsibilities in the applicable specialty-specific Program Requirements and

accompanying FAQs. However, all programs, regardless of specialty, should carefully

assess how the assignment of patient care responsibilities can affect work

compression.

VI.B.3. The program director, in partnership with the Sponsoring Institution,

must provide a culture of professionalism that supports patient

safety and personal responsibility.

(Core)

VI.B.4. Fellows and faculty members must demonstrate an understanding

of their personal role in the:

VI.B.4.a) provision of patient- and family-centered care;

(Outcome)

VI.B.4.b) safety and welfare of patients entrusted to their care,

including the ability to report unsafe conditions and adverse

events;

(Outcome)

Background and Intent: This requirement emphasizes that responsibility for reporting

unsafe conditions and adverse events is shared by all members of the team and is not

solely the responsibility of the fellow.

VI.B.4.c) assurance of their fitness for work, including:

(Outcome)

Background and Intent: This requirement emphasizes the professional responsibility of

faculty members and fellows to arrive for work adequately rested and ready to care for

patients. It is also the responsibility of faculty members, fellows, and other members of

the care team to be observant, to intervene, and/or to escalate their concern about

fellow and faculty member fitness for work, depending on the situation, and in

accordance with institutional policies.

Pediatric Otolaryngology

VI.B.4.c).(1) management of their time before, during, and after

clinical assignments; and,

(Outcome)

VI.B.4.c).(2) recognition of impairment, including from illness,

fatigue, and substance use, in themselves, their peers,

and other members of the health care team.

(Outcome)

VI.B.4.d) commitment to lifelong learning;

(Outcome)

VI.B.4.e) monitoring of their patient care performance improvement

indicators; and,

(Outcome)

VI.B.4.f) accurate reporting of clinical and educational work hours,

patient outcomes, and clinical experience data.

(Outcome)

VI.B.5. All fellows and faculty members must demonstrate responsiveness

to patient needs that supersedes self-interest. This includes the

recognition that under certain circumstances, the best interests of

the patient may be served by transitioning that patient’s care to

another qualified and rested provider.

(Outcome)

VI.B.6. Programs, in partnership with their Sponsoring Institutions, must

provide a professional, equitable, respectful, and civil environment

that is free from discrimination, sexual and other forms of

harassment, mistreatment, abuse, or coercion of students, fellows,

faculty, and staff.

(Core)

VI.B.7. Programs, in partnership with their Sponsoring Institutions, should

have a process for education of fellows and faculty regarding

unprofessional behavior and a confidential process for reporting,

investigating, and addressing such concerns.

(Core)

VI.C. Well-Being

Psychological, emotional, and physical well-being are critical in the

development of the competent, caring, and resilient physician and require

proactive attention to life inside and outside of medicine. Well-being

requires that physicians retain the joy in medicine while managing their

own real life stresses. Self-care and responsibility to support other

members of the health care team are important components of

professionalism; they are also skills that must be modeled, learned, and

nurtured in the context of other aspects of fellowship training.

Fellows and faculty members are at risk for burnout and depression.

Programs, in partnership with their Sponsoring Institutions, have the same

responsibility to address well-being as other aspects of resident

competence. Physicians and all members of the health care team share

responsibility for the well-being of each other. For example, a culture which

encourages covering for colleagues after an illness without the expectation

of reciprocity reflects the ideal of professionalism. A positive culture in a

Pediatric Otolaryngology

clinical learning environment models constructive behaviors, and prepares

fellows with the skills and attitudes needed to thrive throughout their

careers.

Background and Intent: The ACGME is committed to addressing physician well-being

for individuals and as it relates to the learning and working environment. The creation of

a learning and working environment with a culture of respect and accountability for

physician well-being is crucial to physicians’ ability to deliver the safest, best possible

care to patients. The ACGME is leveraging its resources in four key areas to support the

ongoing focus on physician well-being: education, influence, research, and

collaboration. Information regarding the ACGME’s ongoing efforts in this area is

available on the ACGME website:

www.acgme.org/physicianwellbeing.

The ACGME also created a repository for well-being materials, assessments,

presentations, and more on the Well-Being Tools and Resources page in Learn at

ACGME for programs seeking to develop or strengthen their own well-being initiatives.

There are many activities that programs can implement now to assess and support

physician well-being. These include the distribution and analysis of culture of safety

surveys, ensuring the availability of counseling services, and paying attention to the

safety of the entire health care team.

VI.C.1. The responsibility of the program, in partnership with the

Sponsoring Institution, to address well-being must include:

VI.C.1.a) efforts to enhance the meaning that each fellow finds in the

experience of being a physician, including protecting time

with patients, minimizing non-physician obligations,

providing administrative support, promoting progressive

autonomy and flexibility, and enhancing professional

relationships;

(Core)

VI.C.1.b) attention to scheduling, work intensity, and work

compression that impacts fellow well-being;

(Core)

VI.C.1.c) evaluating workplace safety data and addressing the safety of

fellows and faculty members;

(Core)

Background and Intent: This requirement emphasizes the responsibility shared by the

Sponsoring Institution and its programs to gather information and utilize systems that

monitor and enhance fellow and faculty member safety, including physical safety.

Issues to be addressed include, but are not limited to, monitoring of workplace injuries,

physical or emotional violence, vehicle collisions, and emotional well-being after

adverse events.

VI.C.1.d) policies and programs that encourage optimal fellow and

faculty member well-being; and,

(Core)

Background and Intent: Well-being includes having time away from work to engage with

family and friends, as well as to attend to personal needs and to one’s own health,

including adequate rest, healthy diet, and regular exercise.

Pediatric Otolaryngology

VI.C.1.d).(1) Fellows must be given the opportunity to attend

medical, mental health, and dental care appointments,

including those scheduled during their working hours.

(Core)

Background and Intent: The intent of this requirement is to ensure that fellows have the

opportunity to access medical and dental care, including mental health care, at times

that are appropriate to their individual circumstances. Fellows must be provided with

time away from the program as needed to access care, including appointments

scheduled during their working hours.

VI.C.1.e) attention to fellow and faculty member burnout, depression,

and substance use disorder. The program, in partnership with

its Sponsoring Institution, must educate faculty members and

fellows in identification of the symptoms of burnout,

depression, and substance use disorder, including means to

assist those who experience these conditions. Fellows and

faculty members must also be educated to recognize those

symptoms in themselves and how to seek appropriate care.

The program, in partnership with its Sponsoring Institution,

must:

(Core)

Background and Intent: Programs and Sponsoring Institutions are encouraged to review

materials in order to create systems for identification of burnout, depression, and

substance use disorder. Materials and more information are available in Learn at

ACGME (https://dl.acgme.org/pages/well-being-tools-resources).

VI.C.1.e).(1) encourage fellows and faculty members to alert the

program director or other designated personnel or

programs when they are concerned that another

fellow, resident, or faculty member may be displaying

signs of burnout, depression, a substance use

disorder, suicidal ideation, or potential for violence;

(Core)

Background and Intent: Individuals experiencing burnout, depression, a substance use

disorder, and/or suicidal ideation are often reluctant to reach out for help due to the

stigma associated with these conditions, and are concerned that seeking help may have

a negative impact on their career. Recognizing that physicians are at increased risk in

these areas, it is essential that fellows and faculty members are able to report their

concerns when another fellow or faculty member displays signs of any of these

conditions, so that the program director or other designated personnel, such as the

department chair, may assess the situation and intervene as necessary to facilitate

access to appropriate care. Fellows and faculty members must know which personnel,

in addition to the program director, have been designated with this responsibility; those

personnel and the program director should be familiar with the institution’s impaired

physician policy and any employee health, employee assistance, and/or wellness

programs within the institution. In cases of physician impairment, the program director

or designated personnel should follow the policies of their institution for reporting.

Pediatric Otolaryngology

VI.C.1.e).(2) provide access to appropriate tools for self-screening;

and,

(Core)

VI.C.1.e).(3) provide access to confidential, affordable mental

health assessment, counseling, and treatment,

including access to urgent and emergent care 24

hours a day, seven days a week.

(Core)

Background and Intent: The intent of this requirement is to ensure that fellows have

immediate access at all times to a mental health professional (psychiatrist,

psychologist, Licensed Clinical Social Worker, Primary Mental Health Nurse

Practitioner, or Licensed Professional Counselor) for urgent or emergent mental health

issues. In-person, telemedicine, or telephonic means may be utilized to satisfy this

requirement. Care in the Emergency Department may be necessary in some cases, but

not as the primary or sole means to meet the requirement.

The reference to affordable counseling is intended to require that financial cost not be a

barrier to obtaining care.

VI.C.2. There are circumstances in which fellows may be unable to attend

work, including but not limited to fatigue, illness, family

emergencies, and parental leave. Each program must allow an

appropriate length of absence for fellows unable to perform their

patient care responsibilities.

(Core)

VI.C.2.a) The program must have policies and procedures in place to

ensure coverage of patient care.

(Core)

VI.C.2.b) These policies must be implemented without fear of negative

consequences for the fellow who is or was unable to provide

the clinical work.

(Core)

Background and Intent: Fellows may need to extend their length of training depending

on length of absence and specialty board eligibility requirements. Teammates should

assist colleagues in need and equitably reintegrate them upon return.

VI.D. Fatigue Mitigation

VI.D.1. Programs must:

VI.D.1.a) educate all faculty members and fellows to recognize the

signs of fatigue and sleep deprivation;

(Core)

VI.D.1.b) educate all faculty members and fellows in alertness

management and fatigue mitigation processes; and,

(Core)

VI.D.1.c) encourage fellows to use fatigue mitigation processes to

manage the potential negative effects of fatigue on patient

care and learning.

(Detail)

Pediatric Otolaryngology

Background and Intent: Providing medical care to patients is physically and mentally

demanding. Night shifts, even for those who have had enough rest, cause fatigue.

Experiencing fatigue in a supervised environment during training prepares fellows for

managing fatigue in practice. It is expected that programs adopt fatigue mitigation

processes and ensure that there are no negative consequences and/or stigma for using

fatigue mitigation strategies.

This requirement emphasizes the importance of adequate rest before and after clinical

responsibilities. Strategies that may be used include, but are not limited to, strategic

napping; the judicious use of caffeine; availability of other caregivers;

time management

to maximize sleep off-duty; learning to recognize the signs of fatigue, and self-

monitoring performance and/or asking others to monitor performance; remaining active

to promote alertness; maintaining a healthy diet; using relaxation techniques to fall

asleep; maintaining a consistent sleep routine; exercising regularly; increasing sleep

time before and after call; and ensuring sufficient sleep recovery periods.

VI.D.2. Each program must ensure continuity of patient care, consistent

with the program’s policies and procedures referenced in VI.C.2–

VI.C.2.b), in the event that a fellow may be unable to perform their

patient care responsibilities due to excessive fatigue.

(Core)

VI.D.3. The program, in partnership with its Sponsoring Institution, must

ensure adequate sleep facilities and safe transportation options for

fellows who may be too fatigued to safely return home.

(Core)

VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care

VI.E.1. Clinical Responsibilities

The clinical responsibilities for each fellow must be based on PGY

level, patient safety, fellow ability, severity and complexity of patient

illness/condition, and available support services.

(Core)

VI.E.1.a) The workload associated with optimal clinical care of surgical

patients is a continuum from the moment of admission to the point

of discharge.

(Detail)

VI.E.1.b) During the fellowship education process, surgical teams should be

made up of attending surgeons, fellows, residents at various PGY

levels, medical students (when appropriate), and other health care

providers.

(Detail)

VI.E.1.c) The work of the caregiver team should be assigned to team

members based on each individual’s level of education,

experience, and competence.

(Detail)

Background and Intent: The changing clinical care environment of medicine has meant

that work compression due to high complexity has increased stress on fellows. Faculty

members and program directors need to make sure fellows function in an environment

Pediatric Otolaryngology

that has safe patient care and a sense of fellow well-being. Some Review Committees

have addressed this by setting limits on patient admissions, and it is an essential

responsibility of the program director to monitor fellow workload. Workload should be

distributed among the fellow team and interdisciplinary teams to minimize work

compression.

VI.E.2. Teamwork

Fellows must care for patients in an environment that maximizes

communication. This must include the opportunity to work as a

member of effective interprofessional teams that are appropriate to

the delivery of care in the subspecialty and larger health system.

(Core)

VI.E.2.a) Effective surgical practices entail the involvement of members with

a mix of complementary skills and attributes (physicians, nurses,

and other staff). Success requires both an unwavering mutual

respect for those skills and contributions, and a shared

commitment to the process of patient care.

(Detail)

VI.E.2.b) Fellows must collaborate with fellow surgical residents, and with

especially faculty, other physicians outside of their specialty, and

non-traditional health care providers to best formulate treatment

plans for an increasingly diverse patient population.

(Core)

VI.E.2.c) Fellows must assume personal responsibility to complete all tasks

to which they are assigned (or which they voluntarily assume) in a

timely fashion. These tasks must be completed within the hours

assigned, or, if that is not possible, fellows must learn and utilize

the established methods for handing off remaining tasks to

another member of the fellow team so that patient care is not

compromised.

(Core)

VI.E.2.d) Lines of authority should be defined by programs, and all fellows

must have a working knowledge of expected reporting

relationships to maximize quality care and patient safety.

(Core)

VI.E.3. Transitions of Care

VI.E.3.a) Programs must design clinical assignments to optimize

transitions in patient care, including their safety, frequency,

and structure.

(Core)

VI.E.3.b) Programs, in partnership with their Sponsoring Institutions,

must ensure and monitor effective, structured hand-over

processes to facilitate both continuity of care and patient

safety.

(Core)

VI.E.3.c) Programs must ensure that fellows are competent in

communicating with team members in the hand-over process.

(Outcome)

Pediatric Otolaryngology

VI.E.3.d) Programs and clinical sites must maintain and communicate

schedules of attending physicians and fellows currently

responsible for care.

(Core)

VI.E.3.e) Each program must ensure continuity of patient care,

consistent with the program’s policies and procedures

referenced in VI.C.2-VI.C.2.b), in the event that a fellow may

be unable to perform their patient care responsibilities due to

excessive fatigue or illness, or family emergency.

(Core)

VI.F. Clinical Experience and Education

Programs, in partnership with their Sponsoring Institutions, must design

an effective program structure that is configured to provide fellows with

educational and clinical experience opportunities, as well as reasonable

opportunities for rest and personal activities.

Background and Intent: In the new requirements, the terms “clinical experience and

education,” “clinical and educational work,” and “clinical and educational work hours”

replace the terms “duty hours,” “duty periods,” and “duty.” These changes have been

made in response to concerns that the previous use of the term “duty” in reference to

number of hours worked may have led some to conclude that fellows’ duty to “clock

out” on time superseded their duty to their patients.

VI.F.1. Maximum Hours of Clinical and Educational Work per Week

Clinical and educational work hours must be limited to no more than

80 hours per week, averaged over a four-week period, inclusive of all

in-house clinical and educational activities, clinical work done from

home, and all moonlighting.

(Core)

Background and Intent: Programs and fellows have a shared responsibility to ensure

that the 80-hour maximum weekly limit is not exceeded. While the requirement has been

written with the intent of allowing fellows to remain beyond their scheduled work

periods to care for a patient or participate in an educational activity, these additional

hours must be accounted for in the allocated 80 hours when averaged over four weeks.

Scheduling

While the ACGME acknowledges that, on rare occasions, a fellow may work in excess of

80 hours in a given week, all programs and fellows utilizing this flexibility will be

required to adhere to the 80-hour maximum weekly limit when averaged over a four-

week period. Programs that regularly schedule fellows to work 80 hours per week and

still permit fellows to remain beyond their scheduled work period are likely to exceed

the 80-hour maximum, which would not be in substantial compliance with the

requirement. These programs should adjust schedules so that fellows are scheduled to

work fewer than 80 hours per week,

which would allow fellows to remain beyond their

scheduled work period when needed without violating the 80-hour requirement.

Programs may wish to consider using night float and/or making adjustments to the

frequency of in-house call to ensure compliance with the 80-hour maximum weekly limit.

Pediatric Otolaryngology

Oversight

With increased flexibility introduced into the Requirements, programs permitting this

flexibility will need to account for the potential for fellows to remain beyond their

assigned work periods when developing schedules, to avoid exceeding the 80-hour

maximum weekly limit, averaged over four weeks. The ACGME Review Committees will

strictly monitor and enforce compliance with the 80-hour requirement. Where violations

of the 80-hour requirement are identified, programs will be subject to citation and at risk

for an adverse accreditation action.

Work from Home

While the requirement specifies that clinical work done from home must be counted

toward the 80-hour maximum weekly limit, the expectation remains that scheduling be

structured so that fellows are able to complete most work on site during scheduled

clinical work hours without requiring them to take work home. The new requirements

acknowledge the changing landscape of medicine, including electronic health records,

and the resulting increase in the amount of work fellows choose to do from home. The

requirement provides flexibility for fellows to do this while ensuring that the time spent

by fellows completing clinical work from home is accomplished within the 80-hour

weekly maximum. Types of work from home that must be counted include using an

electronic health record and taking calls from home. Reading done in preparation for the

following day’s cases, studying, and research done from home do not count toward the

80 hours. Fellow decisions to leave the hospital before their clinical work has been

completed and to finish that work later from home should be made in consultation with

the fellow’s supervisor. In such circumstances, fellows should be mindful of their

professional responsibility to complete work in a timely manner and to maintain patient

confidentiality.

During the public comment period many individuals raised questions and concerns

related to this change. Some questioned whether minute by minute tracking would be

required; in other words, if a fellow

spends three minutes on a phone call and then a few

hours later spends two minutes on another call, will the fellow need to report that time.

Others raised concerns related to the ability of programs and institutions to verify the

accuracy of the information reported by fellows. The new requirements are not an

attempt to micromanage this process. Fellows are to track the time they spend on

clinical work from home and to report that time to the program. Decisions regarding

whether to report infrequent phone calls of very short duration will be left to the

individual fellow. Programs will need to factor in time fellows are spending on clinical

work at home when schedules are developed to ensure that fellows are not working in

excess of 80 hours per week, averaged over four weeks. There is no requirement that

programs assume responsibility for documenting this time. Rather, the program’s

responsibility is ensuring that fellows report their time from home and that schedules

are structured to ensure that fellows are not working in excess of 80 hours per week,

averaged over four weeks.

VI.F.2. Mandatory Time Free of Clinical Work and Education

VI.F.2.a) The program must design an effective program structure that

is configured to provide fellows with educational

opportunities, as well as reasonable opportunities for rest

and personal well-being.

(Core)

Pediatric Otolaryngology

VI.F.2.b) Fellows should have eight hours off between scheduled

clinical work and education periods.

(Detail)

VI.F.2.b).(1) There may be circumstances when fellows choose to

stay to care for their patients or return to the hospital

with fewer than eight hours free of clinical experience

and education. This must occur within the context of

the 80-hour and the one-day-off-in-seven

requirements.

(Detail)

Background and Intent: While it is expected that fellow schedules will be structured to

ensure that fellows are provided with a minimum of eight hours off between scheduled

work periods, it is recognized that fellows may choose to remain beyond their

scheduled time, or return to the clinical site during this time-off period, to care for a

patient. The requirement preserves the flexibility for fellows to make those choices. It is

also noted that the 80-hour weekly limit (averaged over four weeks) is a deterrent for

scheduling fewer than eight hours off between clinical and education work periods,

as it

would be difficult for a program to design a schedule that provides fewer than eight

hours off without violating the 80-hour rule.

VI.F.2.c) Fellows must have at least 14 hours free of clinical work and

education after 24 hours of in-house call.

(Core)

Background and Intent: Fellows have a responsibility to return to work rested, and thus

are expected to use this time away from work to get adequate rest. In support of this

goal, fellows are encouraged to prioritize sleep over other discretionary activities.

VI.F.2.d) Fellows must be scheduled for a minimum of one day in

seven free of clinical work and required education (when

averaged over four weeks). At-home call cannot be assigned

on these free days.

(Core)

Background and Intent: The requirement provides flexibility for programs to distribute

days off in a manner that meets program and fellow needs. It is strongly recommended

that fellows’ preference regarding how their days off are distributed be considered as

schedules are developed. It is desirable that days off be distributed throughout the

month, but some fellows may prefer to group their days off to have a “golden weekend,”

meaning a consecutive Saturday and Sunday free from work. The requirement for one

free day in seven should not be interpreted as precluding a golden weekend. Where

feasible, schedules may be designed to provide fellows with a weekend, or two

consecutive days, free of work. The applicable Review Committee will evaluate the

number of consecutive days of work and determine whether they meet educational

objectives. Programs are encouraged to distribute days off in a fashion that optimizes

fellow well-being, and educational and personal goals. It is noted that a day off is

defined in the ACGME Glossary of Terms as “one (1) continuous 24-hour period free

from all administrative, clinical, and educational activities.”

VI.F.3. Maximum Clinical Work and Education Period Length

Pediatric Otolaryngology

VI.F.3.a) Clinical and educational work periods for fellows must not

exceed 24 hours of continuous scheduled clinical

assignments.

(Core)

VI.F.3.a).(1) Up to four hours of additional time may be used for

activities related to patient safety, such as providing

effective transitions of care, and/or fellow education.

(Core)

VI.F.3.a).(1).(a) Additional patient care responsibilities must not

be assigned to a fellow during this time.

(Core)

Background and Intent: The additional time referenced in VI.F.3.a).(1) should not be

used for the care of new patients. It is essential that the fellow continue to function as a

member of the team in an environment where other members of the team can assess

fellow fatigue, and that supervision for post-call fellows is provided. This 24 hours and

up to an additional four hours must occur within the context of 80-hour weekly limit,

averaged over four weeks.

VI.F.4. Clinical and Educational Work Hour Exceptions

VI.F.4.a) In rare circumstances, after handing off all other

responsibilities, a fellow, on their own initiative, may elect to

remain or return to the clinical site in the following

circumstances:

VI.F.4.a).(1) to continue to provide care to a single severely ill or

unstable patient;

(Detail)

VI.F.4.a).(2) humanistic attention to the needs of a patient or

family; or,

(Detail)

VI.F.4.a).(3) to attend unique educational events.

(Detail)

VI.F.4.b) These additional hours of care or education will be counted

toward the 80-hour weekly limit.

(Detail)

Background and Intent: This requirement is intended to provide fellows with some

control over their schedules by providing the flexibility to voluntarily remain beyond the

scheduled responsibilities under the circumstances described above. It is important to

note that a fellow may remain to attend a conference, or return for a conference later in

the day, only if the decision is made voluntarily. Fellows must not be required to stay.

Programs allowing fellows to remain or return beyond the scheduled work and clinical

education period must ensure that the decision to remain is initiated by the fellow and

that fellows are not coerced. This additional time must be counted toward the 80-hour

maximum weekly limit.

VI.F.4.c) A Review Committee may grant rotation-specific exceptions

for up to 10 percent or a maximum of 88 clinical and

Pediatric Otolaryngology

educational work hours to individual programs based on a

sound educational rationale.

The Review Committee for Otolaryngology – Head and Neck

Surgery will not consider requests for exceptions to the 80-hour

limit to the fellows’ work week.

VI.F.5. Moonlighting

VI.F.5.a) Moonlighting must not interfere with the ability of the fellow

to achieve the goals and objectives of the educational

program, and must not interfere with the fellow’s fitness for

work nor compromise patient safety.

(Core)

VI.F.5.b) Time spent by fellows in internal and external moonlighting

(as defined in the ACGME Glossary of Terms) must be

counted toward the 80-hour maximum weekly limit.

(Core)

Background and Intent: For additional clarification of the expectations related to

moonlighting, please refer to the Common Program Requirement FAQs (available at

http://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements).

VI.F.6. In-House Night Float

Night float must occur within the context of the 80-hour and one-

day-off-in-seven requirements.

(Core)

VI.F.6.a) The Review Committee for Otolaryngology – Head and Neck

Surgery will not permit night float.

Background and Intent: The requirement for no more than six consecutive nights of

night float was removed to provide programs with increased flexibility in scheduling.

VI.F.7. Maximum In-House On-Call Frequency

Fellows must be scheduled for in-house call no more frequently than

every third night (when averaged over a four-week period).

(Core)

VI.F.8. At-Home Call

VI.F.8.a) Time spent on patient care activities by fellows on at-home

call must count toward the 80-hour maximum weekly limit.

The frequency of at-home call is not subject to the every-

third-night limitation, but must satisfy the requirement for one

day in seven free of clinical work and education, when

averaged over four weeks.

(Core)

VI.F.8.a).(1) At-home call must not be so frequent or taxing as to

preclude rest or reasonable personal time for each

fellow.

(Core)

Pediatric Otolaryngology

VI.F.8.b) Fellows are permitted to return to the hospital while on at-

home call to provide direct care for new or established

patients. These hours of inpatient patient care must be

included in the 80-hour maximum weekly limit.

(Detail)

Background and Intent: This requirement has been modified to specify that clinical work

done from home when a fellow is taking at-home call must count toward the 80-hour

maximum weekly limit. This change acknowledges the often significant amount of time

fellows devote to clinical activities when taking at-home call, and ensures that taking at-

home call does not result in fellows routinely working more than 80 hours per week. At-

home call activities that must be counted include responding to phone calls and other

forms of communication, as well as documentation, such as entering notes in an

electronic health record. Activities such as reading about the next day’s case, studying,

or research activities do not count toward the 80-hour weekly limit.

In their evaluation of fellowship programs, Review Committees will look at the overall

impact of at-home call on fellow rest and personal time.

***

*Core Requirements: Statements that define structure, resource, or process elements

essential to every graduate medical educational program.

†

Detail Requirements: Statements that describe a specific structure, resource, or process, for

achieving compliance with a Core Requirement. Programs and sponsoring institutions in

substantial compliance with the Outcome Requirements may utilize alternative or innovative

approaches to meet Core Requirements.

‡

Outcome Requirements: Statements that specify expected measurable or observable

attributes (knowledge, abilities, skills, or attitudes) of residents or fellows at key stages of their

graduate medical education.

Osteopathic Recognition

For programs with or applying for Osteopathic Recognition, the Osteopathic Recognition

Requirements also apply (www.acgme.org/OsteopathicRecognition).