Initial Accreditation Application Form

Initial Accreditation Application Form
PLEASE READ THIS SECTION BEFORE YOU BEGIN YOUR APPLICATION

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Statement of Purpose
The Neurohospitalist Society fellowship accreditation committee reviews and accredits neurohospitalist fellowship programs to ensure a standard level of educational quality and to promote training opportunities for neurohospitalists.

Overview of accreditation requirements
Accreditation will depend upon the program demonstrating institutional infrastructure capable of supporting the fellowship, in addition to providing a curriculum that meets key training requirements for neurohospitalist practice.

INITIAL APPLICATION FEE: $2000

ANNUAL RENEWAL FEE: $2000

Please review the institutional and core program requirements before submitting your application.
Institutional requirements
Core program requirements

For more information, please contact the Accreditation Committee at accreditation@neurohospitalistsociety.org.
Primary contact information:

First NameLast NameDegree(s)
Email:
example@example.com
Institution:
Institutional Requirements
Sponsoring Institution: Neurohospitalist fellowships must be overseen by a Sponsoring Institution that maintains institutional accreditation with the Accreditation Council for Graduate Medical Education (ACGME) or the Canadian Excellence in Residency Accreditation (CanERA). Programs seeking accreditation must provide a letter, signed by the Designated Institutional Official or representative, stating the Sponsoring Institution’s ACGME or CanERA accreditation is current, and that the Graduate Medical Education Committee (GMEC) or Postgraduate Education Committee has knowledge of the Neurohospitalist fellowship and has approved its application for accreditation as relevant to the Sponsoring Institution.
Name of sponsoring institution:
Upload letter, signed by the Designated Institutional Official or representative, stating the Sponsoring Institution’s ACGME or CanERA accreditation is current, and that the GMEC or Postgraduate Education Committee has knowledge of the neurohospitalist fellowship and has approved its application for sponsorship as relevant to the Sponsoring Institution.

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Upload a copy of the professional liability insurance policy provided by the sponsoring institution for its clinical fellows. The insurance policy must be occurrence based or provide extended reporting endorsement coverage.

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Sponsoring Department: The sponsoring institution must have a department that takes primary responsibility for the neurohospitalist fellowship. The fellowship director must be a member of this department.
Department that takes primary responsibility for the neurohospitalist fellowship:
Is the neurohospitalist fellowship director a member of this department?

YesNo
Stop. The neurohospitalist fellowship director must be a member of the department taking primary responsibility for the fellowship.

Specify the % of Full Time Equivalent (%FTE) provided to the fellowship director for supervision of the program:
Specify the % of Full Time Equivalent (%FTE) provided to the associate fellowship director, if applicable, for supervision of the program:
Specify the % of Full Time Equivalent (%FTE) provided to the fellowship coordinator for administration of the program. If the fellowship coordinator administers multiple programs, estimate the % of time spent on administration of the neurohospitalist fellowship using the following formula: (%FTE for training program administration)/(Total number of trainees in all programs administered)
Specify the source of funding for the neurohospitalist fellowship position (e.g., health system, department, etc.). If there are multiple sources of funding please list all of them.
Upload letter, signed by the department chair, stating their support of the neurohospitalist fellowship program, stating their support of the fellowship director, and listing the resources provided to administer the program (including but not limited to %FTE support for Fellowship Director, %FTE support for Fellowship Coordinator, and source of funding for Fellowship position).

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Participating Sites: Neurohospitalist fellowships may take place at any hospital affiliated with the sponsoring institution. Each participating site must provide documentation of an affiliation agreement with the sponsoring institution that grants the participating site authority to provide an educational experience for trainees under the oversight of the sponsoring institution.

List each participating site where clinical experiences take place during the neurohospitalist fellowship:
Site 1:
Upload affiliation agreement between the participating site and sponsoring institution.

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Upload letter, signed by department chair or medical director of the service where the clinical experience will take place, that describes the specific clinical experience, specifies its duration, and states that the participating site is capable of providing the desired clinical training experience and the necessary level of supervision.

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Site 2 (if applicable)
Site 2:
Upload affiliation agreement between the participating site and sponsoring institution.

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Upload letter, signed by department chair or medical director of the service where the clinical experience will take place, that describes the specific clinical experience, specifies its duration, and states that the participating site is capable of providing the desired clinical training experience and the necessary level of supervision.

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Site 3 (if applicable)
Site 3:
Upload affiliation agreement between the participating site and sponsoring institution.

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Upload letter, signed by department chair or medical director of the service where the clinical experience will take place, that describes the specific clinical experience, specifies its duration, and states that the participating site is capable of providing the desired clinical training experience and the necessary level of supervision.

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Site 4 (if applicable)
Site 4:
Upload affiliation agreement between the participating site and sponsoring institution.

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Upload letter, signed by department chair or medical director of the service where the clinical experience will take place, that describes the specific clinical experience, specifies its duration, and states that the participating site is capable of providing the desired clinical training experience and the necessary level of supervision.

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Site 5 (if applicable)
Site 5:
Upload affiliation agreement between the participating site and sponsoring institution.

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Upload letter, signed by department chair or medical director of the service where the clinical experience will take place, that describes the specific clinical experience, specifies its duration, and states that the participating site is capable of providing the desired clinical training experience and the necessary level of supervision.

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If you have more than 5 sites, please contact the Accreditation Committee at accreditation@neurohospitalistsociety.org.

Core Program Requirements

An accredited program must have at least three faculty members, including the fellowship director.
Fellowship Director:

First NameLast NameDegree(s)
Email:
example@example.com
Specialty:
Current Board Certification:

American Board of Psychiatry and NeurologyRoyal College of Physicians and Surgeons of CanadaAmerican Osteopathic Board of Neurology and Psychiatry
Medical license state/province:
Associate Fellowship Director:

First NameLast NameDegree(s)
Email
example@example.com
Specialty:
Current Board Certification:

American Board of Psychiatry and NeurologyRoyal College of Physicians and Surgeons of CanadaAmerican Osteopathic Board of Neurology and Psychiatry
Medical license state/province:
Fellowship Coordinator:

First NameLast NameDegree(s)
Email:
example@example.com
Faculty:

Application and appointment process:
Check here to certify:

Eligible applicants to this neurohospitalist fellowship must have graduated from an ACGME-accredited or CanERA-accredited adult or pediatric neurology residency program in the United States or Canada. Applicants must be eligible to obtain a license in the State or Province where the fellowship will take place, and must be eligible to live and work in the United States or Canada during the fellowship training period. When an applicant is offered a fellowship position, they are informed of the following: salary and other financial support based on post-graduate year level, vacation, paid sick leave, parental leave, professional liability insurance, and insurance benefits including health, dental, vision, long-term and short-term disability. When the program and applicant mutually agree on a fellowship position, the applicant must be provided with a contract that contains the following: general responsibilities; all items listed in the preceding sentence, and requirements for program completion.
Length of the program, size of program, curriculum, evaluation, and graduation requirements:
Specify the length of the neurohospitalist fellowship in months:
How many months of the fellowship are spent on core clinical rotations?
Learning goals and objectives: List the fellowship’s learning goals and objectives. The program’s goals and objectives must address each of the six core competencies defined by the ACGME (patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, systems-based practice) and the Neurohospitalist core competencies as defined by the Neurohospitalist Society (Neurohospitalist core competencies). You may enter the goals and objectives here or upload below:
Upload goals and objectives:

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Check here to certify that at the outset of the program, the fellowship director provides trainees with the program’s goals and objectives.
Clinical Education Experiences
Provide a list of clinical educational experiences (i.e., rotations). List rotations, the site at which each occurs, and the number of months the fellow spends in each experience. Core clinical rotations should be specified as such. At least six months must be spent in core clinical rotations. A sample list is provided here:

*Learning goals and objectives should be clearly numbered on the document submitted under “Learning goals and objectives." These numbers can then be used to identify goals and objectives in the list of clinical educational experiences.
Upload your fellowship’s list of clinical educational experiences here:

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For fellowships planning to train more than 1 fellow annually: Explain the educational rationale for training additional fellows. This must include a statement that the educational environment can accommodate additional learners without compromising experience of existing learners. Enter N/A if only training 1 fellow per year.
For fellowships planning to train more than 1 fellow annually:

Provide a sample schedule that illustrates how the fellowship plans to accommodate multiple learners. A sample schedule is provided here. Note, in this example both learners are never on the same rotation at the same time, but that does not preclude this option if a rotation can provide a robust learning experience for two fellows simultaneously.
Upload the fellowship sample schedule illustrating multiple learner accommodation here. Leave blank if only training 1 fellow per year.

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Didactics
Upload a list of fellowship-specific didactics provided to trainees in your program during their fellowship. Each didactic must be linked to learning goals and objectives listed using the same method used in the list of clinical educational experiences.

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Fellow evaluation
Describe the process by which fellows are evaluated. Include the frequency of evaluation (including both the frequency with which the fellow is evaluated and the frequency the evaluations are discussed with the fellow), who provides evaluation data, and the content of evaluations. Please review the core program requirements to ensure the process meets the minimum standards. You can enter here or upload below:
Process by which fellows are evaluated:

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Upload a template of the final evaluation that is provided to fellows upon graduation, which incorporates feedback from all program faculty and serves as a final summary evaluation and documentation the fellow has met the program’s graduation requirements and can practice independently. Certification of completion must be based on the fellow’s achieving entrustment for independent Neurohospitalist practice in the six core competencies defined by the ACGME and the Neurohospitalist core competencies. You can enter here or upload below:
Template of final evaluation:

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Describe the process by which faculty in the fellowship program are evaluated. Include the frequency of evaluation and a description of the content of faculty evaluations. Describe the systems in place for fellows to provide written feedback about program faculty, and the system by which fellows can raise concerns and grievances, including those of inadequate supervision and professionalism, confidentially and without concern for retaliation. Please review the core program requirements to ensure the process meets the minimum standards. You can enter here or upload below:
Process by which faculty in the fellowship program are evaluated:

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Describe the process by which the program is evaluated. Include a list of members of the program evaluation committee and describe the frequency of program evaluation. Discuss how the program evaluation addresses the curriculum, outcomes (including fellows’ achievement of educational objectives, fellows’ careers, and quality and safety of patient care), written evaluations by fellows of both the program and faculty, faculty and fellow well-being, recruitment and retention, diversity, and scholarly work such as engagement in patient safety, quality improvement, and medical education. Please review the core program requirements to ensure the process meets the minimum standards. You can enter here or upload below:
Process by which the program is evaluated:

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Initial Accreditation Application Form

Institutional Requirements

Core Program Requirements

Application and appointment process:

Length of the program, size of program, curriculum, evaluation, and graduation requirements:

Clinical Education Experiences

Didactics

Fellow evaluation

Policies

The Learning and Work Environment: