FCCM Mentorship Program -Intake form

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Active member of the Society of Critical Care Medicine at the Professional or Select level for two consecutive years immediately prior to applicationLicensed (if license available) to practice in a healthcare categoryHave a certificate of special competence in critical care or its equivalency based on your profession for the past two yearsDevoted at least 50% of time to critical care in practice, research, administration, or teaching for at least two yearsAt least five years post-training involvement in the field of critical careCurrent member of the SCCM Socal Chapter

The following areas are heavily reviewed by the FCCM Credentials Committee. Your current achievements in these areas will help your mentor determine initial feedback. Please utilize bullet points to summarize your contributions in these areas.

COLLABORATIVE MULTIPROFESSIONAL PRACTICE

This is integral to advancing critical care and aligns with the core principles of the Fellow of the American College of Critical Care Medicine (FCCM) designation. This approach fosters teamwork across disciplines to enhance patient safety, improve clinical outcomes, and drive innovation. By actively engaging in multidisciplinary initiatives, FCCM candidates demonstrate leadership, and system-wide impact.

Examples include:

Sepsis Early Recognition & Management Program
- A hospital-wide sepsis initiative involves pharmacists, ICU nurses, emergency medicine physicians, and rapid response teams working together to implement early goal-directed therapy, standardized sepsis bundles, and rapid antibiotic administration protocols.
ICU Delirium Program
- The implementation of the ABCDEF bundle (Assess, Both spontaneous breathing and awakening trials, Choice of sedation, Delirium monitoring, Early mobility, and Family engagement) requires a multiprofessional approach involving pharmacists, rehabilitation therapists, social workers, intensivists, and bedside nurses.
Interprofessional Simulation

Please enlist which of the above you may have contributed to with a narrative*

PROGRAM DEVELOPMENT
Active participation in the development of or personal improvements to home institution preexisting programs or systems related to any aspect of critical care, including clinical, educational, research and administrative programs.

Examples of such activities include:
• Implementation of the critical care intensivist model to an ICU
• Development or organization of local, regional, or national critical care educational symposium
• Development of regional/state/national programs related to clinical management of the critically ill
• Development of critical care training programs, such as critical care fellowship programs
• Development of ICU-related research programs
• Development of novel local educational/clinical programs if emulated by other organizations
• Development of quality improvement activities and evidence of improvement of patient care

Please enlist which of the above you may have contributed to with a narrative*

SCHOLARLY ACTIVITIES RELATED TO CRITICAL CARE
This includes educational activities, research (in areas related to critical care), and publications. Educational accomplishments may include activities in critical care education directed toward physicians, nurses, students, allied health professionals and/or the lay public.

Examples include:
• Editorial Review Activities in high impact journals
• Lectures on a regional/national/international level
• Original scientific peer-reviewed publications
• Multiple peer-reviewed or non-peer-reviewed educational publications
• SCCM or other national critical care society awards
• High quality education award demonstrating excellence in teaching
• Grants from local/regional/state/national granting agencies
• Development of web-based critical care educational programs
• Development of critical care regional/state/national educational symposium

Please enlist which of the above you may have contributed to with a narrative*

STATE/NATIONAL/INTERNATIONAL ENGAGEMENT
This area includes participation and leadership in organizations devoted to education, practice, administration, and/or research in collaborative multiprofessional critical care. Involvement in the SCCM is desirable but not required. As part of their regular job, committee or task force work within the applicant’s hospital or organization does NOT meet this requirement.

Examples include (does not include all possible categories):
• Committee service leadership
• Elected or appointed positions
• Verifiable active membership in task forces

Please enlist which of the above you may have contributed to with a narrative*

Please upload your CV*