141_CardiovascularDisease_RC

Cardiovascular Disease for Review and Comment

ACGME Program Requirements for

Graduate Medical Education

in Cardiovascular Disease

Definitions

For more information, see the ACGME Glossary of Terms.

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).

Revision Information

Proposed major revision; posted for review and comment January 12, 2023

Updated to include revised Common Program Requirements, effective July 1, 2023

Cardiovascular Disease for Review and Comment

Contents

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

Int.A. Definition of Graduate Medical Education .............................................................. 3

Int.B. Definition of Subspecialty ........................................................................................ 4

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

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

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

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

I.C. Workforce Recruitment and Retention .................................................................... 6

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

I.E. Other Learners and Health Care Personnel .......................................................... 10

II. Personnel ............................................................................................................................. 10

II.A. Program Director ..................................................................................................... 10

II.B. Faculty ...................................................................................................................... 16

II.C. Program Coordinator .............................................................................................. 20

II.D. Other Program Personnel ....................................................................................... 22

III. Fellow Appointments .......................................................................................................... 22

III.A. Eligibility Criteria ..................................................................................................... 22

III.B. Fellow Complement ................................................................................................ 24

III.C. Fellow Transfers ...................................................................................................... 24

IV. Educational Program .......................................................................................................... 24

IV.A. Educational Components ....................................................................................... 25

IV.B. ACGME Competencies ........................................................................................... 25

IV.C. Curriculum Organization and Fellow Experiences .............................................. 31

IV.D. Scholarship .............................................................................................................. 35

V. Evaluation ............................................................................................................................ 37

V.A. Fellow Evaluation .................................................................................................... 37

V.B. Faculty Evaluation ................................................................................................... 41

V.C. Program Evaluation and Improvement ................................................................. 42

VI. The Learning and Working Environment .......................................................................... 45

VI.A. Patient Safety, Quality Improvement, Supervision, and Accountability ............ 45

VI.B. Professionalism ....................................................................................................... 49

VI.C. Well-Being ................................................................................................................ 50

VI.D. Fatigue Mitigation .................................................................................................... 52

VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care ........................... 53

VI.F. Clinical Experience and Education ........................................................................ 54

Cardiovascular Disease for Review and Comment

ACGME Program Requirements for Graduate Medical Education

in Cardiovascular Disease

Common Program Requirements (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 (Fellowship) are intended to explain the

differences.

Introduction

Int.A. Definition of Graduate Medical Education

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, and the importance of inclusive and

psychologically safe learning environments.

Fellows who have completed residency are able to practice autonomously

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

distinguish them from physicians entering residency. 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, cultural sensitivity, 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.

Cardiovascular Disease for Review and Comment

Int.B. Definition of Subspecialty

Cardiovascular disease is the internal medicine subspecialty that focuses on

prevention, diagnosis, and management of disorders of the cardiovascular

system.

Int.C. Length of Educational Program

The educational program in cardiovascular disease must be 36 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, federally qualified health center, 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) A cardiovascular disease fellowship as an integral part of an

ACGME-accredited program in internal medicine. The Sponsoring

Institution must ensure that there is a reporting collaborative

relationship with the program director of the internal medicine

residency program to ensure compliance with the ACGME

accreditation requirements.

(Core)

Cardiovascular Disease for Review and Comment

Subspecialty-Specific Background and Intent: All the subspecialties of internal medicine are

considered dependent subspecialties and, with few exceptions, every subspecialty program is

required to function as an integral part of an internal medicine residency program. Requiring

collaborative meetings between the internal medicine and subspecialty program directors

reinforces the dependent relationship between the programs. It also facilitates the

dissemination of best practices for education and well-being, provides the opportunity to share

expertise across programs, and promotes faculty and program development. One way to

achieve this is through regular meetings between the program directors.

I.B.1.b) The Sponsoring Institution must establish the cardiovascular

disease fellowship within a department of internal medicine or an

administrative unit whose primary mission is the advancement of

internal medicine subspecialty education and patient care.

(Detail)

I.B.1.c) The Sponsoring Institution must ensure that there is a reporting

relationship with the program director of the internal medicine

residency program to ensure compliance with the ACGME

accreditation requirements.

(Core)

[Combined with I.B.1.a)]

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.

Cardiovascular Disease for Review and Comment

Suggested elements to be considered in PLAs will be found in the 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.B.5. The program should ensure that fellows are not unduly burdened by

required rotations at geographically distant sites.

(Core)

Subspecialty-Specific Background and Intent: The Review Committee for Internal Medicine

considers a participating site to be geographically distant if it requires extended travel

(consistently more than one hour each way) or if the distance between the site and the primary

clinical site exceeds 60 miles. The Review Committee acknowledges that some programs may

need to use geographically distant sites to provide fellows with specific required educational

experiences. However, required rotations to multiple geographically distant sites can be

disruptive to fellow well-being, adversely impact faculty member/fellow team interactions and

cohesion, and diminish participation in educational experiences (e.g., conference

attendance/participation, scholarly activity, and continuity of care). Providing travel and/or

housing reimbursement for fellows rotating at a remote site is one way the program can offset

the potential adverse impact on fellow well-being.

I.C. Workforce Recruitment and Retention

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),

fellows, faculty members, senior administrative graduate medical education

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 individuals

underrepresented in medicine and medical leadership in accordance with the

Sponsoring Institution’s mission and aims.

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) Space and Equipment

Cardiovascular Disease for Review and Comment

There must be space and equipment for the program, including

meeting rooms, examination rooms, computers, visual and other

educational aids, and work/study space.

(Core)

I.D.1.b) Facilities

I.D.1.b).(1) Inpatient and outpatient systems must be in place to

prevent fellows from performing routine clerical functions,

such as scheduling tests and appointments, and retrieving

records and letters.

(Detail)

I.D.1.b).(2) The sponsoring institution must provide the broad range of

facilities and clinical support services required to provide

comprehensive care of adult patients.

(Core)

I.D.1.b).(3) Fellows must have access to a lounge facility during

assigned duty hours.

(Detail)

I.D.1.b).(4) When fellows are in the hospital, assigned night duty, or

called in from home, they must be provided with a secure

space for their belongings.

(Detail)

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

I.D.1.c).(1) ensure the program has adequate space available,

including meeting rooms, classrooms, examination rooms,

computers, visual and other educational aids, and office

space;

(Core)

I.D.1.c).(2) ensure that appropriate in-person or remote/virtual

consultations, including those done using

telecommunication technology, are available in settings in

which fellows work;

(Core)

I.D.1.c).(3) provide access to an electronic health record; and,

(Core);

[Edited and moved from I.D.1.f)]

Subspecialty-Specific Background and Intent: An electronic health record (EHR) can include

electronic notes, orders, and lab reporting. Such a system also facilitates data reporting

regarding the care provided to a patient or a panel of patients. It may also include systems for

enhancing the quality and safety of patient care. An EHR does not have to be present at all

participating sites and does not have to include every element of patient care information.

However, a system that simply reports laboratory or imaging results does not meet the

definition of an EHR.

I.D.1.c).(4) provide fellows with access to training using simulation to

support fellow education and patient safety.

(Core)

[Edited

and moved from IV.C.4.]

Subspecialty-Specific Background and Intent: The Review Committee does not expect each

Cardiovascular Disease for Review and Comment

program to own a simulator or to have a simulation center. “Simulation” is used broadly to

mean learning about patient care in settings that do not include actual patients. This could

include objective structured clinical examinations (OSCEs), standardized patients, patient

simulators, or electronic simulation of resuscitation, procedures, and other clinical scenarios.

I.D.1.d) Laboratory Services

Each of The following must be present at the primary clinical site:

I.D.1.d).(1) cardiac catheterization laboratories, including cardiac

hemodynamics and those needed to support the full range

of interventional cardiology;

(Core)

Subspecialty-Specific Background and Intent: The Review Committee has specified the

availability of diagnostic testing and procedural laboratories (e.g., catheterization,

electrophysiology, echocardiography, stress or provocative exercise testing, and imaging) to

ensure the adequate volume and diversity of pathophysiologic conditions are able to be

evaluated. The Review Committee strongly encourages the use of at least two catheterization

laboratories.

I.D.1.d).(2) cardiac radiology laboratory imaging, including magnetic

resonance imaging (MRI) and computed tomography (CT);

(Detail)

I.D.1.d).(3) cardiac radionuclide laboratories;

(Detail)

I.D.1.d).(4) echocardiography laboratories, including Doppler and

transesophageal echocardiography;

(Core)

I.D.1.d).(5) electrocardiogram (ECG), ambulatory ECG, and exercise

testing laboratories;

(Core)

I.D.1.d).(6) electrophysiology laboratories; and,

(Core)

I.D.1.d).(7) non-invasive vascular laboratory; and,

(Core)

I.D.1.e) Other Support Services

The following must be present at the primary clinical site:

I.D.1.e).(1) A cardiac intensive care unit must be present at the primary

clinical site.; and,

(Core)

Subspecialty-Specific Background and Intent: Ideally, the CICU will be a dedicated and

geographically distinct unit with dedicated and distinct nursing staff and allied health personnel

and ABIM or AOBIM certified cardiologist as director. A CICU embedded within a larger

medical or surgical intensive care unit would also be acceptable if it is organized and functions

as separate unit, there is an adequate volume and case-mix of patients, and there is

appropriate staffing and leadership.

Cardiovascular Disease for Review and Comment

I.D.1.e).(2) An active cardiac surgery program should be present at the

primary clinical site or at a participating site.

(Core)

Subspecialty-Specific Background and Intent: The presence of an active cardiac surgery

program provides opportunities for fellows to care for patients who are being evaluated for and

recovering from open heart surgery and conditions requiring surgical guidance. Providing

access to this patient resource ensures the breadth, complexity, and acuity of cases are

available. If programs do not have an active cardiac surgery program at the primary clinical

site, they may establish a rotation to a participating site with an active cardiac surgery

program.

I.D.1.f) Medical Records [Edited and moved to I.D.1.c).(3)]

Access to an electronic health record should be provided. In the

absence of an existing electronic health record, institutions must

demonstrate institutional commitment to its development, and

progress towards its implementation.

(Core)

I.D.1.g) Patient Population

I.D.1.h) The program must provide fellows with a patient population

representative of both the broad spectrum of clinical disorders and

medical conditions managed by subspecialists in this area, and of

the community being served by the program.

(Core)

I.D.1.h).(1) The patient population must have a variety of clinical

problems and stages of cardiovascular diseases.

(Core)

I.D.1.h).(2) There must be patients of each gender, with a broad age

range, including geriatric patients.

(Core)

I.D.1.h).(3) A sufficient number of patients must be available to enable

each fellow to achieve the required educational outcomes.

(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:

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;

(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

Cardiovascular Disease for Review and Comment

should be available when fellows are required to be in the hospital 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.c).(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.E. Other Learners and Health Care Personnel

The presence of other learners and other health care personnel, including

but not limited to residents from other programs, subspecialty fellows, and

advanced practice providers, must not negatively impact 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.

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)

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

Committee (GMEC) must approve a change in program

director and must verify the program director’s licensure and

clinical appointment.

(Core)

II.A.1.a).(1) 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.

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 the

dedicated time and support specified below for administration of

the program:

(Core)

Number of Approved

Fellow Positions

Minimum Support

Required (FTE)

7-9

.25

10-12

13-15

.35

16-18

19-21

.45

>21

II.A.2.b) Programs must appoint at least one of the subspecialty-certified

core faculty members to be associate program director(s), and the

associate program directors(s) must be provided with support

equal to a dedicated minimum time for administration of the

program as follows:

(Core)

Number of Approved

Fellow Positions

Minimum Support

Required (FTE)

7-9

.13

10-12

.14

13-15

.15

16-18

.16

19-21

.17

22-24

.18

25-27

.24

28-30

.30

31-33

.36

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Subspecialty-Specific Background and Intent: As an example, a program with an approved

complement of 12 fellows is required to have at least 30 percent/FTE support for the program

director and at least 14 percent/FTE support for the associate program director(s). Because an

associate program director is also a core faculty member, the minimum dedicated time

requirements for associate program directors are inclusive of core faculty activities. An additional

10 percent FTE for the core faculty position is not required. For example, if one core faculty

member is named the associate program director for a 12-fellow program, the required minimum

support for that position is 14 percent FTE. Further, the Review Committee allows the minimum

34-36

.42

37-39

.48

40-42

.54

43-45

.60

46-48

.66

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).(12). 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

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. The need to ensure adequate

resources, including adequate support and dedicated time for the program director, is

also addressed in Institutional Requirement II.B.1. The amount of support and dedicated

time needed for individual programs will vary based on a number of factors and may

exceed the minimum specified in the applicable specialty/subspecialty-specific Program

Requirements. It is expected that the Sponsoring Institution, in partnership with its

accredited programs, will ensure support for program directors, core faculty members,

and program coordinators to fulfill their program responsibilities effectively.

Cardiovascular Disease for Review and Comment

required FTE support to be shared among multiple associate program directors, as delegated by

and at the discretion of the program director.

The dedicated time for the associate program director(s) may be divided between as many

individuals as the program, in partnership with its Sponsoring Institution, see fit. Further, the

program can redistribute the FTE back to the program director, in this example, the associate

program director(s) could receive 10 percent/FTE support and the program director could

receive 34 percent/FTE support (30 percent plus the remaining four percent from the associate

program director FTE support).

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 must have at least three years of

documented educational and/or administrative experience

and at least three years of participation as an active faculty

member in an ACGME-accredited internal medicine

residency or cardiovascular disease fellowship.

(Core)

Subspecialty-Specific Background and Intent: The educational/administrative experience can be

as an associate program director, core faculty member, faculty member, or subspecialty

education coordinator for an ACGME-accredited internal medicine residency program, or as

program director, associate program director, core faculty member, or faculty member for an

ACGME-accredited internal medicine subspecialty program. The experience does not include

time spent as a fellow. Chief residency experience in a fourth-year position with junior faculty

member responsibilities does count. Teaching/administrative experience is cumulative across

multiple programs.

II.A.3.b) must include current certification in the subspecialty for

which they are the program director by the American Board of

Internal Medicine (ABIM) or by the American Osteopathic Board

of Internal Medicine (AOBIM), or subspecialty qualifications that

are acceptable to the Review Committee.

(Core)

II.A.3.b).(1) The Review Committee only accepts current ABIM or

AOBIM certification in cardiovascular disease.

(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)

Cardiovascular Disease for Review and Comment

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

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 structural

and 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 eliminating 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) have the authority to approve or remove physicians

and non-physicians as faculty members at all

participating sites, including the designation of core

faculty members, and must develop and oversee a

process to evaluate candidates prior to approval;

(Core)

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

approach. The education of fellows by non-physician educators may enable the fellows

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

knowledge. Furthermore, other individuals contribute to the education of fellows 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.A.4.a).(5) have the authority to remove fellows from supervising

interactions and/or learning environments that do not

meet the standards of the program;

(Core)

Cardiovascular Disease for Review and Comment

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.

II.A.4.a).(6) submit accurate and complete information required and

requested by the DIO, GMEC, and ACGME;

(Core)

Background and Intent: This includes providing information in the form and format

requested by the ACGME and obtaining requisite sign-off by the DIO.

II.A.4.a).(7) provide a learning and working environment in which

fellows have the opportunity to raise concerns, report

mistreatment, and provide feedback in a confidential

manner as appropriate, without fear of intimidation or

retaliation;

(Core)

II.A.4.a).(8) ensure the program’s compliance with the Sponsoring

Institution’s policies and procedures related to

grievances and due process, including when action is

taken to suspend or dismiss, not to promote, or 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).(9) ensure the program’s compliance with the Sponsoring

Institution’s policies and procedures on employment

and non-discrimination;

(Core)

II.A.4.a).(9).(a) Fellows must not be required to sign a non-

competition guarantee or restrictive covenant.

(Core)

II.A.4.a).(10) document verification of education for all fellows within

30 days of completion of or departure from the

program; and,

(Core)

II.A.4.a).(11) provide verification of an individual fellow’s education

upon the fellow’s request, within 30 days.

(Core)

Background and Intent: Primary verification of graduate medical education is important

to credentialing of physicians for further training and practice. Such verification must

Cardiovascular Disease for Review and Comment

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.

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 and model exemplary behavior. 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. There must be a sufficient number of faculty members with

competence to instruct and supervise all fellows.

(Core)

II.B.1.a) There must be faculty members with expertise in the analysis and

interpretation of practice data, data management science, clinical

decision support systems, and managing emerging health issues.

(Core)

Subspecialty-Specific Background and Intent: Advances in technology are likely to significantly

impact and redefine patient care, and this requirement is intended to ensure that fellows are

provided with access to faculty members with knowledge, skills, and/or experience in the

analysis and interpretation of practice data, and who are able to analyze and evaluate the

validity of decisions from advanced data management and clinical decision support systems.

Faculty members with expertise in this area can be physicians or non-physicians, and core or

non-core faculty members. Institutions may already have such experts assisting programs in

systematically analyzing practice data to improve patient care. The Review Committee

encourages programs that cannot identify an existing internal candidate with expertise in this

area to consider the option of sharing one with a program that does. The faculty member can

be remotely located and associated with multiple residency programs.

Cardiovascular Disease for Review and Comment

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, equitable,

high-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,

including devoting sufficient time to the educational program

to fulfill their supervisory and teaching responsibilities;

(Core)

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

conducive to educating fellows;

(Core)

II.B.2.e) regularly participate in organized clinical discussions, rounds,

journal clubs, and conferences; and,

(Core)

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

at least annually.

(Core)

Background and Intent: Faculty development is intended to describe structured

programming developed for the purpose of enhancing transference of knowledge, skill,

and behavior from the educator to the learner. Faculty development may occur in a

variety of configurations (lecture, workshop, etc.) using internal and/or external

resources. Programming is typically needs-based (individual or group) and may be

specific to the institution or the program. Faculty development programming is to be

reported for the fellowship program faculty in the aggregate.

II.B.2.g) must have experience working in interdisciplinary, interprofessional

team-based health care delivery models.

(Core)

Subspecialty-Specific Background and Intent: The Review Committee believes that

interdisciplinary, interprofessional, team-based care is the foundation of care delivery.

Individuals working within such teams are essential to fellow education.

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:

Cardiovascular Disease for Review and Comment

II.B.3.b).(1) have current certification in the subspecialty by the

American Board of Internal Medicine or the American

Osteopathic Board of Internal Medicine, or possess

qualifications judged acceptable to the Review

Committee.

(Core)

II.B.3.c) 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 autonomous 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 contribution 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 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) Faculty members must complete the annual ACGME Faculty

Survey.

(Core)

II.B.4.b) In addition to the program director, programs must have the

minimum number of core faculty members who are there must be

at least three core faculty member certified in cardiovascular

disease by the ABIM or the AOBIM based on the number of

approved fellow positions, as follows:

(Core)

[Edited and combined

with II.B.4.c)]

Number of Approved

Positions

Minimum Number of

ABIM or AOBIM

Certified Core Faculty

Cardiovascular Disease for Review and Comment

7-9

10-12

13-15

16-18

19-21

22-24

25-27

28-30

31-33

34-36

37-39

40-42

43-45

46-48

II.B.4.c) In programs approved for more than six fellows, there must be at

least one core faculty member certified in cardiovascular disease

by the ABIM or the AOBIM for every 1.5 fellows.

(Core)

II.B.4.d) At a minimum, tThe required core faculty members, in aggregate

and excluding members of the program leadership, must be

provided with support equal to an average dedicated a minimum of

.1 FTE 10 percent/FTE for educational and administrative

responsibilities that do not involve direct patient care. Additional

support must be provided based on the program size as follows:

(Core)

Number of Approved

Positions

Minimum Aggregate

Support Required

(FTE)

.10

7-9

.15

10-12

.15

13-15

.20

16-18

.20

19-21

.25

22-24

.25

25+

.30

Subspecialty-Specific Background and Intent: The Review Committee specified the

minimum required number of ABIM- or AOBIM-subspecialty-certified core faculty members

and the minimum required aggregate FTE, but did not specify how the aggregate FTE

support should be distributed to allow programs, in partnership with their Sponsoring

Institution, to allocate the support as they see fit. As long as the requirements for the

minimum number of core faculty members and the minimum aggregate FTE are met, how

the aggregate FTE is distributed is flexible.

Cardiovascular Disease for Review and Comment

Because an associate program director is also a core faculty member, the minimum

dedicated time requirements for associate program directors are inclusive of core faculty

activities. An additional 10 percent/FTE for the core faculty position is not required.

For example, in total, a 12-fellow program needs a program director and six ABIM- or

AOBIM-subspecialty-certified faculty members (at least one being an associate program

director) and a minimum FTE of 59 percent (a minimum of 30 percent/FTE for the program

director, an aggregate of 14 percent/FTE for the associate program director(s), and an

aggregate of 15 percent/FTE for the remaining core faculty members). The program could

choose to operationalize the aggregate FTE for core faculty members as five ABIM- or

AOBIM-certified faculty members at three percent/FTE, but it can also have three members

each at five percent/FTE support, or one with 15 percent/FTE and the remaining members

at no FTE support.

A six-fellow program needs a program director and three ABIM- or AOBIM-subspecialty-

certified faculty members (at least one being an associate program director) and a

minimum FTE of 30 percent (a minimum of 20 percent/FTE for the program director, no

additional aggregate FTE for the associate program director(s), and an aggregate of 10

percent/FTE for the core faculty members).

II.C. Program Coordinator

II.C.1. There must be a program coordinator.

(Core)

II.C.2. The program coordinator must be provided with dedicated time and

support adequate for administration of the program based upon its

size and configuration.

(Core)

II.C.2.a) At a minimum, the program coordinator must be provided with the

dedicated time and support specified below for administration of

the program. Additional administrative support must be provided

based on the program size as follows:

(Core)

Number of Approved

Fellow Positions

Minimum FTE Required

for Coordinator Support

Additional Aggregate FTE

Required for Administration

of the Program

1-3

4-6

7-9

.38

10-12

.44

13-15

.50

16-18

.56

19-21

.62

22-24

.68

25-27

.74

28-30

.80

31-33

.86

34-36

.92

37-39

.98

Cardiovascular Disease for Review and Comment

40-42

1.04

43-45

1.10

46-48

1.16

Subspecialty-Specific Background and Intent: As an example, a program with an approved

complement of 12 fellows is required to have at least 74 percent/FTE administrative support: 30

percent/FTE for the program coordinator; and an additional 44 percent/FTE aggregate support.

This additional support may be for the program coordinator only or divided among the program

coordinator and one or more other administrative personnel. The Review Committee has not

specified how the FTE should be distributed to allow programs, in partnership with their

Sponsoring Institution, to allocate the FTE as they see fit.

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

to provide the specified salary support.

Each program requires a lead administrative person, frequently referred to as a program

coordinator, administrator, or as otherwise titled by the institution. This person will

frequently manage the day-to-day operations of the program and serve as an important

liaison and facilitator between the learners, faculty and other staff members, and the

ACGME. Individuals serving in this role are recognized as program coordinators by the

ACGME.

The program coordinator is a key member of the leadership team and is critical to the

success of the program. As such, the program coordinator must possess skills in

leadership and personnel management appropriate to the complexity of the program.

Program coordinators are expected to develop in-depth knowledge of the ACGME and

Program Requirements, including policies and procedures. Program coordinators assist

the program director in meeting accreditation requirements, educational programming,

and support of fellows.

Programs, in partnership with their Sponsoring Institutions, should encourage the

professional development of their program coordinators and avail them of opportunities

for both professional and personal growth. Programs with fewer fellows may not require a

full-time coordinator; one coordinator may support more than one program.

The minimum required dedicated time and support specified in II.C.2.a) is inclusive of

activities directly related to administration of the accredited program. It is understood that

coordinators often have additional responsibilities, beyond those directly related to

program administration, including, but not limited to, departmental administrative

responsibilities, medical school clerkships, planning lectures that are not solely intended

for the accredited program, and mandatory reporting for entities other than the ACGME.

Assignment of these other responsibilities will necessitate consideration of allocation of

additional support so as not to preclude the coordinator from devoting the time specified

above solely to administrative activities that support the accredited program.

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. The need to ensure adequate

resources, including adequate support and dedicated time for the program coordinator, is

also addressed in Institutional Requirement II.B.4. The amount of support and dedicated

Cardiovascular Disease for Review and Comment

time needed for individual programs will vary based on a number of factors and may

exceed the minimum specified in the applicable specialty/subspecialty-specific Program

Requirements. It is expected that the Sponsoring Institution, in partnership with its

accredited programs, will ensure support for program directors, core faculty members,

and program coordinators to fulfill their program responsibilities effectively.

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.

II.D.1. There must be services available from other health care professionals,

including dietitians, language interpreters, nurses, occupational therapists,

physical therapists, and social workers.

(Detail)

[Edited and moved to

VI.E.2.a)]

II.D.2. There must be appropriate and timely consultation from other specialties.

(Detail)

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

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)

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

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

using ACGME, ACGME-I, or CanMEDS Milestones evaluations

from the core residency program.

(Core)

Background and Intent: A reporting feature is available for fellowship programs within

ADS to provide fellowship program directors access to the final Milestones report for an

active fellow's most recently completed residency program. These reports are available to

fellowship program directors in mid-July, and use of this system to retrieve the reports is

Cardiovascular Disease for Review and Comment

encouraged. There are a few scenarios in which these reports may not be available, such

as if a fellow completed residency in a program not accredited by the ACGME, if a fellow

completed residency prior to Milestones implementation, or if a fellow’s previous

experience could not be matched when entered into the program. For those without

Milestones reports, programs must contact the specialty program director from the

fellow's most recent residency program to obtain the required information. This new

reporting feature can be found in ADS by logging in and navigating to the program's

"Reports" tab, and then selecting the “Residency Milestone Retrieval” option.

III.A.1.b) Prior to appointment in the fellowship, fellows should have

completed an internal medicine program that satisfies the

requirements in III.A.1.

(Core)

III.A.1.b).(1) Fellows who did not complete an internal medicine program

that satisfies the requirements in III.A.1. must have

completed at least three years of internal medicine

education prior to starting the fellowship and must have met

all of the criteria in the “Fellow Eligibility Exception” section

below.

(Core)

III.A.1.c) Fellow Eligibility Exception

The Review Committee for Internal Medicine 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)

Cardiovascular Disease for Review and Comment

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. Fellow Complement

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

Review Committee.

(Core)

Background and Intent: Programs are required to request approval of all complement

changes, whether temporary or permanent, by the Review Committee through ADS.

Permanent increases require prior approval from the Review Committee and temporary

increases may also require approval. Specialty-specific instructions for requesting a

complement increase are found in the “Documents and Resources” page of the

applicable specialty section of the ACGME website.

III.B.1. The number of available fellow positions in the program must be at least

one per year.

(Detail)

III.C. Fellow Transfers

The program must obtain verification of previous educational experiences

and a summative competency-based performance evaluation prior to

acceptance of a transferring fellow, and Milestones evaluations upon

matriculation.

(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.

It is recognized that programs may place different emphasis on research,

leadership, public health, etc. It is expected that the program aims will reflect the

Cardiovascular Disease for Review and Comment

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. Educational Components

The curriculum must contain the following educational components:

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, which 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)

IV.A.4.a) Fellows must be provided with protected time to participate in

core didactic activities.

(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. formal educational activities that promote patient safety-related

goals, tools, and techniques.

(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

Cardiovascular Disease for Review and Comment

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:

IV.B.1.a) Professionalism

Fellows must demonstrate a commitment to professionalism

and an adherence to ethical principles.

(Core)

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. 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.

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

patient- and family-centered, compassionate, equitable,

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 the

practice of health promotion, disease prevention,

diagnosis, care, and treatment of patients of each

gender, from adolescence to old age, during health

and all stages of illness; and,

(Core)

IV.B.1.b).(1).(b) Fellows must demonstrate the ability to manage the

care of patients:

IV.B.1.b).(1).(b).(i) in a variety of health care settings, including

inpatient and various ambulatory settings;

(Core)

Subspecialty-Specific Background and Intent: Emerging models of care and needs of

populations served by programs will result in fellows having educational experiences in novel

or non-traditional settings. Examples of non-traditional educational settings include but are

not limited to rotations on mobile buses that travel to areas of increased need, and “pop-up”

health clinics within community centers.

IV.B.1.b).(1).(b).(ii) with whom they have limited or no physical

contact, through the use of telemedicine;

(Core)

IV.B.1.b).(1).(b).(iii) using population-based data; and,

(Core)

Cardiovascular Disease for Review and Comment

Subspecialty-Specific Background and Intent: The ability to interpret population data is vital to

understanding population health within the context of prevention. Fellows need experience

using, understanding, and analyzing population health data so that they can develop health

care plans to improve health outcomes for their patients. For instance, fellows may be

provided experience in analyzing and interpreting data from health registries, and

understanding the local impact of infectious and non-infectious epidemics (e.g., obesity or

opioid) and pandemics, as well as the important role social determinants of health have when

developing and applying health care and preventive care decisions.

IV.B.1.b).(1).(b).(iv) using critical thinking and evidence-based

tools.

(Core)

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

prevention, evaluation, and management of the

following:

(Core)

IV.B.1.b).(1).(c).(i) acute coronary syndromes;

(Core)

IV.B.1.b).(1).(c).(ii) acute myocardial infarction and other acute

ischemic coronary syndromes;

(Core)

IV.B.1.b).(1).(c).(iii) arrhythmias;

IV.B.1.b).(1).(c).(iv) cardiomyopathy;

(Core)

IV.B.1.b).(1).(c).(v) cardiovascular evaluation of patients

undergoing non-cardiac surgery;

(Core)

IV.B.1.b).(1).(c).(vi) congestive heart failure;

(Core)

IV.B.1.b).(1).(c).(vii) coronary heart artery disease;

(Core)

IV.B.1.b).(1).(c).(viii) chronic coronary heart artery disease;

(Core)

IV.B.1.b).(1).(c).(ix) diseases of the aorta;

(Core)

IV.B.1.b).(1).(c).(x) need for end-of-life (palliative) care;

(Core)

IV.B.1.b).(1).(c).(xi) heart disease in pregnancy;

(Core)

IV.B.1.b).(1).(c).(xii) hypertension;

(Core)

IV.B.1.b).(1).(c).(xiii) infectious and inflammatory heart disease;

(Core)

IV.B.1.b).(1).(c).(xiv) lipid disorders and metabolic syndrome;

(Core)

IV.B.1.b).(1).(c).(xv) pericardial disease;

(Core)

IV.B.1.b).(1).(c).(xvi) peripheral vascular disease;

(Core)

Cardiovascular Disease for Review and Comment

IV.B.1.b).(1).(c).(xvii) pulmonary hypertension;

(Core)

IV.B.1.b).(1).(c).(xviii) thromboembolic disorders; and,

(Core)

IV.B.1.b).(1).(c).(xix) valvular heart disease.

(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 the ability

to:

IV.B.1.b).(2).(a).(i) use diagnostic, and/or imaging studies

relevant to the care of the patient;

(Core)

IV.B.1.b).(2).(a).(ii) perform diagnostic and therapeutic

procedures relevant to their specific career

paths; and,

(Core)

IV.B.1.b).(2).(a).(iii) treat their patients’ conditions with practices

that are patient-centered, safe, scientifically

based, effective, timely, and cost-effective.

(Core)

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

performance of the following procedures:

(Core)

IV.B.1.b).(2).(b).(i) basic programming and management of

cardiovascular implantable electronic

devices follow-up surveillance of permanent

pacemakers and ICDs.

(Core)

IV.B.1.b).(2).(b).(ii) direct current cardioversion;

(Core)

IV.B.1.b).(2).(b).(ii).(a) Each fellow must perform 10 direct

current cardioversions.

(Detail)

IV.B.1.b).(2).(b).(iii) echocardiography;

(Core)

IV.B.1.b).(2).(b).(iii).(a) Each fellow must perform a minimum

of 75 echocardiographies and

echocardiograms, interpret a

minimum of 150 studies, and observe

the performance and interpretation of

transesophageal cardiac studies.

(Detail)

IV.B.1.b).(2).(b).(iv) exercise stress testing;

(Core)

Cardiovascular Disease for Review and Comment

IV.B.1.b).(2).(b).(iv).(a) Each fellow must perform a minimum

of 50 stress ECG tests.

(Detail)

IV.B.1.b).(2).(b).(v) conscious moderate sedation; and,

(Core)

IV.B.1.b).(2).(b).(vi) placement and management of temporary

pacemakers, including transvenous and

transcutaneous; and,

(Core)

IV.B.1.b).(2).(b).(vii) right and left heart catheterization, including

coronary arteriography.

(Core)

IV.B.1.b).(2).(b).(vii).(a) Each fellow must participate perform

in a minimum of 100 catheterizations.

(Detail)

IV.B.1.b).(2).(c) Fellows must demonstrate competence in the

interpretation of:

IV.B.1.b).(2).(c).(i) ambulatory ECG recordings;

(Core)

IV.B.1.b).(2).(c).(ii) electrocardiograms;

(Core)

IV.B.1.b).(2).(c).(ii).(a) Each fellow must interpret a minimum

of 3500 electrocardiograms.

(Detail)

IV.B.1.b).(2).(c).(iii) nuclear cardiology; and,.

(Core)

IV.B.1.b).(2).(c).(iii).(a) Each fellow must interpret a minimum

of 100 radionuclide studies to include

SPECT myocardial perfusion imaging

and ventriculograms.

(Detail)

IV.B.1.b).(2).(c).(iv) chest x-rays.

(Core)

IV.B.1.c) Medical Knowledge

Fellows must demonstrate knowledge of established and

evolving biomedical, clinical, epidemiological, and social-

behavioral sciences, including scientific inquiry, as well as the

application of this knowledge to patient care.

(Core)

IV.B.1.c).(1) Fellows must demonstrate knowledge of the scientific

method of problem solving and evidence-based decision

making;

(Core)

IV.B.1.c).(2) Fellows must demonstrate a knowledge of indications,

contraindications, limitations, complications, techniques,

and interpretation of results of those diagnostic and

therapeutic procedures integral to the discipline, including

the appropriate indications for and use of screening

tests/procedures; and,

(Core)

Cardiovascular Disease for Review and Comment

IV.B.1.c).(3) Fellows must demonstrate sufficient knowledge in of the

content following areas:

IV.B.1.c).(3).(a) application of technology appropriate for the clinical

context, including evolving techniques;

(Core)

Subspecialty-Specific Background and Intent: Advances in technology will likely continue to

make substantive changes in patient diagnosis and management. This requirement ensures

that fellows will be able to gain experience and become familiar with emerging technologies.

IV.B.1.c).(3).(b) basic science, including:

(Core)

IV.B.1.c).(3).(b).(i) cardiovascular anatomy;

(Detail)

IV.B.1.c).(3).(b).(ii) cardiovascular metabolism;

(Detail)

IV.B.1.c).(3).(b).(iii) cardiovascular pathology;

(Detail)

IV.B.1.c).(3).(b).(iv) pharmacology, to includeing drug

metabolism, adverse effects, indications, the

effects on aging, relative costs of therapy,

and the effects of non-cardiovascular drugs

on cardiovascular function;

(Detail)

IV.B.1.c).(3).(b).(v) cardiovascular physiology;

(Detail)

IV.B.1.c).(3).(b).(vi) genetic causes of cardiovascular disease;

and,

(Detail)

IV.B.1.c).(3).(b).(vii) molecular biology of the cardiovascular

system.

(Detail)

IV.B.1.c).(3).(b).(viii) primary, andsecondary, and primordial prevention of

cardiovascular disease, including:

(Core)

IV.B.1.c).(3).(b).(ix) biostatistics;

(Detail)

IV.B.1.c).(3).(b).(x) clinical epidemiology;

(Detail)

IV.B.1.c).(3).(b).(xi) cardiac rehabilitation;

(Detail)

IV.B.1.c).(3).(b).(xii) current and emerging risk factors; and,

(Detail)

IV.B.1.c).(3).(b).(xiii) cerebrovascular disease.

(Detail)

IV.B.1.c).(3).(c) evaluation and management of patients with:

IV.B.1.c).(3).(c).(i) adult congenital heart disease;

(Core)

IV.B.1.c).(3).(c).(ii) cardiac trauma;

(Core)

Cardiovascular Disease for Review and Comment

IV.B.1.c).(3).(c).(iii) cardiac tumors;

(Core)

IV.B.1.c).(3).(c).(iv) cerebrovascular disease; and,

(Core)

IV.B.1.c).(3).(c).(v) geriatric cardiology.

(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)

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 structural and 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 the experiences, and the supervisory

continuity. These educational experiences include an appropriate

blend of supervised patient care responsibilities, clinical teaching,

and didactic educational events.

(Core)

IV.C.1.a) Assignment of Rotations must be structured to minimize the

frequency of rotational transitions, and rotations must be of

sufficient length to provide a quality educational experience,

defined by continuity of patient care, ongoing supervision,

longitudinal relationships with faculty members, and to allow for

meaningful assessment and feedback.

(Core)

IV.C.1.b) Clinical experiences should Rotations must be structured to

facilitate learning in a manner that allows fellows to function as part

of an effective interprofessional team that works together towards

the shared goals of patient safety and quality improvement.

(Core)

IV.C.1.c) Schedules must be structured to minimize conflicting inpatient and

outpatient responsibilities.

(Core)

Cardiovascular Disease for Review and Comment

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)

IV.C.3. A minimum time must be spent in the following areas:

(Core)

IV.C.3.a) at least 24 months of clinical experience, including inpatient and

special experiences;

(Core)

IV.C.3.b) fourthree months in the cardiac catheterization laboratory;

(Core)

IV.C.3.c) six months in non-invasive cardiac evaluations, consisting of the

following:

(Core)

IV.C.3.c).(1) a minimum of three months of echocardiography and

Doppler; and,

(Core)

IV.C.3.c).(2) Twothree months of cardiac imaging, to include one month

of nuclear cardiology, to include the fellow’s active

participation in daily nuclear cardiology study interpretation

(a minimum of 80 hours) during the rotationone month of

CT imaging, and one month of MRI.

(Core)

IV.C.3.c).(3) one month of experiences in other noninvasive cardiac

evaluations, to include exercise stress testing; ECG

interpretation; and ambulatory ECG monitoring (continuous

and event recording). This rotation may be done

concurrently with other rotations.

(Core)

IV.C.3.c).(4) experience in cardiac tomography, positron emission

tomography, cardiac magnetic resonance imaging, and,

peripheral vascular imaging. These rotations may be done

concurrently with other rotations.

(Detail)

IV.C.3.d) two months devoted to electrophysiology; and,

(Core)

IV.C.3.e) nine months of non-laboratory clinical practice activities.

(Core)

Subspecialty-Specific Background and Intent: For example, these activities could include

outpatient cardiology, inpatient cardiology, consultation services, vascular medicine, cardiac

clinic, etc.; however, this time cannot be reduced by the time spent in a fellow’s continuity

clinic.

IV.C.4. Fellows must participate in training using simulation.

(Detail)

[Edited and

moved to I.D.1.c)(4)]

IV.C.5. Fellows must have formal instruction and clinical experience to in the

performance of the following:

IV.C.5.a).(1) CT;

(Core)

Cardiovascular Disease for Review and Comment

IV.C.5.a).(2) intra-aortic balloon counterpulsation mechanical

hemodynamic and circulatory support devices;

(Core)

IV.C.5.a).(3) intracardiac interventional electrophysiologic studies

procedures, and;

(Core)

IV.C.5.a).(4) MRI;

(Core)

IV.C.5.a).(5) percutaneous transluminal coronary angioplasty and other

interventional procedures.

(Core)

IV.C.5.a).(6) pericardiocentesis.

(Core)

IV.C.6. Experience with Continuity Ambulatory Patients

IV.C.6.a) Fellows must have continuity ambulatory clinic experience for the

duration of the program that exposes them to the breadth and

depth of the subspecialty.

(Core)

IV.C.6.a).(1) This experience should average one half-day each week.

(Detail)

Subspecialty-Specific Background and Intent: The Review Committee believes this

requirement can be best met through assigning fellows to the same clinic for the duration of

the program or different clinics in six-month intervals to allow for experiences with specific

areas of subspecialty.

IV.C.6.b) Each fellow should, on average, be responsible for four to eight

patients during each half-day session.

(Detail)

IV.C.6.c) The continuity patient care experience should not be interrupted by

more than one month, excluding a fellow’s vacation.

(Detail)

IV.C.6.d) This experience must include an appropriate distribution of patients

of each gender and a diversity of ages,

(Core)

This should be accomplished through either:

IV.C.6.d).(1) a continuity clinic which provides fellows the opportunity to

observe and learn the course of disease; or,

(Detail)

IV.C.6.d).(2) selected blocks of at least six months which address

specific areas of cardiovascular disease.

(Detail)

IV.C.6.e) Fellows should be informed of the status of their continuity patients

when such patients are hospitalized, as clinically appropriate.

(Detail)

IV.C.7. The educational program must provide fellows with individualized

educational experiences to allow them to participate in opportunities

Cardiovascular Disease for Review and Comment

relevant to their future practice or to further skill/competence development

in the foundational educational experiences of the subspecialty.

(Core)

Subspecialty-Specific Background and Intent: The requirements acknowledge that in addition

to providing fellows with broad foundational educational experiences in the subspecialty,

additional educational experiences will take into account future career plans. The program

director will consider demonstrated competence in the foundational areas, program

resources, program aims, and a fellow’s future practice plans when developing an

individualized learning experience. The Review Committee does not specify the amount of

time devoted to such experiences and recognizes that some fellows may need to devote the

entirety of their fellowship experience to achieve competence in the foundational areas of the

subspecialty.

IV.C.8. Required Didactic Experience

IV.C.8.a) The core curriculum educational program must include a didactic

program instruction based on the core knowledge content in the

subspecialty area.

(Core)

IV.C.8.a).(1) The program must afford ensure that each fellows have an

opportunity to review all content from topics covered in

conferences that he or she was unable to they could not

attend.

(Detail) (Core)

Subspecialty-Specific Background and Intent: Core content presented during conferences will

need to be available for fellows who missed the conference. This can include repeating the

conference, recording and making it available electronically, or otherwise sharing the content

from the conference electronically.

IV.C.8.b) Fellows must participate in clinical case conferences, journal clubs,

research conference, and morbidity and mortality or quality

improvement conferences.

(Detail)

IV.C.8.b).(1) All core conferences must have at least one faculty

member present, and must be scheduled as Fellow must

have a sufficient number of didactic sessions to ensure

peer fellow-fellow and peer-fellow-faculty interaction.

(Detail)

(Core))

IV.C.9. Fellows must be provided a patient- or case-based approach to clinical

teaching that includes direct interactions between fellows and the teaching

faculty member, bedside teaching, discussion of pathophysiology, and the

application of current evidence in diagnostic and therapeutic decisions.

(Core)

IV.C.10. Patient-based teaching must include direct interaction between fellows

and faculty members, bedside teaching, discussion of pathophysiology,

and the use of current evidence in diagnostic and therapeutic decisions.

(Core)

The teaching must be occur:

Cardiovascular Disease for Review and Comment

IV.C.10.a) formally conducted on all inpatient, telemedicine, and consultative

services; and,

(Detail)

(Core)

IV.C.10.a).(1) conducted with a frequency and duration that to ensures a

meaningful and continuous teaching relationship between

the assigned supervising teaching faculty member(s) and

the fellows, and;

(Detail)

(Core)

IV.C.11. Fellows must receive instruction in practice management relevant to the

subspecialty cardiovascular disease.

(Detail)

Subspecialty-Specific Background and Intent: Instruction in practice management can include

the organization and financing of clinical practice, including personnel and business

management, scheduling, billing and coding procedures, telephone and telemedicine

management, and maintenance of an appropriate confidential patient record system.

IV.C.12. Procedures and Technical Skills

IV.C.13. Direct supervision of procedures performed by each fellow must occur

until proficiency has been acquired and documented by the program

director.

(Core)

IV.C.14. Faculty members must teach and supervise the fellows in the performance

and interpretation of procedures, which must be documented in each

fellow’s record, including indications, outcomes, diagnoses, and

supervisor(s).

(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

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

Cardiovascular Disease for Review and Comment

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

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

(Core)

IV.D.1.b) The program in partnership with its Sponsoring Institution,

must allocate adequate resources to facilitate fellow and

faculty involvement in scholarly activities.

(Core)

IV.D.2. Faculty Scholarly Activity

IV.D.2.a) Among their scholarly activity, programs must demonstrate

accomplishments in at least three of the following domains:

(Core)

• Research in basic science, education, translational

science, patient care, or population health

• Peer-reviewed grants

• Quality improvement and/or patient safety initiatives

• Systematic reviews, meta-analyses, review articles,

chapters in medical textbooks, or case reports

• Creation of curricula, evaluation tools, didactic

educational activities, or electronic educational

materials

• Contribution to professional committees, educational

organizations, or editorial boards

• Innovations in education

IV.D.2.b) The program must demonstrate dissemination of scholarly

activity within and external to the program by the following

methods:

Background and Intent: For the purposes of education, metrics of scholarly activity

represent one of the surrogates for the program’s effectiveness in the creation of an

environment of inquiry that advances the fellows’ scholarly approach to patient care.

The Review Committee will evaluate the dissemination of scholarship for the program

as a whole, not for individual faculty members, for a five-year interval, for both core

and non-core faculty members, with the goal of assessing the effectiveness of the

creation of such an environment. The ACGME recognizes that there may be

differences in scholarship requirements between different specialties and between

residencies and fellowships in the same specialty.

IV.D.2.b).(1) faculty participation in grand rounds, posters,

workshops, quality improvement presentations,

podium presentations, grant leadership, non-peer-

reviewed print/electronic resources, articles or

publications, book chapters, textbooks, webinars,

service on professional committees, or serving as a

journal reviewer, journal editorial board member, or

editor.

(Outcome)

Cardiovascular Disease for Review and Comment

IV.D.2.b).(1).(a) At least 50 percent of the core faculty members who

are certified in cardiovascular disease by the ABIM

or AOBIM (see Program Requirements II.B.4.b)-c))

must annually engage in a variety of scholarly

activities, as listed in Program Requirement

IV.D.2.b).(1).

(Core)

IV.D.3. Fellow Scholarly Activity

IV.D.3.a) While in the program, at least 50 percent of a program’s all fellows

must engage in more than at least one of the following scholarly

activities: participation in grand rounds; poster; workshops; quality

improvement presentations; podium presentation; grant leadership;

non-peer-reviewed print/electronic resources; articles or

publications; book chapters; textbooks; webinars; service on

professional committees; or serving as a journal reviewer, journal

editorial board member, or editor.

(Outcome)

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.

Cardiovascular Disease for Review and Comment

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) The faculty must discuss this evaluation with each fellow at

the completion of each assignment.

(Core)

V.A.1.a).(2) Assessment of procedural competence should include a

formal evaluation process and not be based solely on a

minimum number of procedures performed.

(Detail) (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 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) For block rotations of greater than three months in

duration, evaluation must be documented at least every

three months.

(Core)

V.A.1.b).(2) Longitudinal experiences such as continuity clinic in

the context of other clinical responsibilities must be

evaluated at least every three months and at

completion.

(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)

Cardiovascular Disease for Review and Comment

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) assist fellows in developing individualized learning

plans to capitalize on their strengths and identify areas

for growth; and,

(Core)

V.A.1.d).(3) 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

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) At least annually, there must be a summative evaluation of

each fellow that includes their readiness to progress to the

next year of the program, if applicable.

(Core)

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

for review by the fellow.

(Core)

Cardiovascular Disease for Review and Comment

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; and,

(Core)

V.A.2.a).(2).(c) 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 who

have extensive contact and experience with the program’s

fellows.

(Core)

Background and Intent: The requirements regarding the Clinical Competency

Committee do not preclude or limit a program director’s participation on the Clinical

Competency Committee. The intent is to leave flexibility for each program to decide the

best structure for its own circumstances, but a program should consider: its program

director’s other roles as fellow advocate, advisor, and confidante; the impact of the

program director’s presence on the other Clinical Competency Committee members’

discussions and decisions; the size of the program faculty; and other program-relevant

factors. Inclusivity is an important consideration in the appointment of Clinical

Competency Committee members, ensuring diverse participation to achieve fair

evaluation. The program director has final responsibility for fellow evaluation and

promotion decisions.

The program faculty may include more than the physician faculty members, such as

other physicians and non-physicians who teach and evaluate the program’s fellows.

There may be additional members of the Clinical Competency Committee.

Cardiovascular Disease for Review and Comment

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 educational

program and for all educators. 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)

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

annually.

(Core)

Cardiovascular Disease for Review and Comment

V.B.3. Results of the faculty educational evaluations should be

incorporated into program-wide faculty development plans.

(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) review of the program’s self-determined goals and

progress toward meeting them;

(Core)

V.C.1.b).(2) guiding ongoing program improvement, including

development of new goals, based upon outcomes; and,

(Core)

V.C.1.b).(3) 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: To achieve its mission and educate 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. The

Program Evaluation Committee advises the program director through program

oversight.

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

outcomes from prior Annual Program Evaluation(s), aggregate

fellow and faculty written evaluations of the program, and

other relevant data in its assessment of the program.

(Core)

Background and Intent: Other data to be considered for assessment include:

• Curriculum

Cardiovascular Disease for Review and Comment

• ACGME letters of notification, including citations, Areas for Improvement, and

comments

• Quality and safety of patient care

• Aggregate fellow and faculty well-being; recruitment and retention; workforce

diversity, including graduate medical education staff and other relevant

academic community members; engagement in quality improvement and patient

safety; and scholarly activity

• ACGME Fellow and Faculty Survey results

• Aggregate fellow Milestones evaluations, and achievement on in-training

examinations (where applicable), board pass and certification rates, and

graduate performance

• Aggregate faculty evaluation and professional development

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 Program Evaluation, including the action plan,

must be distributed to and discussed with the fellows and the

members of the teaching faculty, and be submitted to the DIO.

(Core)

V.C.2. The program must participate in a Self-Study and submit it to the

DIO.

(Core)

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

be integrated into the accreditation Self-Study process. The accreditation Self-Study is

an objective, comprehensive evaluation of the fellowship program, with the aim of

improving it. Underlying the accreditation 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 accreditation Self-Study are provided in the ACGME

Manual of Policies and Procedures. Additionally, a description of the

accreditation Self-

Study process is available on the ACGME website.

V.C.3. One goal of ACGME-accredited education is to educate physicians

who seek and achieve board certification. One measure of the

effectiveness of the educational program is the ultimate pass rate.

The program director should encourage all eligible program

graduates to take the certifying examination offered by the applicable

American Board of Medical Specialties (ABMS) member board or

American Osteopathic Association (AOA) certifying board.

V.C.3.a) For subspecialties in which the ABMS member board and/or

AOA certifying board offer(s) an annual written exam, in the

preceding three years, the program’s aggregate pass rate of

those taking the examination for the first time must be higher

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than the bottom fifth percentile of programs in that

subspecialty.

(Outcome)

V.C.3.b) For subspecialties in which the ABMS member board and/or

AOA certifying board offer(s) a biennial written exam, in the

preceding six years, the program’s aggregate pass rate of

those taking the examination for the first time must be higher

than the bottom fifth percentile of programs in that

subspecialty.

(Outcome)

V.C.3.c) For subspecialties in which the ABMS member board and/or

AOA certifying board offer(s) an annual oral exam, in the

preceding three years, the program’s aggregate pass rate of

those taking the examination for the first time must be higher

than the bottom fifth percentile of programs in that

subspecialty.

(Outcome)

V.C.3.d) For subspecialties in which the ABMS member board and/or

AOA certifying board offer(s) a biennial oral exam, in the

preceding six years, the program’s aggregate pass rate of

those taking the examination for the first time must be higher

than the bottom fifth percentile of programs in that

subspecialty.

(Outcome)

V.C.3.e) For each of the exams referenced in V.C.3.a)-d), any program

whose graduates over the time period specified in the

requirement have achieved an 80 percent pass rate will have

met this requirement, no matter the percentile rank of the

program for pass rate in that subspecialty.

(Outcome)

Background and Intent: Setting a single standard for pass rate that works across

subspecialties is not supportable based on the heterogeneity of the psychometrics of

different examinations. By using a percentile rank, the performance of the lower five

percent (fifth percentile) of programs can be identified and set on a path to curricular

and test preparation reform.

There are subspecialties where there is a very high board pass rate that could leave

successful programs in the bottom five percent (fifth percentile) despite admirable

performance. These high-performing programs should not be cited, and V.C.3.e) is

designed to address this.

V.C.3.f) Programs must report, in ADS, board certification status

annually for the cohort of board-eligible fellows that graduated

seven years earlier.

(Core)

Background and Intent: It is essential that fellowship programs demonstrate knowledge

and skill transfer to their fellows. One measure of that is the qualifying or initial

certification exam pass rate. Another important parameter of the success of the

program is the ultimate board certification rate of its graduates. Graduates are eligible

for up to seven years from fellowship graduation for initial certification. The ACGME will

Cardiovascular Disease for Review and Comment

calculate a rolling three-year average of the ultimate board certification rate at seven

years post-graduation, and the Review Committees will monitor it.

The Review Committees will track the rolling seven-year certification rate as an

indicator of program quality. Programs are encouraged to monitor their graduates’

performance on board certification examinations.

In the future, the ACGME may establish parameters related to ultimate board

certification rates.

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

• Appreciation for the privilege of providing care for patients

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

members, and all members of the health care team

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

VI.A.1. Patient Safety and Quality Improvement

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).(2) Patient Safety Events

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Reporting, investigation, and follow-up of safety

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).(2).(a) Residents, fellows, faculty members, and other

clinical staff members must:

VI.A.1.a).(2).(a).(i) know their responsibilities in reporting

patient safety events and unsafe

conditions at the clinical site, including

how to report such events; and,

(Core)

VI.A.1.a).(2).(a).(ii) be provided with summary information of

their institution’s patient safety reports.

(Core)

VI.A.1.a).(2).(b) Fellows must participate as team members in

real and/or simulated interprofessional clinical

patient safety and quality improvement

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).(3) Quality Metrics

Access to data is essential to prioritizing activities for

care improvement and evaluating success of

improvement efforts.

VI.A.1.a).(3).(a) Fellows and faculty members must receive data

on quality metrics and benchmarks related to

their patient populations.

(Core)

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

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required to enter the unsupervised practice of medicine; and

establishes a foundation for continued professional growth.

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

faculty members, other members of the health

care team, and patients.

(Core)

Background and Intent: Each patient will 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.

VI.A.2.a).(2) 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)

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. The level of supervision for each fellow is

commensurate with that fellow’s level of independence in practice; this level of

supervision may be enhanced based on factors such as patient safety, complexity,

acuity, urgency, risk of serious safety events, or other pertinent variables.

VI.A.2.b) Levels of Supervision

To promote appropriate fellow supervision while providing for

graded authority and responsibility, the program must use the

following classification of supervision:

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

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

with the fellow during the key portions of the

patient interaction; or,

VI.A.2.b).(1).(b) the supervising physician and/or patient is not

physically present with the fellow and the

supervising physician is concurrently

monitoring the patient care through appropriate

telecommunication technology.

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VI.A.2.b).(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.

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

provide review of procedures/encounters with feedback

provided after care is delivered.

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

supervising physician is required.

(Core)

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)

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VI.B. Professionalism

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

educate fellows and faculty members concerning the professional

and ethical responsibilities of physicians, including but not limited to

their obligation to be appropriately rested and fit to provide the care

required by their patients.

(Core)

Background and Intent: This requirement emphasizes the professional responsibility

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

for patients. It is also the responsibility of fellows, faculty members, 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. This includes recognition of impairment,

including from illness, fatigue, and substance use, in themselves, their peers, and

other members of the health care team, and 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 practitioner.

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

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

fulfill non-physician obligations;

(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 n

ursing 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.b) ensure manageable patient care responsibilities; and,

(Core)

Background and Intent: The Common Program Requirements do not define “manageable

patient care responsibilities” as this is variable by specialty/subspecialty and PGY level.

Review Committees will provide further detail regarding patient care responsibilities in

the applicable specialty- and subspecialty-specific Program Requirements and

accompanying FAQs. However, all programs, regardless of specialty/subspecialty,

should carefully assess how the assignment of patient care responsibilities can affect

work compression.

VI.B.2.c) include efforts to enhance the meaning that each fellow finds

in the experience of being a physician, including protecting

time with patients, providing administrative support,

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promoting progressive independence and flexibility, and

enhancing professional relationships.

(Core)

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)

Background and Intent: The accurate reporting of clinical and educational work hours,

patient outcomes, and clinical experience data are the responsibility of the program

leadership, fellows, and faculty.

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

their personal role in the safety and welfare of patients entrusted to

their care, including the ability to report unsafe conditions and safety

events.

(Core)

VI.B.5. Programs, in partnership with their Sponsoring Institutions, must

provide a professional, equitable, respectful, and civil environment

that is psychologically safe and that is free from discrimination,

sexual and other forms of harassment, mistreatment, abuse, or

coercion of students, fellows, faculty, and staff.

(Core)

Background and Intent: Psychological safety is defined as an environment of trust and

respect that allows individuals to feel able to ask for help, admit mistakes, raise

concerns, suggest ideas, and challenge ways of working and the ideas of others on the

team, including the ideas of those in authority, without fear of humiliation, and the

knowledge that mistakes will be handled justly and fairly.

VI.B.6. 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. A positive culture in a clinical

learning environment models constructive behaviors, and prepares fellows

with the skills and attitudes needed to thrive throughout their careers.

Cardiovascular Disease for Review and Comment

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

Institution, must include:

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

that impacts fellow well-being;

(Core)

VI.C.1.b) 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 safety

events.

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

medical, mental health, and dental care appointments,

including those scheduled during their working hours.

(Core)

VI.C.1.d) education of fellows and faculty members in:

VI.C.1.d).(1) identification of the symptoms of burnout, depression,

and substance use disorders, suicidal ideation, or

potential for violence, including means to assist those

who experience these conditions;

(Core)

VI.C.1.d).(2) recognition of these symptoms in themselves and how

to seek appropriate care; and,

(Core)

VI.C.1.d).(3) access to appropriate tools for self-screening.

(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).

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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 may be 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/well-being programs within the institution.

In cases of physician impairment, the program director or designated personnel should

follow the policies of their institution for reporting.

VI.C.1.e) providing 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 medical, parental, or caregiver 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 and ensure continuity 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

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VI.D.1. Programs must educate all fellows and faculty members in

recognition of the signs of fatigue and sleep deprivation, alertness

management, and fatigue mitigation processes.

(Detail)

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.

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. 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)

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

that has safe patient care and a sense of fellow well-being. 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 and promotes safe, interprofessional, team-based

care in the subspecialty and larger health system.

(Core)

VI.E.2.a) The program must provide educational experiences that allow

fellows to interact with and learn from other health care

professionals, such as physicians in other specialties, advanced

practice providers, nurses, social workers, physical therapists,

Cardiovascular Disease for Review and Comment

case managers, language interpreters, and dieticians, to achieve

effective, interdisciplinary, and interprofessional team-based care.

(Core)

[Edited and moved from II.D.1.]

Background and Intent: Effective programs will have a structure that promotes safe,

interprofessional, team-based care. Optimal patient safety occurs in the setting of a

coordinated interprofessional learning and working environment.

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-off

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-off process.

(Outcome)

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: 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 terms are used 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.

Cardiovascular Disease for Review and Comment

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 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.

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) Fellows should have eight hours off between scheduled

clinical work and education periods.

(Detail)

Background and Intent: 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 occurs within the context of the 80-hour and the one-

day-off-in-seven requirements. 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.b) Fellows must have at least 14 hours free of clinical work and

education after 24 hours of in-house call.

(Core)

Cardiovascular Disease for Review and Comment

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.c) 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

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.

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: to continue to provide care to a single

severely ill or unstable patient; to give humanistic attention to

Cardiovascular Disease for Review and Comment

the needs of a patient or patient’s family; or to attend unique

educational events.

(Detail)

VI.F.4.b) These additional hours of care or education must 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

educational work hours to individual programs based on a

sound educational rationale.

The Review Committee for Internal Medicine 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.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)

Cardiovascular Disease for Review and Comment

VI.F.7.a) Internal Medicine fellowships must not average in-house call 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)

Background and Intent: As noted in VI.F.1., clinical work done from home when a fellow

is taking at-home call must count toward the 80-hour maximum weekly limit. This

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.

***