323_PediatricCriticalCareMedicine

ACGME Program Requirements for

Graduate Medical Education

in Pediatric Critical Care Medicine

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

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

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

Pediatric Critical Care Medicine

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 ............................................................ 8

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

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

II.B. Faculty ...................................................................................................................... 13

II.C. Program Coordinator .............................................................................................. 17

II.D. Other Program Personnel ....................................................................................... 19

III. Fellow Appointments .......................................................................................................... 19

III.A. Eligibility Criteria ..................................................................................................... 19

III.B. Fellow Complement ................................................................................................ 21

III.C. Fellow Transfers ...................................................................................................... 21

IV. Educational Program .......................................................................................................... 21

IV.A. Educational Components ....................................................................................... 22

IV.B. ACGME Competencies ........................................................................................... 23

IV.C. Curriculum Organization and Fellow Experiences .............................................. 26

IV.D. Scholarship .............................................................................................................. 27

V. Evaluation ............................................................................................................................ 29

V.A. Fellow Evaluation .................................................................................................... 29

V.B. Faculty Evaluation ................................................................................................... 33

V.C. Program Evaluation and Improvement ................................................................. 34

VI. The Learning and Working Environment .......................................................................... 37

VI.A. Patient Safety, Quality Improvement, Supervision, and Accountability ............ 37

VI.B. Professionalism ....................................................................................................... 41

VI.C. Well-Being ................................................................................................................ 43

VI.D. Fatigue Mitigation .................................................................................................... 45

VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care ........................... 46

VI.F. Clinical Experience and Education ........................................................................ 47

Pediatric Critical Care Medicine

ACGME Program Requirements for Graduate Medical Education

in Pediatric Critical Care Medicine

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

Pediatric Critical Care Medicine

expertise achieved, fellows develop mentored relationships built on an

infrastructure that promotes collaborative research.

Int.B. Definition of Subspecialty

Pediatric critical care medicine programs provide fellows with an understanding

of the biology of acute, life-threatening disease and injury and providing end-of-

life care, as well as the necessary cognitive and technical skills to prepare them

to serve as skilled clinicians, competent educators, and scholars who contribute

to scientific advances in the field.

Int.C. Length of Educational Program

The educational program 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) An accredited pediatric critical care program must be an integral

part of a core pediatric residency program, and should be

Pediatric Critical Care Medicine

sponsored by the same ACGME-accredited Sponsoring

Institution.

(Core)

I.B.1.a).(1) The pediatric critical care program should be

geographically proximate to the core pediatric residency

program.

(Detail)

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.

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,

Pediatric Critical Care Medicine

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

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

(Core)

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 GME 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) The program must be based in a specifically designed pediatric

intensive care unit (PICU) at the primary clinical site.

(Core)

I.D.1.b) Facilities and equipment in and related to that unit must be those

of a modern PICU available on a 24-hour-a-day basis, and

appropriately staffed and equipped to meet the educational needs

of the program including, but not limited to:

(Core)

I.D.1.b).(1) pediatric cardiac catheterization facility;

(Core)

I.D.1.b).(2) availability of continuous renal replacement therapy and

acute hemodialysis;

(Core)

I.D.1.b).(3) laboratories that provide complete and prompt evaluation

and support; and,

(Core)

I.D.1.b).(4) timely bedside pediatric imaging and EEG services for

patients.

(Core)

I.D.1.c) Facilities and services, including a comprehensive laboratory,

pathology and imaging, must be available.

(Core)

I.D.1.d) The program must have access to laboratories in order to perform

testing specific to pediatric critical care medicine.

(Core)

I.D.1.e) An adequate number and variety of PICU patients, ranging in age

from newborn through young adulthood, must be available to

ensure fellows develop competence in the management of such

Pediatric Critical Care Medicine

patients, including those requiring pre and post-operative care.

(Core)

I.D.1.e).(1) There should be a minimum of 700 admissions annually to

the PICU at the primary clinical site.

(Core)

I.D.1.e).(1).(a) A program having fewer admissions must

specifically demonstrate that it is able to provide the

breadth of experience required for the number of

fellows in the program.

(Core)

I.D.1.e).(2) The number of patients requiring mechanical ventilation,

and with single or multi-system organ failure, severe

trauma, and major neurologic or neurosurgical problems,

must be sufficient to provide each fellow with adequate

opportunity to become skilled in their management.

(Core)

I.D.1.e).(3) There must be sufficient exposure to the use of invasive

and non-invasive hemodynamic and intracranial monitoring

to ensure fellows’ understanding of their uses and

limitations.

(Core)

I.D.1.e).(4) There must be an affiliated pediatric cardiac surgical

program with a volume of at least 100 cases per year.

(Core)

Subspecialty-Specific Background and Intent: Pediatric cardiac surgery patients will not

necessarily all be present in the PICU since, in some sites, care for post-operative cardiac

surgery patients may be provided in a separate pediatric cardiac surgical ICU. In such cases,

therefore, provision must be made for fellows to have substantial patient care experience in

the pediatric cardiac surgical ICU, and such rotations should be considered mandatory rather

than elective experiences.

I.D.1.e).(5) Pediatric patients available to the fellows should include

those with solid organ transplantations.

(Detail)

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

Pediatric Critical Care Medicine

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)

Pediatric Critical Care Medicine

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)

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) Program leadership, in aggregate, must be provided with support

equal to a dedicated minimum time specified below for

administration of the program. This may be time spent by the

program director only or divided between the program director and

one or more associate (or assistant) program directors.

(Core)

Number of Approved

Fellow Positions

Minimum Support

Required (FTE)

< 7

0.2

7-10

0.4

11-15

0.5

>15

0.6

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.

Pediatric Critical Care Medicine

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 to fulfill their program responsibilities effectively.

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.b) must include current certification in the subspecialty for

which they are the program director by the American Board

of Pediatrics or subspecialty qualifications that are acceptable

to the Review Committee; and,

(Core)

[Note that while the Common Program Requirements deem

certification by a certifying board of the American Osteopathic

Association (AOA) acceptable, there is no AOA board that offers

certification in this subspecialty]

Subspecialty-Specific Background and Intent: Qualifications other than pediatric critical care

medicine certification by the American Board of Pediatrics (ABP) will be considered only in

exceptional circumstances. For a program director without pediatric critical care medicine

certification from the ABP, the Review Committee will consider the following criteria in

determining whether alternate qualifications are acceptable:

• completion of a pediatric critical care medicine fellowship program

• scholarship within the field of pediatric critical care medicine; specifically, evidence of

on-going scholarship documented by contributions to the peer-reviewed literature in

pediatric critical care medicine, and pediatric critical care medicine presentations at

national meetings

• leadership and/or participation on committees in national pediatric subspecialty

organizations

• current clinical activity in pediatric critical care medicine

Years of practice are not an equivalent to specialty board certification, and the Review

Committee does not accept the phrase "board eligible."

II.A.3.c) must include a record of ongoing involvement in scholarly

activities

(Core)

II.A.4. Program Director Responsibilities

Pediatric Critical Care Medicine

The program director must have responsibility, authority, and

accountability for: administration and operations; teaching and

scholarly activity; fellow recruitment and selection, evaluation, and

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

and fellow education in the context of patient care.

(Core)

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

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

(Core)

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

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

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

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

importance, therefore, that the program director model outstanding professionalism,

high quality patient care, educational excellence, and a scholarly approach to work.

The program 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)

Pediatric Critical Care Medicine

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)

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)

Pediatric Critical Care Medicine

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 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.2. Faculty members must:

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

(Core)

Pediatric Critical Care Medicine

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;

(Core)

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

at least annually; and,

(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) mentor fellows in the application of scientific principles,

epidemiology, biostatistics, and evidence-based medicine to the

clinical care of patients.

(Core)

II.B.3. Faculty Qualifications

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

their field and hold appropriate institutional appointments.

(Core)

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

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

American Board of Pediatrics or possess qualifications

judged acceptable to the Review Committee.

(Core)

[Note that while the Common Program Requirements

deem certification by a certifying board of the American

Osteopathic Association (AOA) acceptable, there is no

AOA board that offers certification in this subspecialty]

Pediatric Critical Care Medicine

Subspecialty-Specific Background and Intent: For a faculty member without pediatric critical

care medicine certification from the ABP, the Review Committee will consider the following

criteria in determining whether alternate qualifications are acceptable:

• completion of a pediatric critical care medicine fellowship program

• scholarship within the field of pediatric critical care medicine; specifically, evidence of

on-going scholarship documented by contributions to the peer-reviewed literature in

pediatric critical care medicine, and pediatric critical care medicine presentations at

national meetings

• leadership and/or participation on committees in national pediatric subspecialty

organizations

• current clinical activity in pediatric critical care medicine

If a faculty member is a recent graduate of a pediatric critical care medicine program, the

Review Committee expects that individual to take and pass the next eligible ABP subspecialty

certifying examination. If the faculty member is unable to take the next administration of the

certifying examination, an explanation should be provided.

Years of practice are not an equivalent to specialty board certification, and the Review

Committee does not accept the phrase "board eligible."

Provision of documentation of alternate qualifications is the responsibility of the program

director.

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.3.c).(1) In addition to the pediatric critical care medicine faculty

members, ABP- or AOBP-certified faculty members and

consultants in the following subspecialties must be

available:

II.B.3.c).(1).(a) neonatal-perinatal medicine;

(Core)

II.B.3.c).(1).(b) pediatric cardiology;

(Core)

II.B.3.c).(1).(c) pediatric endocrinology;

(Core)

II.B.3.c).(1).(d) pediatric emergency medicine;

(Core)

II.B.3.c).(1).(e) pediatric gastroenterology;

(Core)

II.B.3.c).(1).(f) pediatric hematology-oncology;

(Core)

II.B.3.c).(1).(g) pediatric infectious diseases; and,

(Core)

Pediatric Critical Care Medicine

II.B.3.c).(1).(h) pediatric nephrology.

(Core)

II.B.3.c).(2) The faculty should also include the following specialists

with substantial experience with pediatric problems:

II.B.3.c).(2).(a) allergist and immunologist(s);

(Core)

II.B.3.c).(2).(b) anesthesiologist(s);

(Core)

II.B.3.c).(2).(c) child abuse pediatrician(s);

(Core)

II.B.3.c).(2).(d) child and adolescent psychiatrist(s);

(Core)

II.B.3.c).(2).(e) child neurologist(s);

(Core)

II.B.3.c).(2).(f) congenital cardiac surgeon(s);

(Detail)

II.B.3.c).(2).(g) medical geneticist(s);

(Detail)

II.B.3.c).(2).(h) neurological surgeon(s);

(Core)

II.B.3.c).(2).(i) neuroradiologist(s);

(Detail)

II.B.3.c).(2).(j) orthopaedic surgeon(s);

(Detail)

II.B.3.c).(2).(k) otolaryngologist(s);

(Core)

II.B.3.c).(2).(l) pathologist(s);

(Detail)

II.B.3.c).(2).(m) pediatric surgeon(s);

(Core)

II.B.3.c).(2).(n) physiatrist(s);

(Detail)

II.B.3.c).(2).(o) radiologist(s); and,

(Core)

II.B.3.c).(2).(p) trauma surgeon(s).

(Detail)

Subspecialty-Specific Background and Intent: The Review Committee recognizes that some

programs may not have access to board certified pediatric subspecialists in some disciplines

and will allow adult subspecialists with pediatric expertise. However, it is expected that faculty

members have pediatric subspecialty certification, in those subspecialties where pediatric

subspecialty board certification is available, whenever possible. Adult subspecialists should

not be appointed as faculty members or consultants if pediatric subspecialists are available.

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

Pediatric Critical Care Medicine

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.a).(1) To ensure the quality of the educational and scholarly

activity of the program, and to provide adequate

supervision of fellows, there must be at least four core

faculty members, inclusive of the program director, who

are certified in pediatric critical care medicine by the ABP,

or who have other qualifications acceptable to the Review

Committee.

(Core)

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:

(Core)

Pediatric Critical Care Medicine

Number of Approved

Fellow Positions

Minimum FTE

1-3

0.3

4-6

0.5

7-9

0.68

10-12

0.74

13-15

0.8

16-18

0.86

19-21

0.92

22-24

0.98

25-27

1.04

28-30

1.1

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

Pediatric Critical Care Medicine

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 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 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. In order to enhance fellows’ understanding of the multidisciplinary nature

of pediatric intensive care, the following personnel with pediatric focus

and experience should be available:

II.D.1.a) child life therapist(s);

(Detail)

II.D.1.b) dietician(s);

(Detail)

II.D.1.c) hospice and palliative medicine professional(s);

(Detail)

II.D.1.d) critical care nurse(s);

(Core)

II.D.1.e) pharmacist(s);

(Core)

II.D.1.f) respiratory therapist(s),

(Core)

II.D.1.g) physical and occupational therapist(s);

(Detail)

II.D.1.h) social worker(s); and,

(Core)

II.D.1.i) speech and language therapist(s).

(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

Pediatric Critical Care Medicine

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 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) Prerequisite education for entry into a pediatric critical care

medicine program must include the satisfactory completion of a

pediatrics or combined internal medicine-pediatrics residency

program that satisfies the requirements listed in III.A.1.

(Core)

III.A.1.c) Fellow Eligibility Exception

The Review Committee for Pediatrics 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)

Pediatric Critical Care Medicine

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)

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 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.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

Pediatric Critical Care Medicine

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

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.

Pediatric Critical Care Medicine

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

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 develop competence in the clinical

skills needed in pediatric critical care medicine.

(Core)

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

consultation, perform a history and physical

examination, make informed diagnostic and

therapeutic decisions that result in optimal clinical

judgement, and develop and carry out management

plans.

(Core)

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

transfer of care that ensures seamless transitions.

(Core)

IV.B.1.b).(1).(d) In order to promote emotional resilience in children,

adolescents, and their families, fellows must:

Pediatric Critical Care Medicine

IV.B.1.b).(1).(d).(i) provide care that is sensitive to the

developmental stage of the patient with

common behavioral and mental health

issues, and the cultural context of the

patient and family; and,

(Core)

IV.B.1.b).(1).(d).(ii) demonstrate the ability to refer and/or co-

manage patients with common behavioral

and mental health issues along with

appropriate specialists when indicated.

(Core)

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

or coordinating care with a medical home for

patients with complex and chronic diseases.

(Core)

IV.B.1.b).(1).(f) Fellows must competently use and interpret

laboratory tests, imaging, and other diagnostic

procedures.

(Core)

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

and manage patients with acute, life-threatening

problems.

(Core)

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

compassionate end-of-life care and be able to

perform an accurate brain death examination.

(Core)

IV.B.1.b).(1).(i) Fellows must have the knowledge and skills to

safely direct transport of a critically-ill patient.

(Core)

IV.B.1.b).(1).(j) Fellows must demonstrate competence and

effective participation in team-based care of

critically-ill patients whose primary problem is

surgical.

(Core))

IV.B.1.b).(1).(j).(i) To meet these objectives, there must be

coordination of care and collegial

relationships among pediatric surgeons,

neonatologists, and critical care intensivists

concerning the management of medical

problems in these complex critically-ill

patients.

(Detail)

IV.B.1.b).(1).(k) Fellows must demonstrate leadership skills to

enhance team function, the learning environment,

and/or the health care delivery system/environment

with the ultimate intent of improving care of

patients.

(Core)

Pediatric Critical Care Medicine

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 the necessary

procedural skills and develop an understanding of

the indications, risks, and limitations.

(Core)

IV.B.1.b).(2).(a).(i) These procedures include peripheral arterial

and venous catheterization, central venous

catheterization, endotracheal intubation,

thoracostomy tube placement, and

resuscitation and procedural sedation.

(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 biostatistics,

clinical and laboratory research methodology, study

design, preparation of applications for funding and/or

approval of clinical research protocols, critical literature

review, principles of evidence-based medicine, ethical

principles involving clinical research, and teaching

methods.

(Core)

IV.B.1.c).(2) Fellows must demonstrate competence in their knowledge

of physiologic and pharmacologic principles, and their

ability to apply these principles to the critically-ill patient.

(Core)

IV.B.1.c).(3) Fellows must demonstrate their knowledge of life-

sustaining therapies.

(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)

Pediatric Critical Care Medicine

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 meaningful

assessment and feedback.

(Core)

IV.C.1.b) Clinical experiences should be structured to facilitate learning in a

manner that allows fellows to function as part of an effective

interprofessional team that works together longitudinally with

shared goals of patient safety and quality improvement.

(Core)

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

management if applicable for the subspecialty, including recognition

of the signs of substance use disorder.

(Core)

IV.C.3. Fellows must have a minimum of 12 months of clinical experience in an

ICU in which they have primary responsibility for providing patient care.

(Core)

IV.C.3.a) Fellows must have a minimum of eight months of critical care

experience in the PICU.

(Core)

IV.C.3.b) Fellows’ clinical experience in critical care settings other than the

PICU, including burn, medical, or neonatal ICUs, must be no more

than four months; however, if there is a pediatric cardiac ICU

separate from the PICU, two additional months may be spent in

the pediatric cardiac ICU for a total of six months of rotations in

critical care settings outside of the PICU.

(Core)

Subspecialty-Specific Background and Intent: ICU rotations in critical care environments other

than in the PICU may provide different educational experiences. However, these rotations

cannot completely replace those in the PICU. Experiences in which a fellow consults or solely

performs procedures on the care of the critically-ill patient, rather than provides primary

Pediatric Critical Care Medicine

responsibility for all facets of patient care, are not included in the limit. The operating room is

also not considered a critical care environment.

IV.C.4. Fellow education must include experience in serving as a role model and

providing supervision to residents and/or medical students.

(Core)

IV.C.5. Fellows must have a formally structured educational program in the

clinical and basic sciences related to pediatric critical care medicine.

(Core)

IV.C.5.a) The program must utilize didactic and clinical experience for fellow

education.

(Core)

IV.C.5.b) Pediatric critical care medicine conferences must occur regularly,

and must involve active fellow participation in planning and

implementation.

(Core)

IV.C.5.c) Fellow education must include instruction in:

IV.C.5.c).(1) basic and fundamental disciplines, as appropriate to

pediatric critical care medicine, such as anatomy,

physiology, biochemistry, embryology, pathology,

microbiology, pharmacology, immunology, genetics, and

nutrition/metabolism;

(Core)

IV.C.5.c).(2) pathophysiology of disease, reviews of recent advances in

clinical medicine and biomedical research, conferences

dealing with complications and death, as well as the

scientific, ethical, and legal implications of confidentiality

and informed consent;

(Core)

IV.C.5.c).(3) bioethics; and,

(Core)

IV.C.5.c).(3).(a) This should include attention to physician-patient,

physician-family, physician-physician/allied health

professional, and physician-society relationships.

(Detail)

IV.C.5.c).(4) the economics of health care and current health care

management issues, such as cost-effective patient care,

practice management, preventive care, population health,

quality improvement, resource allocation, and clinical

outcomes.

(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

Pediatric Critical Care Medicine

Program Requirements. Scholarly activities may include discovery,

integration, application, and teaching.

The ACGME recognizes the diversity of fellowships and anticipates that

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

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

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

For example, some programs may concentrate their scholarly activity on

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

programs might choose to utilize more classic forms of biomedical

research as the focus for scholarship.

IV.D.1. Program Responsibilities

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

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

(Core)

IV.D.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

Pediatric Critical Care Medicine

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)

IV.D.2.b).(1).(a) Scholarly activity must be in a field such as basic

science, clinical care, health services, health policy,

quality improvement, or education, as it relates to

pediatric critical care medicine.

(Core)

IV.D.2.b).(2) peer-reviewed publication.

(Outcome)

IV.D.3. Fellow Scholarly Activity

IV.D.3.a) Where appropriate, the core curriculum in scholarly activity should

be a collaborative effort involving all of the pediatric subspecialty

programs at the institution.

(Detail)

IV.D.3.b) Each fellow must design and conduct a scholarly project under the

guidance of the program director and a designated mentor.

(Core)

IV.D.3.c) The program must provide a scholarship oversight committee for

each fellow to oversee and evaluate their progress as related to

the scholarly project.

(Core)

IV.D.3.c).(1) Where applicable, the process of establishing fellow

scholarship oversight committees should be a collaborative

effort involving other pediatric subspecialty programs or

other experts.

(Detail)

IV.D.3.d) The scholarly experience must begin in the first year and continue

throughout the duration of the educational program.

(Core)

IV.D.3.d).(1) Fellows must have a minimum of 12 months dedicated to

research and scholarly activity including the development

of requisite skills, project completion, and presentation of

results to the scholarship oversight committee.

(Core)

V. Evaluation

V.A. Fellow Evaluation

V.A.1. Feedback and Evaluation

Pediatric Critical Care Medicine

Background and Intent: Feedback is ongoing information provided regarding aspects

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

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

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

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

Formative and summative evaluation have distinct definitions. Formative evaluation is

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

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

opportunities. More specifically, formative evaluations help:

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

• program directors and faculty members recognize where fellows are struggling

and address problems immediately

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

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

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

program completion.

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

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

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

rotations and to successfully complete the fellowship program.

Feedback, formative evaluation, and summative evaluation compare intentions with

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

subspecialty expertise.

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

frequently provide feedback on fellow performance during

each rotation or similar educational assignment.

(Core)

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

Pediatric Critical Care Medicine

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)

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.

Pediatric Critical Care Medicine

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)

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)

Pediatric Critical Care Medicine

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.

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.

Pediatric Critical Care Medicine

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)

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)

Pediatric Critical Care Medicine

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

• 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

Pediatric Critical Care Medicine

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

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.

Pediatric Critical Care Medicine

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 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

Pediatric Critical Care Medicine

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

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.

Pediatric Critical Care Medicine

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

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.

Subspecialty-Specific Background and Intent: Licensed independent professionals may

include, but are not limited to: nurse practitioners, physician assistants, psychologists,

physical and occupational therapists, speech and language therapists, dieticians, counselors,

and audiologists, as appropriate.

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, training locations, and fellow skills and abilities, even at the

same level of the educational program. The degree of supervision is expected to

Pediatric Critical Care Medicine

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.

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)

Pediatric Critical Care Medicine

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

fellows and residents in recognition of their progress

toward independence, based on the needs of each

patient and the skills of the individual resident or

fellow.

(Detail)

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

in which fellows must communicate with the supervising

faculty member(s).

(Core)

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

authority, and the circumstances under which the

fellow is permitted to act with conditional

independence.

(Outcome)

Background and Intent: The ACGME Glossary of Terms defines conditional

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

oversight.

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

duration to assess the knowledge and skills of each fellow

and to delegate to the fellow the appropriate level of patient

care authority and responsibility.

(Core)

VI.B. Professionalism

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

educate fellows and faculty members concerning the professional

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

Pediatric Critical Care Medicine

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

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

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

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

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

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

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

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

VI.B.2.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,

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.

Pediatric Critical Care Medicine

The ACGME is unable to adjudicate disputes between individuals, including residents,

faculty members, and staff members. However, information that suggests a pattern of

behavior that violates the requirement above will trigger a careful review and, if

deemed appropriate, action by the Review Committee and/or ACGME, in accordance

with ACGME Policies and Procedures.

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.

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)

Pediatric Critical Care Medicine

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).

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)

Pediatric Critical Care Medicine

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

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.

Pediatric Critical Care Medicine

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.1.a) The program director must have the authority and responsibility to

set and adjust the clinical responsibilities and ensure that fellows

have appropriate clinical responsibilities and an appropriate

patient load.

(Core)

Subspecialty-Specific Background and Intent: Insufficient patient experiences do not meet

educational needs; an excessive patient load suggests an inappropriate reliance on fellows

for service obligations, which may jeopardize the educational experience.

VI.E.1.a).(1) This must include progressive clinical, technical, and

consultative experiences that will enable each fellow to

develop expertise as a pediatric critical care medicine

consultant.

(Core)

VI.E.1.a).(2) Lines of responsibility for the fellows must be clearly

defined.

(Core)

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)

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.

Subspecialty-Specific Background and Intent: Nurses, physician assistants, advanced

practice providers, pharmacists, social workers, child-life specialists, physical and

occupational therapists, speech and language therapists, audiologists, respiratory therapists,

Pediatric Critical Care Medicine

psychologists, and dieticians are examples of professional personnel who may be part of the

interprofessional teams.

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.

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

Pediatric Critical Care Medicine

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)

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

Pediatric Critical Care Medicine

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

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)

Pediatric Critical Care Medicine

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 Pediatrics 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)

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

Pediatric Critical Care Medicine

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.