Accreditation/Re-Accreditation Information

Programs must first be approved for membership prior to undergoing the accreditation process. If you have not applied and been approved by the Membership Committee and the Board of Directors, begin here. New member programs will undergo the accreditation process six to seven months into their first Fellowship Council matched fellow’s year. Until new programs have been site visited, their accreditation status will be listed as “Pending.”

The Benefit of Accreditation

The benefit to your program from this process is that you will be recognized as an Accredited program under the auspices of the Fellowship Council.  We hope this process will enable all programs to achieve a standard of excellence in training for our fellows in minimally invasive, gastrointestinal, bariatric, non-ACGME colorectal, non-ACGME thoracic, and hepato-pancreato-biliary surgery.


Fellowship Council Accreditation Process-New Programs

In Preparation for the Site Visit

New programs will be notified when they may expect a site visit. To prepare for your Fellowship Council site visit, you will need to furnish to the Fellowship Council office all materials listed below. The site visit will be re-scheduled (at the program’s expense) and the program’s accreditation status delayed if these materials are not completely provided by the application deadline, as provided by the Fellowship Council office. Programs may submit the materials prior to the deadline to schedule an earlier site visit.

Submission Materials-Materials must be submitted via the online accreditation submission system. Programs may access this system by logging into their regular Fellowship Council User Accounts, then going to the section marked  Accreditation/Re-Accreditation and clicking on the link for Accreditation/Re-Accreditation Application. The system will pull data from the existing program listing as well as from the case log system. Therefore, prior to starting, programs will want to ensure that the information in the account (listing) and the fellows’ cases are up-to-date.

  1. Completed Fellowship Council Program Accreditation Online Application
  2. Copies of the Program Director(s) and Associate Program Director CV(s)
  3. Copies of Affiliated Faculty CV(s)
  4. Copies of Current Fellow(s) CV(s)
  5. Case Log Report-Current Fellow(s) summary report by category from the Fellowship Council Case Log System. Ensure that your current fellow is keeping their case log entry current in the Fellowship Council case log system. The Accreditation Committee will rely solely on the case log system for current case data.
  6. Case Logs-Previous Fellow(s) from the last 3 years (if applicable) summarized by case category and surgeon role (Primary, First Assistant, or Teaching Assistant)
  7. Summary ACGME Defined Category Data for Graduating Chief Residents or Canadian equivalent in the surgery training program affiliated with the fellowship for the last 3 years. Please provide the report which shows only the graduating Chief experience summarized by defined category (1-2 page report). The general surgery residency program office should have this report available.
  8. The program is required to complete the mandatory quarterly assessments as outlined here. The required mandatory technical skills assessments are here. If the program also completes an additional evaluation of the fellow, a sample evaluation may be included (de-identified).
  9. Sample Evaluation of Program and/or Faculty (de-identified)
  10. Additional Appendices (optional): Please list, e.g. curriculum, goals and objectives, etc.

Fee

The accreditation site visit fee of $2000 will need to be remitted before December 31, 2016.

The Day of the Site Visit
The site visitor will expect on the day of the site visit to interview:

-Fellowship Director and Associate Program Director
-Program Director of the General Surgery Residency at the same institution (if applicable)
-Chair or Chief of Surgery
-DIO (Designated Institutional Official) if different than Chair of Surgery
-Representatives of the teaching faculty of the fellowship
-A chief resident(s) in Surgery of the associated surgical training program at the institution (if applicable)
-Current fellow(s) presently completing the fellowship

The site reviewer has, at their discretion, the ability to contact past fellows. A tour of the facility should also be planned. The site review should take no less than four hours and no more than one day.

Following the Site Visit

Following the site review, the reviewer will make a formal written report to the Accreditation Committee of the Fellowship Council. That report will then be acted upon at a Committee meeting, and the recommendation of the Accreditation Committee will be submitted to the Fellowship Council Board of Directors. Shortly after the meeting of the Board you will be informed of the decision regarding your program’s accreditation status. The potential decisions include  3 Years, 2 Years, 1 Year Probation, and Not Accredited/Suspended. Should a program receive a decision of Probation, Not Accredited, or Suspended the process to appeal is specified in the Guidelines of the Fellowship Council. Your status will be listed on your directory listing. Programs that receive a final status of Probation or Not Accredited must notify any current and incoming fellows of that status.

The Benefit of Accreditation

The benefit to your program from this process is that you will be recognized as an Accredited program under the auspices of the Fellowship Council. We hope this process will enable all programs to achieve a standard of excellence in training for our fellows in minimally invasive, gastrointestinal, bariatric, non-ACGME colorectal, non-ACGME thoracic, and hepato-pancreato-biliary surgery. Thank you very much for your cooperation with the process.

For Accreditation Guidelines and Definitions-Click Here
For Program Guidelines- Click Here
For Curricula- Click Here


Fellowship Council Re-Accreditation Process-Online Review

All programs which received a 3 year accreditation designation are eligible for re-accreditation without a site visit. Programs may have no more than 2 consecutive reviews without a site visit. Programs which received a 1 or 2 Year accreditation designation without the stipulation of a site visit should also follow this process.

Please note: Programs which received a stipulated site visit for re-accreditation must scroll down to the appropriate section below.

In Preparation for the Re-Accreditation Review

The Fellowship Council office will notify programs that will be undergoing an online accreditation review. In order to proceed with the process, programs will need to furnish to the Fellowship Council office all materials listed below. We strongly encourage programs to submit the required materials earlier rather than later to ensure that the review process and accreditation decision can be finalized prior to the next application closing date. The program’s accreditation status may be delayed or revoked if these completed materials are not provided by the deadline date. Once the materials have been received in full, the Accreditation Committee will then assign a reviewer for your program.

Submission Materials-Materials must be submitted via the online accreditation submission system. Programs may access this system by logging into their regular Fellowship Council User Accounts, then going to the section marked  Accreditation/Re-Accreditation and clicking on the link for Accreditation/Re-Accreditation Application. The system will pull data from the existing program listing as well as from the case log system so prior to starting, programs will want to ensure that the information in the account (listing) and the fellows’ cases are up-to-d

  1. Completed Fellowship Council Program Accreditation Online Application. Programs must address any citations from the time of your last review.
  2. Copies of the Program Director(s) and Associate Program Director CV(s)
  3. Copies of Affiliated Faculty CV(s)
  4. Copies of Current Fellow(s) CV(s)
  5. Case Log Report-Current Fellow(s) summary report by category from the Fellowship Council Case Log System. Ensure that your current fellow is keeping their case log entry current in the Fellowship Council case log system. The Accreditation Committee will rely solely on the case log system for current case data.
  6. Case Logs-Previous Fellow(s) from the last 3 years (if applicable) summarized by case category and surgeon role (Primary, First Assistant, or Teaching Assistant)
  7. Summary ACGME Defined Category Data for Graduating Chief Residents or Canadian equivalent in the surgery training program affiliated with the fellowship for the last 3 years.  Please provide the report which shows only the graduating Chief experience summarized by defined category (1-2 page report). The general surgery residency program office should have this report available.
  8. The program is required to complete the mandatory quarterly assessments as outlined here. The required mandatory technical skills assessments are here. If the program also completes an additional evaluation of the fellow, a sample evaluation may be included (de-identified).
  9. Sample Evaluation of Program and/or Faculty (de-identified)
  10. Additional Appendices (optional): Please list, e.g. curriculum, goals and objectives, etc.

Additional Required Materials-These should be completed at the time of submission of the above materials. It is the program’s responsibility to follow up with the appropriate personnel to ensure that the surveys have been completed.

  1. The current Fellow(s) must complete the following survey: https://www.surveymonkey.com/r/2017_CurrentFellow
  2. All past Fellows from the time of your last site visit/review must complete the following survey: https://www.surveymonkey.com/r/2017_PastFellow
  3. The General Surgery Program Director must complete a survey: https://www.surveymonkey.com/r/2017_GSR_PD

Re-accreditation Fee:
· $850 (paper review only/no site visit required) – due on December 31, 2016
· $2000 (if site visit required) – balance of fee ($1150) due prior to physical site visit

When to Expect a Site Visit

Site visits may be deemed necessary after an initial review based on a variety of factors that include but are not limited to the following: a change in Program Director, a change in the number of fellows, a change in program type, a significant change in the associate faculty, insufficient case logs, program complaints, failure to address previous citations, and conflicts with the residency program.

Following the Initial Review

Following the initial review, the reviewer will make a formal written report to the Accreditation Committee of the Fellowship Council.  That report will then be acted upon at a Committee meeting, and the recommendation of the Accreditation Committee will be submitted to the Fellowship Council Board of Directors.  At this time you may be notified of the necessity of a physical site review.

If your review does not necessitate a site visit, shortly after the meeting of the Board you will be informed of the decision regarding your program’s accreditation status. The potential decisions include  3 Years, 2 Years, 1 Year Probation, and Not Accredited/Suspended. Should a program receive a decision of Probation, Not Accredited, or Suspended the process to appeal is specified in the Guidelines of the Fellowship Council. Your status will be listed on the program’s directory listing. Programs that receive a final status of Probation or Not Accredited must notify any current and incoming fellows of that status.

If a review has not been concluded by a specified date due to a delay by the program, the program may receive a Not-Accredited status.

Following the Site Visit (if applicable)

If a site review is deemed necessary, a reviewer will plan to visit your program. Your accreditation status will be listed as Provisional Accreditation-Under Review. Please follow the information listed below in The Day of the Site Visit section. Following the site review, the reviewer will make a formal written report to the Accreditation Committee of the Fellowship Council.  That report will then be acted upon at a Committee meeting, and the recommendation of the Accreditation Committee will be submitted to the Fellowship Council Board of Directors.The potential decisions include  3 Years, 2 Years, 1 Year Probation, and Not Accredited/Suspended. Should a program receive a decision of Probation, Not Accredited, or Suspended the process to appeal is specified in the Guidelines of the Fellowship Council. Your status will be listed on the program’s directory listing. Programs that receive a final status of Probation or Not Accredited must notify any current and incoming fellows of that status.

For Accreditation Guidelines and Definitions- Click Here
For Program Guidelines- Click Here
For Curricula- Click Here


Fellowship Council Re-Accreditation Process-Site Visit

In Preparation for the Site Visit

All previously accredited programs which received a stipulated site visit on their next review should follow this process below.

The Fellowship Council office will send the program a notification letter regarding its re-accreditation review. To prepare for your upcoming Fellowship Council site visit,  you will need to furnish to the Fellowship Council office all materials listed below.  Your accreditation status may be delayed or revoked if these completed materials are not provided by the deadline date as stipulated by the Fellowship Council office.

Submission Materials-Materials must be submitted via the online accreditation submission system. Programs may access this system by logging into their regular Fellowship Council User Accounts, then going to the section marked  Accreditation/Re-Accreditation and clicking on the link for Accreditation/Re-Accreditation Application. The system will pull data from the existing program listing as well as from the case log system so prior to starting, programs will want to ensure that the information in the account (listing) and the fellows’ cases are up-to-date.

  1. Completed Fellowship Council Program Accreditation Online Application. Programs must address any citations from the time of your last review.
  2. Copies of the Program Director(s) and Associate Program Director CV(s)
  3. Copies of Affiliated Faculty CV(s)
  4. Copies of Current Fellow(s) CV(s)
  5. Case Log Report-Current Fellow(s) summary report by category from the Fellowship Council Case Log System. Ensure that your current fellow is keeping their case log entry current in the Fellowship Council case log system. The Accreditation Committee will rely solely on the case log system for current case data.
  6. Case Logs-Previous Fellow(s) from the last 3 years (if applicable) summarized by case category and surgeon role (Primary, First Assistant, or Teaching Assistant)
  7. Summary ACGME Defined Category Data for Graduating Chief Residents or Canadian equivalent in the surgery training program affiliated with the fellowship for the last 3 years. please provide the report which shows only the graduating Chief experience summarized by defined category (1-2 page report). The general surgery residency program office should have this report available.
  8. The program is required to complete the mandatory quarterly assessments as outlined here. The required mandatory technical skills assessments are here. If the program also completes an additional evaluation of the fellow, a sample evaluation may be included (de-identified).
  9. Sample Evaluation of Program and/or Faculty (de-identified)
  10. Additional Appendices (optional): Please list, e.g. curriculum, goals and objectives, etc.

Additional Required Materials-These should be completed at the time of submission of the above materials. It is the program’s responsibility to follow up with the appropriate personnel to ensure that the surveys have been completed.

  1. The current Fellow(s) must complete the following survey: https://www.surveymonkey.com/r/2017_CurrentFellow
  2. All past Fellows from the time of your last site visit/review must complete a survey: https://www.surveymonkey.com/r/2017_PastFellow
  3. The General Surgery Program Director must complete a survey: https://www.surveymonkey.com/r/2017_GSR_PD

Fee

The accreditation site re-visit fee of $2000 will need to be remitted before December 31, 2016.

The Day of the Site Visit

The site visitor will expect on the day of the site visit to interview:

-Fellowship Director and Associate Program Director
-Program Director of the General Surgery Residency at the same institution (if applicable)
-Chair or Chief of Surgery
-DIO (Designated Institutional Official) if different than Chair of Surgery
-Representatives of the teaching faculty of the fellowship
-A chief resident(s) in Surgery of the associated surgical training program at the institution (if applicable)
-Current fellow(s) presently completing the fellowship

The site reviewer has, at their discretion, the ability to contact past fellows. A tour of the facility should also be planned. The site review should take no less than four hours and no more than one day.

Following the Site Visit

Following the site review, the reviewer will make a formal written report to the Accreditation Committee of the Fellowship Council. That report will then be acted upon at a Committee meeting, and the recommendation of the Accreditation Committee will be submitted to the Fellowship Council Board of Directors.  Shortly after the meeting of the Board you will be informed of the decision regarding your program’s accreditation status. The potential decisions include  3 Years, 2 Years, 1 Year Probation, and Not Accredited/Suspended. Should a program receive a decision of Probation, Not Accredited, or Suspended the process to appeal is specified in the Guidelines of the Fellowship Council. Your status will be listed on the program’s directory listing. Programs that receive a final status of Probation or Not Accredited must notify any current and incoming fellows of that status.

For Accreditation Guidelines and Definitions-Click Here
For Program Guidelines- Click Here
For Curricula- Click Here