INSTITUTIONAL POLICIES & PROCEDURES GRADUATE MEDICAL EDUCATION. Jamaica Hospital Medical Center

Transcription

1 INSTITUTIONAL POLICIES & PROCEDURES GRADUATE MEDICAL EDUCATION Jamaica Hospital Medical Center 2010

2 Table of Contents INSTITUTIONAL POLICIES & PROCEDURES... i I. INTRODUCTION... 1 II. INSTITUTIONAL ORGANIZATION AND RESPONSIBILITIES:... 1 A. Sponsoring Institution - Jamaica Hospital Medical Center... 1 B. Commitment to Graduate Medical Education (GME)... 1 C. Director of Academic Affairs... 2 D. Institutional Agreements:... 3 E. Accreditation for Patient Care in Sponsoring and Major Participating Sites... 3 III. INSTITUTIONAL RESPONSIBILITIES FOR RESIDENTS... 3 A. Eligibility, Selection of Residents and Application Process:... 3 B. Financial Support for Residents:... 4 C. Benefits and Conditions of Appointment:... 4 D. Agreement of Appointment:... 4 E. Resident Participation in Educational and Professional Activities... 9 F. Resident Educational and Work Environment... 9 IV. GRADUATE MEDICAL EDUCATION COMMITTEE (GMEC) A. GMEC Composition and Meetings B. GMEC Responsibilities: V. INTERNAL REVIEW A. Process: B. Internal Review Report VI. RESIDENT RESPONSIBILITIES A. Obligations: B. Adherence to Laws and Hospital Policies: C. OSHA Regulations: D. DutyAssignment..17 E. Credentialing and Delineation of Privileges VII. HIPAA/PATIENT PRIVACY Appendices 1. DISASTER POLICY DISMISSAL AND DISCIPLINARY ACTION POLICY DISRUPTIVE BEHAVIOR POLICY DUTY HOUR POLICY ELIGIBILITY, SELECTION POLICY and APPLICATION PROCESS GRIEVANCE POLICY & DUE PROCESS POLICY MOONLIGHTING POLICY POLICY ON RESIDENT CONFERENCE TRAVEL RESIDENT PHYSICIAN IMPAIRMENT POLICY RESIDENT FATIGUE, STRESS AND SLEEP DEPRIVATION POLICY HARASSMENT POLICY EQUAL OPPORTUNITY EMPLOYMENT POLICY VENDOR POLICY WORKPLACE VIOLENCE POLICY...48 i

3 GRADUATE MEDICAL EDUCATION I. INTRODUCTION Purpose of Graduate Medical Education: The purpose of Graduate Medical Education is to provide an organized structured educational program with supervision and guidance for all residents, facilitating the residents ethical, professional and personal development. Jamaica and its GME programs, through curricula, evaluation, and resident supervision, support safe and appropriate patient care. II. INSTITUTIONAL ORGANIZATION AND RESPONSIBILITIES: A. Sponsoring Institution - Jamaica Hospital Medical Center All residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) must operate under the authority and control of one Sponsoring Institution. Institutional responsibility extends to resident assignments at all participating sites of our programs. As a Sponsoring Institution, we must be in substantial compliance with the ACGME Institutional Requirements and must ensure that all of our ACGME accredited programs are in substantial compliance with the Institutional, Common and specialty-specific Program Requirements, and the ACGME Policies and Procedures. Any failure to maintain Institutional accreditation will jeopardize the accreditation of all our ACGME sponsored programs. B. Commitment to Graduate Medical Education (GME) Jamaica Hospital Medical Center s (JHMC) commitment to Graduate Medical Education is exhibited by the provision of leadership, organizational structure and resources, educational, financial and human that enables this Institution to achieve substantial compliance with the Institutional Requirements and to enable ACGME accredited programs to achieve substantial compliance with Program Requirements. This includes providing an ethical, professional and educational environment in which the curricular requirements as well as the applicable requirements of scholarly activity and the general competencies can be met. The regular assessment of the quality of the GME programs, the performance of our Residents and the use of outcome assessment results for program improvement are essential components of this Institutional commitment. Our commitment is illustrated in our Declaration of Institutional Commitment which is reviewed, dated and signed by representatives of Jamaica s governing body, administration and GME leadership. 1

4 C. Director of Academic Affairs There will be a qualified Director of Academic Affairs appointed by the governing body of Jamaica Hospital Medical Center who will act as the designated institutional official (DIO). In this role, the Director of Academic Affairs has the authority and responsibility along with the Graduate Medical Education Committee (GMEC) for the oversight and administration of all the GME programs in the Institution and is responsible for assuring compliance with ACGME Common, specialty/subspecialty-specific Program, and Institutional Requirements. The DIO will establish and implement procedures to ensure that s/he, or a designee in the absence of the DIO, reviews and cosigns all program information forms and any documents or correspondence submitted to the ACGME by program directors. The DIO and/or the Chair of the GMEC will present an annual report to the Organized Medical Staff (OMS) and the governing body of the Hospital. This report must also be given to the OMS and governing body of major participating sites that do not sponsor GME programs. This annual report will review the activities of the GMEC during the past year with attention to, at a minimum, resident supervision, resident responsibilities, resident evaluation, compliance with duty-hour standards and resident participation in patient safety and quality of care education. The GMEC and the Medical Staff will regularly communicate about the safety and quality of patient care provided by the residents. Jamaica Hospital Medical Center must provide institutional resources to ensure the effective implementation and support of its programs in compliance with the Institutional, Common, and specialty/subspecialty-specific Program Requirements. 1. Jamaica must ensure that the DIO has sufficient financial support and protected time to effectively carry out his/her educational and administrative responsibilities to the institution. 2. Jamaica must ensure that program directors have sufficient financial support and protected time to effectively carry out their educational and administrative responsibilities to their respective programs. 3. Jamaica and the program must ensure sufficient salary support and resources (e.g., time, space, technology, supplies) to allow for effective administration of the GME Office and all of its programs. 4. Faculty and residents must have ready access to adequate communication resources and technological support. 2

5 5. Residents must have ready access to specialty/subspecialty-specific and other appropriate reference material in print or electronic format. Electronic medical literature databases with search capabilities will be available. There must be administrative support for GME programs and residents in the event of a disaster or interruption in patient care and include assistance for continuation of resident assignments. See Appendix 1 for the Disaster Policy. D. Institutional Agreements: Jamaica, as the Sponsoring Institution, retains responsibility for the quality of GME, including when resident education occurs in other sites. Master affiliation agreements must be renewed every five years and must exist between the Institution and all of its major participating sites. Jamaica Hospital Medical Center must assure that each of its programs has established program letters of agreement with its participating sites in compliance with the Common Program Requirements. E. Accreditation for Patient Care in Sponsoring and Major Participating Sites that are Hospitals: As the Sponsoring Institution, Jamaica Hospital Medical Center and/or major Participating sites that are Hospitals should be accredited by The Joint Commission; accredited by another entity with reasonably equivalent standards as determined by the Institutional Review Committee (IRC); accredited by another entity granted deeming authority for participation in Medicare under Federal regulations; or recognized by another entity with reasonably equivalent standards as determined by the IRC. If a sponsoring or participating institution is not so accredited or recognized, then the Sponsoring Institution must provide a satisfactory explanation to the IRC of why neither has been granted or sought. If the Sponsoring Institution or Major Participating Sites loses its accreditation or recognition, the Sponsoring Institution must notify and provide a plan of response to the IRC within 30 days of such loss. Based on the particular circumstances, the IRC may request the ACGME to invoke its egregious or catastrophic policy. III. INSTITUTIONAL RESPONSIBILITIES FOR RESIDENTS A. Eligibility, Selection of Residents and Application Process: Jamaica has written policies and procedures for resident recruitment and appointment. Each program must be monitored for compliance. See Appendix 5 for the Eligibility and Selection of Residents Policy. 3

6 B. Financial Support for Residents: Jamaica Hospital Medical Center and participating institutions will provide all residents with appropriate financial support and benefits to ensure that residents are able to fulfill the responsibilities of their educational programs. Annual salary rates of House Staff are negotiated by the residents union, the Committee of Interns and Residents/SEIU (CIR) and Jamaica Hospital Medical Center and are as set forth in the Collective Bargaining Agreement/CIR contract. The CIR contract provides a uniform agreement of financial support and benefit package for all GME programs. Deductions required by law will be calculated and taken from all employees pay in accordance with existing legal authority and direction. Voluntary deductions will be made when authorized by eligible employees. The hospital's payroll system makes available a "direct deposit" to employees individual banking institutions. Direct Deposit is a privilege extended to residents; however, it can be cancelled at the discretion of the Director of Academic Affairs if residents fail to meet their responsibilities, such as completion of Medical Records. C. Benefits and Conditions of Appointment: The information on the terms, conditions and benefits of appointment are on the Jamaica Hospital Medical Center website. Candidates for Jamaica Hospital Medical Center s GME programs (applicants who are invited for an interview) are informed, in writing or by electronic means, of the terms, conditions, and benefits of appointment, including financial support; vacations; parental, sick, and other leaves of absence; professional liability, hospitalization, health, disability and other insurance provided for the residents and their families; and the conditions under which living quarters, meals, laundry services, or their equivalents are to be provided. The CIR Agreement provides a uniform agreement of benefits for all GME programs. The preceding terms, conditions and benefits of appointment are contained in the currently existing CIR contract and in the CIR SEIU VHHSBP Benefits Plan. D. Agreement of Appointment: All GME Programs must assure that residents are provided with a written agreement of appointment/contract, provided by the Office of Academic Affairs that outlines the terms and conditions of their appointment to a GME program. 4

7 Jamaica Hospital Medical Center monitors programs with regard to implementation of terms and conditions of appointment by program directors. Jamaica and the Program Directors must ensure that residents are informed of and adhere to established educational and clinical practices, policies, and procedures in all sites to which residents are assigned. The written agreement of appointment must contain or provide a reference to at least the following: 1. Residents responsibilities; 2. Duration of appointment; 3. Financial support; 4. Conditions for reappointment; 5. Non-renewal of Contract: In instances where a resident s contract is not going to be renewed, Programs must provide the resident(s) with a written notice of intent not to renew the resident s contract no later than seven and one-half months prior to the end of their annual contract year. However, if the primary reason(s) for the non-renewal occurs within the seven and one-half months prior to the end of the contract, programs must ensure that residents are provided with as much written notice of the intent not to renew as the circumstances will reasonably allow, prior to the end of the contract. PGY-1 residents and residents who have transferred into a Jamaica Hospital residency training program shall be notified in writing during their first year of training, six and one-half months prior to the end of their annual contract year if their contract is to be non-renewed. When a resident will not be promoted to the next level of training the Programs must provide the resident(s) with a written notice of intent no later than four months prior to the end of the resident s current agreement. If the primary reason(s) for the non-promotion occurs within the four months prior to the end of the contract, Jamaica must ensure that its programs provide the resident(s) with as much written notice of the intent not to promote as circumstances will reasonably allow, prior to the end of the contract. Residents must be allowed to implement the institution s grievance procedures (See Appendix 6 Grievance Policy or Article 13, Grievance Procedure, in the CIR contract) if they have received a written notice of intent not to renew their contracts or of intent to renew their contract but not to promote them to the next level of training. 6. Professional Liability Insurance: It is the policy of Jamaica Hospital Medical Center that Residents in all JHMC GME programs shall be provided with professional liability coverage for the 5

8 duration of residency or fellowship training. Each Resident shall be protected by such coverage regardless of whether the Resident is still employed by the Hospital at the time a professional liability claim or lawsuit is made, filed, or served, provided that such claim or lawsuit arises from acts or omissions occurring within the scope of the Resident s employment. As set forth in the Collective Bargaining Agreement between the Hospital and the Committee of Interns and Residents, such coverage provides indemnification against any and all liabilities, loss damage, costs and expenses of whatever kind or nature including counsel and attorneys fees arising from any professional liability claim or lawsuit which residents may incur by reasons of negligent acts or omissions committed or performed within the scope of the residents' employment, studies, administrative or committee functions or responsibilities, subject to certain exclusions. A detailed explanation of exclusions to coverage, rights and responsibilities of Residents and rights and responsibilities of the Hospital is set forth in the Collective Bargaining Agreement between the Hospital and the Committee of Interns and Residents, Article Health and Disability Insurance: It is the policy of Jamaica Hospital Medical Center to provide hospital and health insurance benefits for the residents and their families through the Committee for Interns & Residents Union (CIR). All insurance begins the first day of the residents contract. The Hospital provides insurance to all residents for disabilities resulting from activities that are part of the educational program. The terms of such benefits are set forth in the CIR SEIU VHHSBP Benefits Plan. 8. Leaves of Absence: a) Leave for maternity or disability is covered by the CIR contact. Leave for other reasons, personal or academic, may be approved by the program director. Approved leave is without pay or benefits and does not reduce previously earned credit. The effect of leave on earned credit (the number of months meeting GME standards towards completing requirements for board eligibility) must be provided to the resident in writing. The program director should contact ACGME and the specialty board if there is any question regarding the criteria for earned credit months. All contractual leave policies are superseded by the residents specialty Board requirements. Each program must provide information relating to access to eligibility for certification by the relevant certifying board. b) Twelve (12) days of paid sick leave shall be provided per year cumulative to a maximum of forty-eight (48) days. Disability due to maternity shall be considered as sick leave. 6

9 c) Residents who are pregnant shall, upon their request and with proper notification to their departments and documentation from their personal physician, be assigned electives and rotations appropriate to their condition, relieved of a reasonable and limited amount of night call and exposure to particularly harmful disease, radiation, and chemicals, and be allowed to schedule personal medical visits when necessary. Such requested changes shall be in conformity with the rules of the Resident s specialty board. The Hospital may require such residents to present documentation from their personal physician that they are able to continue at or return to work. Unless the department chairman declares that they are unable to work, pregnant residents may continue to work as long as they perform their modified duties in such a way as to meet satisfactory levels appropriate to their specialty board and departmental requirements before they use their accrued paid and unpaid leave time. d) Upon request, residents shall be granted up to 12 months leave of absence without pay in addition to accrued paid holidays, sick and vacation time for maternity, childcare and disability. Such residents shall be allowed to return to their positions without loss of earned credit for full or partial years of service providing that such accreditation allowances shall be made within the rules or guidelines of the resident s specialty board. Payment of short term and long- term disability compensation and the extension of insurance coverage shall be as per the provisions specified in the respective plans. e) The residents shall be allowed to schedule time for childbirth training classes for themselves or with their spouses as necessary. Adoption shall be treated the same as birth for all appropriate, leave-time purposes. Any child or day-care services provided to other hospital employees shall also be offered to residents. f) When a resident is absent for an episode of illness for several days including two consecutive nights of on-call (or is relieved as above) and upon request provides satisfactory documentation from his/her personal physician, or where a resident resigns from his/her residency program the coverage shall be provided by residents who shall either receive compensation time-off or be paid at the normal hospital resident pay rate, at the chairman s option, when performing duty above that normally published in their regular on-call schedule. Daytime coverage for a sick or disabled resident shall be shared by the remaining residents where such additional duties are not unreasonably burdensome. Where it is practical for a resident to make-up to one night s absence due to sickness or disability, he/she shall do so. g) A resident shall be paid at his/her regular pay for three (3) working days absence in the event of the death of a grandparent, parent, spouse, dependent or brother or sister; two (2) days paternity leave; and three (3) days marital leave. 7

10 h) Time off with pay for specialty exams, will be granted for a period not to exceed 3 days in which the exams are actually given. i) Education leave up to 3 days with pay, to attend medical conferences shall be granted to eligible employees, provided that appropriate coverage can be arranged within the department. Eligible employees are those residents in the final year of their basic residency, and any resident who is a chief resident or fellow. Further terms regarding educational leave including but not limited to monetary allowances and reimbursable expenses arising out of residents participation in educational conferences, are set forth in the CIR contract. j) When a resident is required to take the ACLS course, he/she shall be given time off for the length of the course. Coverage shall be arranged by the Department as required, except in an emergency, but at no additional cost to the Hospital. Paid leave time granted to a CIR delegate shall be determined by the terms of the CIR contract. k) A professional leave of absence may be granted by the chairman of the department with the approval of administration. There will be no pay benefits or credited time granted by Jamaica Hospital Medical Center during this time. 9. Counseling Services: Each Program Director must maintain a counseling system. There must be easy access to psychologists and/or psychiatrists. Preceptors will monitor & assess residents and refer to psychologists and/or psychiatrists when necessary. Program directors are responsible for monitoring residents for evidence of fatigue, behavioral changes, examples of which may include but are not limited to moodiness, self neglect, poor hygiene and/or disruptive, uncooperative, contentious behavior. Residents should refer to the CIR contract which sets forth the terms of coverage and provision for outpatient services for the treatment of mental, psychoneurotic and personality disorders. See Appendix 9 Resident Physician Impairment Policy. 10. Harassment: The Hospital has a written policy covering sexual and other forms of harassment. Appendix 11 Harassment Policy. See 11. Accommodation for disabilities: The Hospital has a written policy regarding accommodation for residents with disabilities. See Appendix Residency Closure/Reduction: 8

11 If Jamaica Hospital Medical Center intends to close or reduce the size of a GME program or close the institution, the GMEC, DIO and residents must be informed as early as possible. In the event of such a reduction or closure, residents already who are already in the program must be allowed to complete their education or such residents must be assisted in enrolling in an ACGME accredited program in which they can continue their education. 13. Restrictive Covenants: GME programs must not require residents to sign a non competition guarantee. E. Resident Participation in Educational and Professional Activities 1. Each GME program must provide effective educational experiences for residents that lead to measurable achievement of educational outcomes in the ACGME competencies as outlined in the Common and specialty/subspecialty-specific Program Requirements. 2. Residents must participate on committees and councils whose actions affect their education and/or patient care; and, 3. Residents must participate in an educational program regarding physician impairment, including substance abuse and sleep deprivation. F. Resident Educational and Work Environment Jamaica Hospital Medical Center and its GME programs provide an educational and work environment in which residents may raise and resolve issues without fear of intimidation or retaliation. This includes the following: Provision of an organizational system for residents to communicate and exchange information on their work environment and their GME programs. This may be accomplished through their participation on the GMEC, through their resident union, the CIR or other forums in which to address resident issues. A process by which individual residents can address concerns in a confidential and protected manner. Any resident may meet with the DIO to discuss any issues. All such discussions will remain confidential. Jamaica Hospital Medical Center provides services and develops health care delivery systems to minimize resident work that is extraneous to their GME programs educational goals and objectives. These services and systems include: 1. Patient support services: Peripheral intravenous access placement, phlebotomy services, and laboratory and transporter services, must be provided in a manner appropriate to and consistent with educational objectives and quality patient care. 2. Laboratory/Pathology/Radiology Services: laboratory, pathology, and radiology services must be in place to support timely and quality patient care. 9

12 3. Medical Records: A medical records system that documents the course of each patient's illness and care must be available at all times and must be adequate to support quality patient care, residents education, quality assurance activities, and provide a resource for scholarly activity. Jamaica Hospital Medical Center ensures a healthy and safe work environment that provides for: 1. Food Services: Residents have access to appropriate food services 24 hours a day while on duty in all institutions. 2. Call Rooms: Residents on call must be provided with adequate and appropriate sleeping quarters that are safe, quiet and private where possible. 3. Security/Safety: Appropriate security and personal safety measures must be provided to residents at all locations including but not limited to: parking facilities, on-call quarters, hospital and institutional grounds, and related facilities. IV. GRADUATE MEDICAL EDUCATION COMMITTEE (GMEC) A. GMEC Composition and Meetings The Graduate Medical Education Committee is responsible for monitoring and advising on all aspects of residency education. Voting membership on the committee includes the DIO; residents nominated by their peers, representative program directors, administrators, and may include other members of the faculty. At minimum two residents are elected from each program to assure consistent, adequate representation. The committee meets quarterly and maintains written minutes documenting fulfillment of the committee's responsibilities. Minutes, once approved, will be forwarded to Administration and the governing body. B. GMEC Responsibilities: The Committee will establish and implement policies and procedures regarding the quality of education and the work environment for the residents in all our programs. These policies must include: 1. The Committee will review funding for resident positions. 2. Communication with program directors: The GMEC must: a) Ensure that communication mechanisms exist between the GMEC and all program directors within the institution. 10

13 b) Ensure that program directors maintain effective communication mechanisms with the site directors at each participating site for their respective programs to maintain proper oversight at all clinical sites affiliated with the GME programs of Jamaica Hospital Medical Center. 3. The GMEC develops and implements formal written policies and procedures governing resident duty hours to ensure compliance with the Institutional, Common and specialty/subspecialty-specific Program Requirements. There are no exceptions to the resident working hours. See Appendix 4 for the Duty Hour Policy. Each GME program has established formal written policies governing resident duty hours that are consistent with the Institutional and Program Requirements and with applicable New York State Laws and Regulations, along with the negotiated terms of the CIR Agreement. These formal policies apply to all participating institutions used by the residents and address the following requirements: The educational goals of the program and learning objectives of residents must not be compromised by excessive reliance on residents to fulfill institutional service obligations. Duty-hours and call schedules must be monitored by both Jamaica Hospital Medical Center and programs and adjustments made as necessary to address excessive service demands and/or resident fatigue. Duty hours, however, must reflect the fact that responsibilities for continuing patient care are not automatically discharged at specific times. All residents are to be provided appropriate backup support when patient care responsibilities are especially difficult or prolonged; and, structuring of duty hours and on-call schedules must focus on the needs of the patient, continuity of care, and the educational needs of the resident. 4. Resident supervision: Monitor programs supervision of residents and ensure that supervision is consistent with: a) Provision of safe and effective patient care, b) Educational needs of residents, c) Progressive responsibility appropriate to residents level of education, competence, and experience; and, d) Other applicable Common and specialty/subspecialty-specific Program Requirements. 5. Communication with Medical Staff: Communication between leadership of the medical staff regarding the safety and quality of patient care that includes: a) The annual report to the OMS; b) Description of resident participation in patient safety and quality of care education; and, 11

14 c) The accreditation status of programs and any citations regarding patient care issues. 6. Curriculum and evaluation: Assurance that each program provides a curriculum and an evaluation system to ensure that residents demonstrate achievement of the six general competencies as defined in the Common and specialty/subspecialty-specific Program Requirements. 7. Resident Status: selection, evaluation, promotion, and dismissal of residents in compliance with the Institutional and Program Requirements. 8. Oversight of program accreditation: Review of all ACGME program accreditation letters of notification and monitoring of action plans for correction of citations and areas of noncompliance. 9. Management of institutional accreditation: Review of the Institutions ACGME letter of notification from the IRC and monitoring of action plans for correction of citations and areas of noncompliance. 10. Oversight of program changes: Review of the following for approval, prior to submission to the ACGME by program directors. a) All applications for ACGME accreditation of new programs; b) Changes in resident complement; c) Major changes in program structure or length of training; d) Additions and deletions of participating site; e) Appointments of new program directors; f) Progress reports requested by any Review Committee; g) Responses to all proposed adverse actions; h) Voluntary withdrawal of program accreditation; i) Requests for an appeal of an adverse action; and, j) Appeal presentations to a Board of Appeal or the ACGME. 11. Experimentation and innovation: Oversight of all phases of educational experiments and innovations that may deviate from Institutional, Common, and specialty/subspecialty-specific Program Requirements, including: 12

15 a) Approval prior to submission to the ACGME and/or respective Review Committee; b) Adherence to Procedures for Approving Proposals for Experimentation or Innovative Projects in ACGME Policies and Procedures; and; c) Monitoring quality of education provided to residents for the duration of such a project. 12. Oversight of reductions and closures: Oversight of all processes related to reductions and/or closures of: a) Individual programs; b) Major participating sites; and, c) The Sponsoring Institution. 13. Vendor interactions: Provision of a statement that addresses interactions between vendor representatives/corporations and residents/gme programs, see Appendix 13, Vendor Policy. V. INTERNAL REVIEW A. Process: 1. The GMEC must develop, implement, and oversee an internal review process as follows: a. The GMEC must designate an internal review committee(s) to review each GME program sponsored by Jamaica Hospital Medical Center. The internal review committee must include faculty, residents, and administrators from within the institution but not from within the GME program being reviewed. External reviewers may also be included on the committee as determined by the GMEC. Administrators from outside the program may also be included. b. The review must follow a written protocol approved by the GMEC that incorporates, at a minimum, the ACGME Institutional Requirements on internal reviews. 2. Internal Reviews must be in process and documented in the GMEC minutes by approximately the midpoint of the accreditation cycle. The accreditation cycle is calculated from the date of the meeting at which the final accreditation action was taken to the time of the next site visit. 13

16 3. If there are no residents enrolled in the program at the mid-point of the review cycle: the GMEC must demonstrate continued oversight of those programs through a modified internal review that ensures the program has maintained adequate faculty and staff resources, clinical volume, and other necessary curricular elements required to be in substantial compliance with the Institutional, Common and specialty-specific Program Requirements prior to the program enrolling a resident. After enrolling a resident, an internal review must be completed within the second six-month period of the resident s first year in the program. 4. The Internal Review should assess each program s: a. Compliance with the Common, specialty/subspecialty-specific Program, and Institutional Requirements; b. Educational objectives and effectiveness in meeting those objectives; c. Educational and financial resources; d. Effectiveness in addressing areas of noncompliance and concerns in previous ACGME accreditation letters of notification and previous internal reviews; e. Effectiveness of educational outcomes in the ACGME general competencies; f. Effectiveness in using evaluation tools and outcome measures to assess a resident's level of competence in each of the ACGME general competencies; and, g. Annual program improvement efforts in: Resident performance using aggregated resident data; Faculty development; Graduate performance including performance of program graduates on the certification examination; and, Program quality 5. Materials and data to be used in the review process must include: a. The ACGME Common, specialty/subspecialty-specific Program and Institutional Requirements in effect at the time of the review; 14

17 VI. b. Accreditation letters of notification from previous ACGME reviews and progress reports sent to the respective RRC; c. Reports from previous internal reviews of the program; d. Previous annual program evaluations; and, e. Results from internal or external resident surveys, if available. 6. The internal review committee must conduct interviews with the program director, key faculty members, at least one peer-selected resident from each level of training in the program, and other individuals deemed appropriate by the committee. B. Internal Review Report The written report of the internal review for each program must contain, at a minimum: The name of the program reviewed; The date of the assigned midpoint and the status of the GMEC s oversight of the internal review at that midpoint; The names and titles of the internal review committee members; A brief description of how the internal review process was conducted, including the list of the groups/individuals interviewed and the documents reviewed; Sufficient documentation to demonstrate that a comprehensive review followed the GMEC s internal review protocol; A list of the citations and areas of non-compliance or any concerns or comments from the previous ACGME accreditation letter of notification with a summary of how the program and/or institution subsequently addressed each item. The DIO and the GMEC must monitor the response by the program to actions recommended by the GMEC in the internal review process. The Sponsoring Institution must submit the most recent internal review report for each training program as a part of the Institutional Review Document (IRD). If the institutional site visitor simultaneously conducts individual program reviews at the same time as the institutional review, the internal review reports for those programs must not be shared with the site visitor. RESIDENT RESPONSIBILITIES All physicians enrolled in a Graduate Medical Education program at Jamaica Hospital Medical Center (JHMC) should perform the duties enumerated in this policy. Specific job descriptions 15

18 which further delineate the resident members' duties are the responsibility of each program to develop and distribute. A. Obligations: The following are obligations that must be met in order to provide medical care to patients. Adherence to these procedures will ensure that obligations to patients and the various accrediting organizations have been fulfilled. Residents are required to: 1. Consult the attending of record about his/her patient's condition and treatment plan at the time of admission, or within 24 hours, and any time there is a change in the patient's condition. 2. Legibly document that the patient's condition, treatment plan and orders have been discussed with the attending, who must be identified. Documentation must occur subsequent to each discussion with the attending. 3. Identify themselves by pharmacy registration identification number and year of postgraduate training. 4. Examine all patients that they are responsible for, as indicated by program's schedule, on at least a daily basis. 5. Legibly document objective observations of the patient, focusing on an assessment related to whatever problems the patient has and his/her response to a treatment or procedure. For example, if a patient had vascular surgery performed on his/her left leg; legibly document the objective findings of a vascular assessment of the left leg on at least a daily basis. 6. Respond to all requests for consults and/or intervention by your service. Requests from the Emergency Department should be responded to immediately, if possible. Only after examining the patient and discussing the patient's condition with an attending from your service, may you tell another service that intervention by your service is not indicated. 7. Legibly document that the patient has been examined and the patient's condition discussed with an attending from the resident's department. 8. Document that based upon your discussion with the attending, who is identified, admission and/or intervention or follow-up by your resident's service is not indicated. B. Adherence to Laws and Hospital Policies: Residents are required to comply with all Federal, State and Local Laws, Rules and Regulations, as well as Jamaica Hospital Medical Center s policies, procedures, rules and regulations. This includes, but is not limited to, reporting treatments and/or procedures and other occurrences having an adverse impact upon a patient, visitor or other person. 16

19 Occurrence reports must be completed by the staff member who discovers the occurrence or to whom the occurrence was reported and by the physician responsible for assessing, evaluating and treating the patient, visitor or other person. All adverse occurrences must be reported immediately to the Clinical Nurse Manager or during evening hours to the Nursing Supervisor. The Nursing Department will forward occurrence reports to the Department of Risk Management. Jamaica Hospital Medical Center will be subject to fines and other penalties when occurrences subject to mandatory reporting requirements are not reported in accordance to New York State Department of Health Regulations governing occurrence reporting requirements. C. OSHA Regulations: In addition, residents are required to comply with OSHA Regulations that prohibit wearing scrubs, booties, masks and caps, which were worn during a surgical procedure, outside of the operating room. D. Duty Assignment: Residents may be required to perform duties usually assigned to a resident at a lower or higher year of training. This may be required when needed to accomplish the education and patient care mission of the department, to improve performance deficiencies of a resident or to allow a qualified resident to advance educationally. Any such variations will be at the discretion of the program director and will be temporary. E. Credentialing and Delineation of Privileges Each GME program is responsible for the development of procedures for credentialing and privilege delineation that comply with institutional objectives. Program Directors and Departmental Chairpersons are responsible to ensure that residents are granted privileges in compliance with department specific examination, treatment and procedures. All residents will be supervised by more senior residents and by the Attending staff. In accordance with Part of the New York State Health Code, postgraduate trainees in acute care specialties such as family practice, medicine, obstetrics, pediatrics, psychiatry and surgery must be supervised by physicians who are board certified or admissible in those respective specialties or who have completed a minimum of four post-graduate years of training in such specialty. Each program must develop a plan for delineation of privileges for residents. Departmental plans for delineation of privileges should include but are not limited to the following: An explicit statement of the roles of attendings, fellows and residents in the clinical activities of the department. A general delineation of privileges for residents in each post-graduate year of training. A list of examinations, procedures and/or treatments at which the resident is to gain proficiency and the year of training in which proficiency is expected to be achieved. Such list should specify those 17

20 procedures requiring general supervision and those requiring direct supervision. A mechanism by which documentation of proficiency will take place. VII. The Departmental Chairperson or designee must be responsible for granting privileges based upon documentation of proficiency. Documentation of delineation of privileges must be maintained in residents files. Receipt and verification of documentation of delineated privileges of residents on rotation from affiliated hospitals will be the responsibility of the departmental office and the departmental Chairperson. Restrictions of delineation of privileges of residents on rotation from affiliated hospitals will be the responsibility of the department Chairperson. Evaluations of residents will be completed by the supervising physicians at the conclusion of each respective rotation within that department. Copies of all evaluations must be maintained in the residents files. The maintenance of residents credentials files is a departmental responsibility. Departments must: Conduct all required credential checks prior to acceptance into the specific residency program. Obtain all appropriate verifications of such credentials Maintain current delineation of privileges and periodic evaluations. Forward copies of all required credentialing materials to the Office of Academic Affairs. Where immediate emergency medical care is required to preserve life or to prevent serious impairment of the health of a patient, all residents must be permitted to do everything possible within the scope of their knowledge and skill to preserve the life of the patient or to prevent the occurrence of serious harm to the patient. In such case, Attending staff or a senior resident must be consulted as soon as possible. In all other cases, performance of procedures in violation of departmental credentialing requirements may lead to the contemplation of disciplinary action. As such, due process procedures pursuant to the CIR may be invoked. HIPAA/PATIENT PRIVACY Jamaica Hospital Medical Center is committed to protecting the privacy and confidentiality of health information of its patients. Protected health information (PHI) is strictly confidential and must not be given, nor confirmed to anyone who is not authorized under the medical center s policies or applicable law to receive this information. Patient health information is defined as: Any patient information in any form (written, spoken or electronic) including name or address, that relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual, and either identifies the individual or could reasonably be used to identify the individual. 18

21 PHI must be kept out of public viewing and hearing and must not be left in conference rooms, on desks, counters, or other areas that may be accessible to the public or to other employees or individuals who do not have a need to know the PHI. Caution must be exercised in sharing PHI with families and friends of patients. Such information may generally only be shared with a personal representative or with a family member, relative, or close personal friend who is involved in the patient s care or payment for that care. Information cannot be disclosed unless the patient has had an opportunity to agree or object to the disclosure. Disclosure of information that is relevant to the involvement of that family member, relative, or close personal friend in the patient s care or payment for the patient s care is permissible. Caution must be taken to protect PHI in confidential databases and workstations, when downloading, copying or removing PHI and when ing and faxing patient information. Violations of this policy will lead to disciplinary action up to and including termination of employment or contract. Any resident who knows or has reason to believe that another person has violated this policy should report the matter promptly to his or her program director or departmental chairperson or the hospital s privacy officer. 19

22 Appendix 1 Jamaica Hospital Medical Center Graduate Medical Education DISASTER POLICY In the event of a disaster impacting the graduate medical education programs sponsored by the Jamaica Hospital Medical Center the GMEC establishes this policy to protect the well being, safety and educational experience of residents enrolled in our training programs. The definition of a disaster is an event or set of events causing significant alteration to the residency experience at one or more residency programs as defined by the ACGME. Following the declaration of a disaster, the GMEC working with the DIO and other sponsoring institution leadership will strive to restructure or reconstitute the educational experience as quickly as possible following the disaster. As quickly as possible the DIO and GMEC will make the determination whether transfer to another program is necessary. Once the DIO and GMEC determine that the sponsoring institution can no longer provide an adequate educational experience for its residents, the sponsoring institution will, to the best of its ability, arrange for the temporary transfer of the residents to programs at other sponsoring institutions until such time as the Hospital is able to resume providing the experience. Where possible, residents will be transferred to one of the institutions in our network. Residents who transfer to other programs as a result of a disaster will be provided by their Program Directors with an estimated time that relocation to another program will be necessary. Should that initial time estimate need to be extended, the resident will be notified by their Program Directors using written or electronic means identifying the estimated time of the extension. If the disaster prevents the sponsoring institution from re-establishing an adequate educational experience within a reasonable amount of time following the disaster, then permanent transfers will be arranged. The DIO will be the primary institutional contact with the ACGME and the Institutional Review Committee Executive Director regarding disaster plan implementation and needs within the sponsoring institution. In the event of a disaster affecting other sponsoring institutions of graduate medical education programs, the program leadership at Jamaica Hospital Medical Center will work collaboratively with the DIO who will coordinate the ability to accept transfer residents from other institutions. This will include the process to request complement increases with the ACGME that may be required to accept additional residents for training. Programs currently under a proposed or 20

23 actual adverse accreditation decision by the ACGME will not be eligible to participate in accepting transfer residents. Programs will be responsible for establishing procedures to protect the academic and personnel files of all residents from loss or destruction by disaster. This should include at least a plan for storage of data in a separate geographic location away from the sponsoring institution. 21

24 Appendix 2 Jamaica Hospital Medical Center Graduate Medical Education DISMISSAL AND DISCIPLINARY ACTION It is the policy of Jamaica Hospital Medical Center to maintain the right to dismiss any employee. There shall be no dismissal, demotion or fine assessed against any resident except for cause until there has been a hearing between the CIR and the Hospital. Grounds for dismissal include, but are not limited to: Substance abuse; Intoxication or drinking on the Medical Center premises; Habitual or excessive absenteeism; Pilfering, theft or the deliberate destruction of Medical Center Property; Destruction or harm due to repeated acts of negligence; Insubordination; Incompetence; Fighting or creating a disturbance; Failure to follow rules and established practices; Interference with the work of others; Soliciting tips; Jeopardizing patients safety or health; Use or possession of illegal substances or dangerous weapons; Any improper conduct towards patients or other employees; Gambling; Uncorrected problems relating to personal hygiene; 22

25 Use and Disclosure of patient health information in violation of privacy regulations and the policies and procedures of the institution; Failure to render a personal service to any patient of the Medical Center if such service is within the normal and usual scope of the residents duties or is required by reason of any emergency; Misrepresentation on employment applications; Falsification of records and reports including time cards; Destruction, misuse, defacement, willful misplacement or removal of property or equipment belonging to the institution, patients, visitors, or employees without authorization. When disciplinary action is contemplated, procedures set forth in the CIR contract shall be followed. See, Benefits and Conditions of Appointment, Grievance Procedures and Due Process. 23