Hennepin County Medical Center Internal Medicine Residency Program. Resident Handbook: Policies and Guidelines

Hennepin County Medical Center Internal Medicine Residency Program Resident Handbook: Policies and Guidelines 1

Welcome On behalf of the institution and the Department of Internal Medicine, welcome to Hennepin County Medical Center. We are pleased you have chosen to train in our independent residency program with a long history of training internists in preparation for clinical, academic and community leadership positions. This manual contains information about program policies and procedures, resident roles and responsibilities, the ACGME core competencies, and the national duty hour requirements. It is meant as an accompaniment to the institutional residency manual, also available here on the New Innovations Residency Management Suite (RMS). Residents are responsible for knowing and adhering to the guidelines and policies included in this handbook. If any questions or concerns arise, residents are expected to contact the Program Director. Mission Statement The core mission of the Internal Medicine Residency at Hennepin County Medical Center is to provide outstanding training in the practice of medicine by offering our residents the opportunity to practice in an atmosphere of supervised autonomy and of scholarly inquiry. Our faculty is committed to training professionally responsible physicians focused on patient care, medical education, and scholarship. 2

Hennepin County Medical Center Internal Medicine Residency Manual I. ACGME Six General Competencies... 4 Definitions and Residency Policy Competency-Based Educational Goals and Objectives by Year of Training Clinical Responsibilities by Year of Training II. Duty Hours.. 15 Duty Hour Policy and Documentation Moonlighting Policy and Medical Licensure Ward Coverage to Ensure Duty Hour Compliance III. Elective and Selective Programs... 20 IV. Evaluation of Residents and Training Program..... 23 Evaluation of Resident Performance Policy and Grievance Procedure Evaluation of Resident Performance Sample forms Resident Evaluation of Educational Experiences Policy Resident Evaluation of Educational Experiences Sample forms Resident Selection, Evaluation, Promotion, and Dismissal Policy V. Inpatient Services: Policies and Procedures... 30 Cardiopulmonary Arrest Team (CODE team) Care of Non-Teaching Patients Consultation by and for the Department of Medicine: Guidelines Delinquent and Incomplete Charts Limitations of Resident Service: Admission and Census Caps Limited Care Plans Lines of Responsibility for Residents and Attending Physicians Order Writing Patient Death Procedures Patient Discharge from Medicine Service Patient Transfer and Transport Procedure Policy and Documentation Team Structure Sick Call and Back-up Coverage VI. Leave Policies.. 54 Extended (Family Leave) Academic Vacation VII. Medicine Clinic Policies... 60 VIII. Resident Research... 64 3

ACGME SIX GENERAL COMPETENCIES 4

GENERAL COMPETENCY DEFINITIONS AND PROGRAM POLICY The residency program requires our residents to develop the competencies in the 6 areas below to the level expected of a new practitioner. Toward this end, we define specific knowledge, skills, and attitudes required for promotion and provide educational experiences as needed in order for our residents to demonstrate the competencies. PATIENT CARE: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: 1. Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families 2. Gather essential and accurate information about their patients 3. Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment 4. Develop and carry out patient management plans 5. Counsel and educate patients and their families 6. Use information technology to support patient care decisions and patient education 7. Perform competently all medical and invasive procedures considered essential for the area of practice 8. Provide health care services aimed at preventing health problems or maintaining health 9. Work with health care professionals, including those from other disciplines, to provide patient-focused care MEDICAL KNOWLEDGE: Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to: 1. Demonstrate an investigatory and analytic thinking approach to clinical situations 2. Know and apply the basic and clinically supportive sciences which are appropriate to their discipline PRACTICE-BASED LEARNING AND IMPROVEMENT: Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to: 1. Analyze practice experience & perform practice-based improvement activities using a systematic methodology 2. Locate, appraise, & assimilate evidence from scientific studies related to their patients health problems 3. Obtain and use information about their population of patients and the larger population from which their patients are drawn 5

4. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness 5. Use information technology to manage information, access on-line medical information; and support their education 6. Facilitate the learning of students and other health care professionals INTERPERSONAL AND COMMUNICATION SKILLS: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to: 1. Create and sustain a therapeutic and ethically sound relationship with patients 2. Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills 3. Work effectively with others as a member or leader of a health care team or other professional group PROFESSIONALISM: Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: 1. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development 2. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices 3. Demonstrate sensitivity and responsiveness to patients culture, age, gender, and disabilities SYSTEMS-BASED PRACTICE: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to: 1. Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice 2. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources 3. Practice cost-effective health care and resource allocation that does not compromise quality of care 4. Advocate for quality patient care and assist patients in dealing with system complexities 5. Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance 6

COMPETENCY-BASED EDUCATIONAL GOALS AND OBJECTIVES BY YEAR OF TRAINING BY COMPLETION OF THE PGY1 YEAR, RESIDENTS SHOULD BE ABLE TO PERFORM THE FOLLOWING WITH 1. Up to 5 new admissions 2. Up to 10 hospitalized patients 3. Up to 6 patients in a ½ day continuity clinic session: Patient Care 1. Acquire accurate and relevant history from patients 2. Seek and obtain appropriate data from secondary sources 3. Perform an accurate, targeted physical exam and track important changes over time 4. Synthesize all available data to define patients central clinical problems 5. Make appropriate clinical decisions based on results of common diagnostic changes 6. Recognize urgent/emergent situations and when to seek additional guidance 7. Manage common clinical conditions with supervision, and stabilize emergent conditions Medical Knowledge 1. Understand relevant pathophysiology and basic science for common medical conditions 2. Demonstrate sufficient knowledge to diagnose and treat common medical conditions 3. Understand indications for and basic interpretation of common diagnostic testing Practice-Based Learning and Improvement 1. Appreciate the responsibility to assess and improve care collectively for a panel of patients 2. Identify learning needs as they emerge in patient care activities 3. Access appropriate medical information resources to answer clinical questions/support decisions 4. Effectively and efficiently search NLM database for original clinical research articles 5. With assistance, appraise study design, conduct and statistical analysis in clinical research papers 6. Determine if clinical evidence can be generalized to an individual patient 7. Respond productively to feedback from ALL members of the health care team 7

8. Actively participate in teaching conferences Interpersonal and Communication Skills 1. Provide comprehensive, timely verbal and written communication to patients/families/advocates 2. Effectively use verbal/nonverbal skills to establish rapport with patients/families/advocates 3. Effectively use an interpreter to engage patients, including in patient education 4. Effectively communicate with other caregivers to maintain continuity in transitions of care 5. Deliver appropriate, succinct, hypothesis-driven oral presentations 6. Effectively communicate plan of care to all members of health care team 7. Request consultative services in an effective manner 8. Clearly communicate the role of the consultant to the patient, in support of primary care team 9. Provide accurate, complete, timely written clinical documentation congruent with medical standards Professionalism 1. Document and report clinical information truthfully 2. Accept personal errors and honestly acknowledge them 3. Demonstrate empathy & compassion for all patients, with a commitment to relieve pain and suffering 4. Communicate constructive feedback to other members of the health care team 5. Respond promptly and appropriately to clinical responsibilities, including all calls and pages 6. Carry out timely interactions with colleagues, patients, and their designated caregivers 7. Recognize and manage obvious conflicts of interest 8. Ensure prompt completion of clinical, administrative and curricular tasks 9. Recognize disparities in health care that may impact care of the individual patient Systems-Based Practice 1. Understand unique roles and services provided by local health care delivery systems 2. Appreciate roles of a variety of health care providers (eg. social workers, pharmacists, PHNs) 3. Work effectively as a member within the interprofessional team to ensure safe patient care 4. Recognize health system forces that increase the risk for error 5. Identify, reflect on and learn from critical incidents (eg, near misses, preventable errors) 8

6. Reflect awareness of common socioeconomic barriers that impact patient care 7. Understand how cost-benefit analysis is applied to patient care (eg, screening guidelines) 8. Identify costs for common diagnostic or therapeutic tests and minimize unnecessary care 9

IN ADDITION TO OBJECTIVES FOR THE PGY1 YEAR, BY COMPLETION OF THE PGY2 YEAR, RESIDENTS SHOULD BE ABLE TO PERFORM THE FOLLOWING WITH 1. Up to 10 new admissions (via supervision of 2 PGY1s) 2. Up to 20 hospitalized patients (via supervision of 2 PGY1s) 3. Up to 7 patients in a ½ day continuity clinic session: Patient Care 1. Obtain relevant historical subtleties that inform and prioritize differential diagnoses and diagnostic plans, including those that might not be volunteered by patients 2. Teach how to elicit important physical findings to junior members of health care team 3. Appropriately modify differential diagnosis and care plan based on clinical course 4. Make appropriate clinical decisions based on results of more advanced diagnostic tests 5. Provide specific, responsive consultations to other services Medical Knowledge 1. Demonstrate knowledge to diagnose and manage common ambulatory and inpatient conditions, including intensive care 2. Demonstrate sufficient knowledge to provide appropriate preventive care 3. Understand indications for and have basic skills in interpreting more advanced diagnostic tests 4. Understand concepts of prior probability and test performance characteristics Practice-Based Learning and Improvement 1. Perform audit of panel of patients using standardized, disease-specific evidence-based criteria 2. Reflect on audit compared with local/national benchmarks and explore possibilities for discrepancies 3. Classify and articulate clinical questions and develop system to track, pursue and reflect on them 4. Efficiently and effectively search and apply evidence-based summary medical information resources 5. With assistance, appraise clinical guidelines 6. Customize clinical evidence for individual patients 7. Calibrate self-assessment with feedback and other external data, reflect in plans for improvement 8. Integrate teaching, feedback and evaluation with supervision of interns and students patient care 10

Interpersonal and Communication Skills 1. Engage patients/advocates in shared decision making 2. Use patient-centered education strategies 3. Role model and teach effective communication with other caregivers during transitions of care 4. Ensure succinct, relevant, and patient-specific written communication Professionalism 1. Provide support to dying patients and their families 2. Provide team leadership that respects patient dignity and autonomy 3. Recognize, respond to, & report impairments in colleagues or substandard care via review process 4. Recognize & take responsibility for times where public health supersedes individual patient needs 5. Recognize need to assist colleagues in provision of duties Systems-Based Practice 1. Manage and coordinate care and care transitions across multiple delivery systems 2. Dialogue with team members to identify risk for and prevention of medical error 3. Understand mechanisms for analysis and correction of systems errors 4. Identify the role of various health care stakeholders, including providers, suppliers, purchasers, etc 5. Understand coding and reimbursement principles 6. Demonstrate the incorporation of cost-awareness principles into standard clinical judgments 11

IN ADDITION TO OBJECTIVES FOR THE PGY1 AND PGY2 YEARS, BY COMPLETION OF THE PGY3 YEAR, RESIDENTS SHOULD BE ABLE TO: Patient Care 1. Role model gathering subtle and reliable information from the patient for junior members of the team 2. Routinely identify subtle or unusual physical findings that may influence clinical decision making 3. Recognize disease presentations that deviate from common patterns and require complex decisions 4. Manage patients with a broad spectrum of clinical disorders seen in the practice of general medicine 5. Customize care in the context of the individual patients preferences and overall health 6. Provide internal medicine consultation for patients with more complex clinical problems requiring complex risk assessment Medical Knowledge 1. Demonstrate sufficient knowledge to evaluate complex or rare medical conditions and multiple coexistent conditions 2. Understand relevant pathophysiology and basic science for uncommon/complex medical conditions 3. Demonstrate sufficient understanding of sociobehavioral sciences (eg. ethics, health economics) Practice-Based Learning and Improvement 1. Identify areas in own practice/system that can be changed to improve care 2. Engage in quality improvement intervention 3. Appraise quality of medical information resources; among them select one appropriate to question 4. Independently assess clinical guidelines for bias and cost-benefit considerations 5. Communicate risks, benefits and alternatives to patients 6. Integrate clinical evidence, clinical context and patient preferences into clinical decision making 7. Reflect, when surprised, apply new insights into future care, and reflect back on process 8. Take a leadership role in education of all members of the health care team Interpersonal and Communication Skills 1. Engage patients in shared decision making for difficult, ambiguous or controversial scenarios 2. Counsel patients about risks/benefits of tests/procedures, highlighting cost awareness/resource allocation. 12

3. Role model effective communication skills in challenging situations 4. Engage in collaborative communication with all members of the health care team 5. Communicate consultative recommendations to referring team in an effective manner Professionalism 1. Serve as a professional role model for more junior colleagues 2. Effectively advocate for individual patient needs 3. Recognize and manage conflict when patient values differ from their own 4. Embrace physicians role in assisting the public/policy makers in understanding and addressing causes of disparity in disease and suffering 5. Advocates for appropriate allocation of limited health care resources Systems-Based Practice 1. Negotiate patient-centered care among multiple care providers 2. Demonstrate how to manage the team by using skills and coordinating activities of interprofessional team members 3. Demonstrate ability to understand and engage in a system-level quality improvement intervention 4. Partner with other health care professionals to identify and propose improvement opportunities within the system 5. Demonstrate the incorporation of cost-awareness principles into complex clinical scenarios ***PLEASE REFER TO THE INSTITUTIONAL POLICY TO REVIEW REQUIREMENTS FOR SUCCESSFUL COMPLETION OF THE USMLE STEP III EXAMINATION*** 13

CLINICAL RESPONSIBILITIES BY YEAR OF TRAINING PGY1s PGY2s PGY3s Inpatient Wards: 1. Admit up to 5 patients/night H&Ps and formulate plan Admission orders Provide initial evaluation for cross coverage on call 2. Care for up to 10 inpatients Examine patients at least twice daily Daily progress notes** Write all orders Knowledge of care plan and rationale for patients Provide written & verbal signouts on PGY2/3s day off 3. Familiarize themselves with patients cared for by medical students and PGY2/3 Answer questions about care plan Act as primary provider on medical student day off Sign out medical student patients on senior day off Consultative Services: Provide initial evaluation for all patients with weekday consultation request for covered service on day of request unless otherwise specified by primary team. Provide weekend coverage for consults as agreed upon by primary team, provided they have, on average, at least one full day off in 7, including at home pager call. Ambulatory: 1. See 6 patients in a ½ day clinic 2. Create a primary care patient list on EHR, to ensure timely lab review and admission notification 2. Provide appropriate follow-up care for primary care pts 3. Complete visit notes on day of service Inpatient Wards: 1. Supervise admissions of up to 10 patients/night Review intern H&P, review of key elements Write a brief clarifying or supporting admit note after reviewing intern admission Review admission orders Provide back-up support for interns on cross cover 2. Supervise care for up to 20 inpatients Interview/examine patients at least daily Review notes & sign orders on medical student patients Dictate discharge summaries on all patients Knowledge of care plan and rationale for patients Review & cosign notes/sign all orders for medical student patients Provide verbal and written sign-outs to on-call interns Notify primary care physician of patient admission, major change in patient status, and plan for patient discharge Communicate at least daily with supervising staff physician, more frequently as necessary due to changes in patient status PGY3 responsibilities are as the PGY2s, with the addition of being responsible for in hospital consultation for PGY2s with questions or concerns Consultative Services: Responsibilities as PGY1s, with the exception that on all PGY2 consult rotations, some with weekend responsibilities. PGY3 responsibilities as PGY2s, with the exception that residents are responsible to provide weekend coverage, provided they have, on average, at least one full day off in 7, including at home pager call Ambulatory: Responsibilities as the PGY1s, with the exception of being responsible for the care of up to 9 patients per ½ day session **The progress notes should be entered in a problem oriented fashion & should include a pertinent evaluation of the patient s general condition, important events in the course of the patient s illness, & changes in physical findings. They should include the results of specific diagnostic maneuvers or any changes in treatment schedule. This policy was instituted to ensure that the residents appraisal, thought processes and plan for the patient are documented in the chart, thereby communicating to staff and consultants the rationale for the patient s care plan. 14

DUTY HOURS 15

DUTY HOURS POLICY Duty hours are defined as all clinical and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. 1. Duty hours are limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities and inclusive of internal and external moonlighting. 2. Duty periods of PGY1 residents must not exceed 16 hours duration. 3. PGY1 residents are not allowed to moonlight. 4. Residents are provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a four-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities. If you are not getting the days off, please contact one of the Chief Residents and/or the Program Director. 5. Adequate time for rest and personal activities is provided. This consists of a minimum 10-hour time period or a mandatory 8-hour time period (with justification), provided between all daily duty periods, and after in-house call. On-Call Activities The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal workday when residents are required to be immediately available at HCMC. 1. In-house call will occur no more frequently than every third night. 2. Continuous on-site duty, including in-house call, will not exceed 24 consecutive hours. Residents may remain on duty for up to 2 additional hours to participate in didactic activities, transfer care of patients and maintain continuity of medical care. Interns will not work beyond 16 consecutive hours. 3. No new patients may be accepted after 24 continuous hours on duty. A new patient is defined as any patient for whom the resident has not previously provided care. 4. At-home call (pager call) is defined as call taken from outside HCMC. 5. The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident. Residents taking at-home call are provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. 6. When residents are called into HCMC from home, the hours residents spend in-house are counted toward the 80-hour limit. Medical Students: Please follow Dr. Samuel Ives s policy on days off for students. 16

DUTY HOURS DOCUMENTATION The program requires residents to document their duty hours on a weekly basis and periodically reviews these duty hour logs to ensure compliance with ACGME requirements. These logs are also used to identify rotations consistently not in compliance, to target areas that need structural modification. We use Residency Management Suite (RMS) to track duty hours and clinical responsibilities. PLEASE TRUTHFULLY DOCUMENT IN RMS TO ACCURATELY REFLECT YOUR HOURS WORKED. MOONLIGHTING POLICY NO PGY1s ARE PERMITTED TO MOONLIGHT All residents eligible to moonlight must sign a moonlighting permission form from the Medicine Education Office at the beginning of their G2 year, and must meet requirements outlined within. We recommend against any moonlighting activity while on ward call rotations. Moonlighting activity may occur on non-ward, non-call rotations as long as it does not interfere with educational and patient care performance in the residency. Instances in which moonlighting activity is suspected to adversely impact resident performance will be investigated by the Chief Residents and the Program Director. If necessary, appropriate remediation will be initiated. Residents are not allowed to moonlight more than one consecutive night. Residents cannot moonlight when they are on back-up call. When on the Jeopardy Service, the Chief Residents will need to approve any moonlighting shifts. Residents must have a Minnesota medical license to moonlight off campus. J1 visa holders are not able to moonlight. This is consistent with ECFMG requirements. Residents MUST NOT exceed the 80 hours/week rule or the 24 hours continuous duty plus 6 additional hours for follow-up with internal or external moonlighting. The program tracks these hours. Moonlighting activity may be prohibited by the Program Director and/or Clinical Competency Committee for residents whose performance is deemed marginal. 17

MEDICAL LICENSURE A Minnesota medical license may be obtained after successfully completion of the G1 residency year. Residents must complete USMLE Step 3 by January of their PGY2 year. They are encouraged to apply for licensure as soon as possible after completion of this exam, as this reduces complications when applying for jobs at the end of residency. Additionally, once licensure is obtained, DEA registration can be completed through HCMC on a fee-exempt status, saving the resident almost $400. Completion of the USMLE Step 3 exam early during training has the additional benefit of allowing residents to focus on preparation for the ABIM certification exam during their PGY2 and PGY3 years, rather than needing to focus on preparation for the USMLE Step 3 exam, not all of which is applicable for the certification examination. International medical graduates (IMGs) must have 2 years of US medical training to apply for a MN medical license. IMGs training on a J-1 visa MAY NOT moonlight inside or outside of the training program. 18

WARD COVERAGE General Inpatient Medicine: The General Inpatient Medicine ward services consist of 6 geographical unit-based inpatient resident teams: Med1 (Nokomis), Med2 (Calhoun), Med3 (Isles), CaRe1 (Harriet), CaRe2 (Hiawatha), CMIC (Cedar). Each team will be responsible for day to day care of all patients on their team, in addition, will be responsible for admissions to their Superunit every third day from 7a-7p. Superunits are divided between the Red 5 Inpatient Medicine units (Med1, Med2, Med3) and the CaRe/CMIC units (CaRe1, CaRe2, CMIC) Night float will consist of 3 senior residents and will admit patients from 7pm-7am. There will also be a Swinger/Admitter resident to help the call teams from 4:30pm-9pm. Please ask the Chiefs if there are any questions or concerns. Yellow Medicine: There are four MICU resident teams; Yellow A, Yellow B, Yellow C, and Yellow D. In addition, there is a nightfloat system on Yellow Medicine that has been modified several times over the years to ensure duty hour compliance and to optimize quality of patient care and residents experience. The Yellow nightfloat arrives at 8pm for a verbal signout session with the Yellow Senior resident. They admit all MICU patients overnight and stay through team rounds the next morning, typically between 9-10am. This provides the opportunity for some overlap and continuity in the staff morning rounds. Interns will rotate for night coverage one week out of their four weeks in the MICU. Staff are expected to begin rounds at 8am and first see new and most unstable patients with the nightfloat resident present. Red Medicine: There are two Red (Renal) Medicine teams; Red A and Red B. In addition, there is a Red nightfloat system. The nightfloat resident covers admissions from 8pm until 7:30am. The nightfloat resident stays through post call rounds to present any overnight admissions. They must leave by 10 am at the latest. In the first half of the academic year, this responsibility will fall to PGY2s. PGY1s who have completed a month of red medicine may do some nightfloat shifts in the second half of the PGY1 year. 19

ELECTIVE AND SELECTIVE PROGRAM 20

ELECTIVE POLICY The HCMC categorical internal medicine residency is committed to providing protected time for residents to pursue professional interests in an in-depth fashion. The elective months provide an opportunity to explore clinical and clinical research opportunities not otherwise offered during the structured curriculum, or to pursue a clinically based research project. In order to maintain consistency of educational experiences and to document resident activities, the Medicine Education Office requires an elective request form to be completed at least six weeks prior to the elective period. The Program Director must approve all electives. Due to criteria for Medicare reimbursement, the elective needs to include clinical care and if research based, the research MUST BE clinical and clearly linked to the patient care experiences of the resident. Elective time spent exclusively on independent study and/or board review is not acceptable. International Health Electives Each academic year, the institution sponsors up to four internal medicine residents and up to one emergency-medicine/internal medicine resident to each spend one 4-week rotation on an international health elective. There is a competitive selection process in the spring proceeding each academic year, and residents have the opportunity to apply for one of the spots. The program has an academic exchange with a program in Bangalore, India, and San Jose, Costa Rica. Residents are encouraged to consider applying for elective time at one of these sites, but any international health elective with carefully documented structure and educational rationale will be considered. Residents in the Global Health Pathway have priority for three of the available slots each year. In addition, third year residents receive priority for international health electives, but residents from each training year are encouraged to apply. Funding is available for up to $1500 for international travel. See Michelle Herbers for an international travel packet and reimbursement paperwork AT LEAST 8-12 weeks prior to travel dates and plan to meet with the International Health Director, Dr. Ron Johannsen. Out-of-State Electives Due to administrative challenges regarding Medicare reimbursement and malpractice coverage, it is very difficult for the program to approve elective time spent outside the state of Minnesota. However, we recognize the importance of the opportunity for residents to participate in clinical care and/or research at an institution at which they are considering further training. Any resident who would like to pursue an elective at an out-of-state facility should contact the Program Director at least 6 months prior to their elective period. Local Non-HCMC Electives Many residents opt to spend elective time at a University of Minnesota based clinic or hospital. This is facilitated by the Office of Medical Education. Some residents elect to spend elective time at other facilities in the Twin Cities area (non-university based), for example, Planned Parenthood. Continuity Clinics during Elective Periods Residents should not cancel continuity clinic during their elective periods unless they have approval for an away rotation (outside of MN) AT LEAST six weeks prior to the beginning of the elective month. Refer to the Extended Leave Policy regarding arrangement of coverage for clinic related issues. Residents spending elective time at other local facilities are expected to continue their continuity clinic sessions during their elective. Residents are encouraged to consider using the relative flexibility of this month to add additional continuity clinics if they are in need of additional time to catch-up with patients who ve had difficulty getting appointments during residents inpatient months. 21

SELECTIVE POLICY We are also committed to allowing senior residents the opportunity to tailor a component of their final year of training, to address specific clinical deficiencies and/or prepare optimally for their specific planned scope of practice. The selective weeks are an opportunity to choose from a menu of HCMC based clinical opportunities not otherwise offered during the structured curriculum. In order to maintain consistency of educational experiences and to document resident activities, the Medicine Education Office has developed a number of ambulatory clinic options for selectives: if they do not choose, they will be assigned to ambulatory clinics. Alternatively, residents are welcome to design their own selective rotation. All residents must do 8 out of 10 half days a week of clinical work and they can schedule what they want in the other 2 half days a week. In order to maintain consistency of educational experiences and to document resident activities, the Medicine Education Office requires a selective request form to be completed at least six weeks prior to the selective period. The Program Director must approve all selectives. Continuity Clinics during Selective Periods Residents may not cancel continuity clinic during their selective periods. As with electives, residents are encouraged to consider using the relative flexibility of this month to add additional continuity clinics if they are in need of additional time to catch-up with patients who ve had difficulty getting appointments during residents inpatient months. 22

EVALUATION OF RESIDENTS AND TRAINING PROGRAM 23

Evaluation of Resident Performance The program is committed to the effective assessment of resident performance throughout the program, and to the use of this assessment to provide meaningful guidance and timely feedback to the residents. Through the Residency Review Committee Internal Medicine s Educational Innovations Project, we are in the process of modifying our resident evaluation process. Over the next year, we will shift to a more compete portfolio model. With support and input from a faculty advisor, each resident will be responsible for documenting developing competency in each of the six general competency areas. While there are several mechanisms through which we currently assess resident performance, the core assessment occurs through the following ways: Faculty evaluations (forms available for review in RMS): 1. Inpatient rotations: At the end of each 4 week rotation, faculty supervisors are required to provide written feedback to the residents with specific questions about their competence in each of the six core competencies. They also are expected to provide face-to-face feedback. 2. Continuity Clinic: Twice per year, the resident s core faculty preceptor in their continuity clinic Is asked to complete a written evaluation and use the form as the basis of a face-to-face session of feedback on resident performance. Continuity Clinic Evaluations (forms available for review in RMS): 1. Continuity Clinic: Periodically, continuity clinic nurses evaluate each resident s competency in professionalism, communication skills, patient care and systems- based practice. The faculty inpatient evaluations are available for resident review on-line upon completion of the evaluation. The faculty and continuity clinic evaluations are reviewed by the residents upon completion. All of these evaluations are reviewed by the Program Director or an Associate Program Director with the resident at the Semi-Annual Review. They are also reviewed by the Clinical Competency Committee on a quarterly basis. Patient Evaluations (forms available upon request from Michelle Herbers): Continuity Clinic: Each year, we ask up to 25 of your patients to complete a confidential survey about their experience of your care. The survey tool is adapted from the American Board of Internal Medicine and is similar to tools that you will encounter in practice once you complete training. The results of this survey are provided for you in summary form each year. Procedure for Appeal of a Negative Evaluation: Each resident has the right to appeal any negative faculty or nursing evaluation. They may make an appointment with the Program Director or one of the Associate Program Directors to discuss the evaluation. This appeal will be formally noted in the resident file. At the discretion of the Program Director and the resident, the resident can meet individually or in the Program Director s presence with the evaluating faculty member to discuss the evaluation. Grievance Procedure for Adverse Action by Residency Monitoring Committee In accordance with HCMC institutional policy described in HCMC Resident Reference Guide, residents have the right to appeal an adverse action recommended by the Residency Monitoring Committee. Attempts shall be made to resolve any grievance with those directly involved. Residents are encouraged 24

to work out grievances with their program director or chief of service. If the outcome is unsatisfactory to the resident, the resident can refer the grievance to the Office of the Medical Director. Residents who wish to remain anonymous may also bring grievances and complaints to their chief resident for resolution by the Resident Council or the appropriate party. Some items must be reported to the program director or medical director such as alleged harassment, suspected impairment or potential risk to patients or staff. 25

Resident Evaluation of Educational Experiences Residents have the opportunity to evaluate the quality of their educational experiences. They are encouraged to provide informal feedback to the Medicine Education Office in an informal manner and are also regularly asked to provide such feedback in the following formal ways: 1. Medicine Resident Evaluation of Faculty and Training Experience (sample form on RMS): at the end of each 4 week rotation, residents complete an on-line evaluation of the effectiveness of their faculty supervisor and of the educational value of the rotation as a whole. These evaluations are released to evaluated faculty every 6 months. They are also reviewed by the Program Director, the appropriate Division Directors, and the Chief of Medicine. They are used for departmental performance evaluations and academic promotions, and for recommendations for attending assignments. 2. Resident Evaluation of the Continuity Clinic Experience (sample forms on RMS): every 6 months, the resident evaluates their primary faculty preceptor in continuity clinic and the clinic staff and systems. These evaluations are reviewed by the evaluated faculty, the Division Director, and the Program Director. 3. End-of-Year Resident Survey: The Graduate Medical Education Committee administers a confidential survey to all HCMC Internal Medicine Residents at the end of each academic year. This is separate from and in addition to the annual ACGME survey residents complete each year. This information is presented to the Medicine Education Office in aggregate and is used to design curricular change. 4. Semi-annual Review: an explicit purpose of the semi-annual review with the Program Director or an Associate Program Director is to provide a forum for direct feedback to the program leadership about any concern a resident has with the residency program. 26

RESIDENT SELECTION, EVALUATION, PROMOTION AND DISMISSAL POLICY Our institution has formal procedures for the recruitment and appointment of residents that comply with the requirements listed below. Programs must monitor the compliance of each program with these procedures. To be eligible for a residency program at HCMC, all applicants must meet the following qualifications: A. Graduates of medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME). B. Graduates of medical schools in the United States and Canada accredited by the American Osteopathic Association (AOA). C. Graduates of medical schools outside the United States and Canada who meet one of the following qualifications: 1. Have received a currently valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) or: 2. Have a full and unrestricted license to practice medicine in a U.S. licensing jurisdiction. D. U.S. citizen graduates from medical schools outside the United States and Canada who cannot qualify under "C" (noted above), but who have successfully completed the licensure examination in a U.S. jurisdiction in which the law or regulations provide that a full and unrestricted license to practice will be granted without further examination after successful completion of a specified period of graduate medical education. E. Graduates of medical schools in the United States and its territories not accredited by the LCME but recognized by the educational and licensure authorities in a medical licensing jurisdiction who have completed the procedures described in paragraph "D" (noted above). Graduates of medical schools outside the United States who have completed a Fifth Pathway program provided by an LCME-accredited medical school (U.S. or Canadian School). Residents who meet the eligibility requirements and are selected by the faculty shall receive a contract confirming their appointment for one-year to the resident staff. Resident appointments are for a one year time period. Resident Evaluation Resident evaluation is the responsibility of the Program Director or his/her designee. A resident is evaluated at the end of each resident rotation by the medical staff and this is sent to the Program Director or his/her designee. In addition, other feedback to the Program Director or his/her designee may include the results of standardized tests, patient simulations, input from patients and other hospital staff. The Program Director or his/her designee must meet with each resident at least twice a year and, based on the resident's progress, may promote the resident to the next year of training. Residents may also be placed on suspension, probation or dismissed based on the judgment of the Program Director or his/her designee. Residents have access to an appeal mechanism and due process in accord with their contract. 27

Resident Promotion All residents enter into annual contracts with Hennepin County Medical Center, regardless of the expected duration of their training program. Most training positions are ongoing "categorical" positions, while some programs may use a small percentage of "preliminary" or temporary slots. Residents in categorical positions will be promoted from each level of training after satisfying all requirements for that training level and offered subsequent annual contracts through program completion unless: They are dismissed or their contracts are not renewed based on academic performance which is below satisfactory; They are dismissed or their contracts are not renewed based on non-academic behavioral violations; They are ineligible for a continued appointment at the time renewal decisions are made based on failure to satisfy licensure, visa, immunization, registration or other eligibility requirements for training; or Their residency program is reduced in size or closed. It is unlikely that existing residents will be displaced by a program closure or reductions. However, if this occurs, HCMC will make every effort to assist the residents in locating another training program where they can continue their education. Resident Dismissal A. The following actions shall entitle the resident to a hearing upon timely and proper request. 1. Non-renewal of contract; 2. Suspension of over 30 days from residency program; or 3. Termination from residency program. B. Prior to the imposition of any action which entitles a resident to a hearing, the resident shall be given written notice which: 1. States the specific grounds upon which the action is based; 2. Advises the resident of the opportunity to meet with the Residency Director, Department Head or his/her designee; 3. Advises the resident of his/her right to request a hearing; 4. Informs the resident he/she has 14 days, after receipt, to request a hearing; 5. Informs the resident a written request for hearing is to be directed to the Medical Director; and 6. States that failure to request a hearing constitutes waiver of all rights to appeal. C. Following the receipt of a request for hearing the Medical Director shall convene a hearing panel consisting of one member of the medical staff and one resident. D. The appeal hearing shall be informal as opposed to an evidentiary hearing. At the appeal, the resident shall have the right to an advisor, who may be a fellow resident, faculty member, an attorney or any other advisor of the resident s choosing. E. The resident and program director shall have the right to present information, including written or oral statements from individuals whose attendance he/she is able to arrange if pertinent to the issues at hand. Personal attendance of fact evidence is preferred so that questions may be asked. 28

F. The panel shall have the right to adopt, reject, or modify the previous decision and shall make a recommendation to the medical director. The medical director shall make a final decision and notify the resident and program director of his/her decision in writing. G. The medical director s decision shall be final. No further appeal process is available. The Medical Center and the resident s department shall impose immediate suspension upon a resident if they determine that the resident s continued participation in the program is detrimental to patient safety or the delivery of quality patient care. 29

INPATIENT SERVICES: POLICIES AND PROCEDURES CARDIOPULMONARY ARREST PROCEDURES 30

HCMC ARREST TEAM PURPOSE: Provide timely, consistent, and appropriate response to medical emergencies that occur within the medical center. I. Members of the Arrest Team (CODE team) A. Physicians 1. Staff physician (Chief resident or hospitalist) to provide oversight 2. All on-call medicine residents available on all teams. 3. A senior Surgery resident will also respond to arrests and provide assistance with any necessary procedures. B. Respiratory Therapist C. ICU staff nurse (CCU, MICU or SICU) D. Nursing Supervisor E. Nurse Anesthetist Note: Due to concerns for overcrowding, students are asked to NOT enter the room during a code unless specifically asked. II. Guidelines for Arrest Team Members A. Each member of the arrest team will be oriented to: Use of the code beepers (admission pager), location of HCMC departments, specific roles of arrest team members, and location and use of emergency equipment. B. Team members will respond to all emergency situations, including all intensive care units and patient care areas, and will be individually excused from the area if not needed. C. Team members should respond STAT to all emergency pages. D. The code beeper will be passed from arrest team member to arrest team member to ensure continuous coverage. The beeper will be passed on at the end of the team member s shift and at any time the team member determines he/she is unable to respond in a timely manner to a code page. III. Arrest Team Beepers (Code Beepers) A. Each of the Medicine service admission pagers receives CODE pages. Initially, residents will be paged with the message 1111 followed by a later page with the specific location of the code. B. Beepers carried at all times by arrest team members, in addition to beepers carried for normal communications. IV. Roles of Arrest Team Members A. Physicians: For all emergency situations that involve inpatients, the patient s primary physician will direct the resuscitation efforts. In the absence of the primary physician, the arrest team physician will be in charge until the arrival of the primary physician. The code team leader should identify themselves and run the code. 31

If the arrest victim is a surgery patient, the Surgery resident will direct the resuscitation efforts with the assistance of the Medicine residents (i.e., line placements, blood draws, monitoring rhythm). If the arrest victim is not a surgery patient or is not a patient, the Medicine resident will direct the resuscitation efforts with the assistance of the Surgery resident. B. Nurse Anesthetist: Performs intubation as needed. C. Respiratory Therapist: Maintains airway and ventilates patient, sets up respiratory equipment. D. ICU Staff Nurse: Note: If the arrest victim is a patient in a unit or team center, or in an outpatient clinic, the patient s assigned nurse will maintain primary nursing responsibility for the patient. The ICU staff nurse will prepare medications, IV set-ups, and syringes for blood draws; assist with the monitor/defibrillator; and act as a resource regarding the location of specialized equipment that may be requested. E. Off-shift, weekend, or holiday: Nursing Supervisor 1. Page additional personnel to location, if necessary. 2. Act as recorder, if no other personnel available. 3. Notify unit of impending transfer, as appropriate. 4. Assist with family members. F. Security Guard: For emergencies occurring in non-patient areas, a security guard will be paged to the scene by the operator. The guard will bring a stretcher to the scene for transport to an ICU or to the ED. V. Procedure for Emergencies on Inpatient Areas (Team Centers and ICUs) A. Management of cardiopulmonary arrest prior to arrival of arrest team. 1. Initiate resuscitation in accordance with the recommendation of the AHA for witnessed or unwitnessed cardiopulmonary arrest. If alone, summon help while initiating CPR. 2. Nurses will likely be the first medical personnel on the scene of an arrest and will be responsible for initiation of CPR until the arrival of the arrest team. 3. Activate the emergency paging system by calling x116. Inform the operator of the arrest and its location. ICU areas should push the red emergency button on the life support column. STATE THE RESIDENT IN CHARGE OF THE PATIENT. 4. The emergency operator will a. Activate the code beeper paging system, causing the simultaneous paging of all arrest team members, and b. Overhead page Code Team to (location). The page will be repeated twice, thirty seconds apart. 32