E. Assurance that each residency program establishes and implements formal written criteria and processes for the selection, evaluation, promotion, and dismissal of residents in compliance with both the Institutional and relevant Program Requirements.

F. Assurance of an educational environment in which residents may raise and resolve issues without fear of intimidation or retaliation. This includes:

1. Establishment of a resident subcommittee with peer elected representatives from each residency program which meets monthly to communicate and exchange information on working environment and educational programs.
2. As directed by the GMEC, the Associate Dean for GME serves as an ombudsman for all resident concerns. Residents are also encouraged to discuss their concerns with the Chair of the GMEC.
3. Establishment and implementation of fair institutional policies and procedures for academic or other disciplinary actions taken against residents (see Due Process Policy below)
4. Establishment and implementation of fair institutional policies and procedures for adjudication of resident complaints and grievances related to actions which could result in dismissal or could significantly threaten a resident's career development. (See Due Process Policy)
   

G. Collecting of intra-institutional information and making recommendation on the appropriate funding for resident positions, including benefits and support services.

H. Monitoring of the programs in establishing an appropriate work environment and the duty hours of residents. This is accomplished by:

1. Site visits in conjunction with Internal Reviews
2. Regular monitoring by GMEC resident subcommittee and GMEC Subcommittee on
   Resident Working Conditions
3. Quarterly surveys of resident working hours and compliance with 405. regulations
   

I. Assurance that the residents curriculum provides a regular review of ethical, socioeconomic, medical/legal, and cost-containment issues that affect GME and medical practice. The curriculum must also provide an appropriate introduction to communication skills and research design, statistics, and critical review of the literature necessary for acquiring skills for lifelong learning. The Core curriculum of each program is monitored through annual reports and a GME Office annual document audit site visit that is submitted to the GMEC.



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GMEC EXECUTIVE COMMITTEE

The GMEC appoints from among its members an Executive Committee empowered to act in its behalf when not in session. The Executive Committee will consist of the Chair of the GMEC and Chair or Program Directors from Emergency Medicine, Internal Medicine, Ob/Gyn, Pediatrics, Psychiatry, Surgery, one department rotating annually, and the resident representative to the GMEC. The Dean of the Medical School and the Associate Dean for GME serve ex officio. Appointments to the Executive Committee will be for a term of one academic year beginning July 1 and ending June 30. All actions of the Executive Committee are subject to final approval by the GMEC at its next scheduled meeting.



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GMEC SUBCOMMITTEES
The following subcommittees are charged with monitoring and assuring program compliance with GMEC policies.
ACGME General Competencies and Outcomes Assessment - (Chair, Stephan Wadowski, M.D., Pediatrics Program Director)
Educational Policy - (Chair, Stanley Fisher, M.D., Pediatrics Department Chair)
Program Directors - (Chair, Monica Dweck, M.D., Ophthalmology Program Director)
Resident Working Conditions - (Chair, Audree Bendo, M.D. Anesthesiology Program Director)
Resident Subcommittee Sub-committee members (and alternates) from each core program are elected annually by their peers. The Resident Subcommittee serves as a forum for communication and exchange of information, and provides input to the GMEC on resident issues and concerns. Meetings are scheduled on the same day as the GMEC from 12:30 -1:30 pm.
Institutional Review Committees for the following areas of concern:
- Monitoring of RRC citations
- Computer Technology
- Resident Communication
- Inadequate Scholarly Activity


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INSTITUTIONAL AFFILIATION AGREEMENTS
When resident education occurs in a participating institution, SUNY-DOWNSTATE continues to have responsibility for the quality of that educational experience and must retain authority over the residents’ activities.

Master Affiliation Agreements must exist with all of our major participating institutions and Letters of Agreement for each residency program are to be appended to the Master Agreements. These letters must include:

1. names and titles of the officials at the participating institution or facility who will assume administrative, educational, and supervisory responsibility for the resident(s); Participating Affiliate Faculty must maintain faculty appointments with the SUNY Downstate College of Medicine.
2. an outline the educational goals and objectives to be attained within the participating institutions;
3. the period of assignment of the residents to the participating institution, the financial arrangements, and the details for insurance and benefits;
4. a statement of the participating institution's responsibilities for teaching, supervision, and formal evaluation of the residents' performances;
5. the participating institution’s policies and procedures that govern the residents' education while rotating to the participating institution.

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ACCREDITATION FOR PATIENT CARE
All affiliated hospitals participating in SUNY sponsored residency programs must be accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).


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QUALITY ASSURANCE
SUNY Downstate at Brooklyn must monitor and ensure resident knowledge of, and participation in its formal quality assurance programs. This will be accomplished through the GMEC’s periodic internal reviews and on-going oversight by the GME Office. In addition, presentations on quality assurance, including lectures and educational films, will be given to all new residents at orientation held each June.



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RESIDENT ADMISSIONS POLICY — ELIGIBILITY AND SELECTION
All programs must select from among eligible applicants on the basis of their preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity. No program may discriminate with regard to sex, race, age, religion, color, national origin, disability or veteran status.

Applicants with one of the following qualifications are eligible for appointment to accredited residency programs at SUNY-Downstate :
- Graduates of medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME)
- Graduates of colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA)
- Graduate of medical schools outside the United States and Canada who meet one of the following qualifications:
- Have a currently valid certificate from the Educational Commission for Foreign Medical Graduates or
- Have a full and unrestricted license to practice medicine in a U.S. licensing jurisdiction.
- Graduates of medical schools outside the U.S. who have completed a Fifth Pathway program provided by an LCME accredited medical school

Dental residents must hold a DDS or DMD degree from a school approved by the Commission on Dental Accreditation and a NYS License/Limited Permit.

All programs must participate in the National Residency Matching Program. Any exceptions must be approved by the GMEC. When programs do not fill through the match, residents may subsequently be appointed to unfilled positions from the pool of unmatched students, or other sources, as long as they meet institutional standards.

Each program must have a set of written standards, appropriate to the specialty, to guide resident selection. For each program, the selection of residents should be the responsibility of a committee of the faculty which has the opportunity to review application materials, rate residents against the published selection standards, and agree as a group on those residents to be selected either through the match or otherwise. Such decisions should ordinarily not be those of an individual program leader.

The enrollment of non-eligible residents may be a cause for withdrawal of accreditation by the ACGME.

Completion of USMLE or COMLEX Licensing examinations by residents in training at SUNY – Downstate Medical Center.

Purpose: To insure that residents enrolled in graduate medical education programs meet eligibility requirements to obtain medical licensure beyond the level of the Physician in
Training permit.

Policy:
The GME Committee at SUNY –Downstate Medical Center believes that graduates of GMEC approved programs must be capable, by completion of their training, of performing competent and independent practice in that specialty. A medical license is necessary for independent medical practice. An essential parameter for obtaining a medical license is the satisfactory completion of the USMLE or COMLEX examinations.

Entry into PGY-1 Year
All residents in SUNY Downstate Medical Center GMEC approved programs are required to successfully complete and pass USMLE Step 1 or COMLEX Part 1 for appointment to a PGY-1 position. Graduates of international medical schools must have passed both Steps 1 and 2(CK and CS) of the USMLE and hold a valid ECFMG certificate.

Entry into PGY-2 Year
All residents in SUNY Downstate Medical Center GMEC approved programs are required to successfully complete and pass USMLE Step 2 (CK and CS) or COMLEX
Part 2 examinations by November 1st in the first post-graduate year of training. Failure to demonstrate passage within the stated time line will result in a notice of non-renewal of training which may be rescinded by the program if the resident passes the required examinations by the end of the academic year.

Entry into PGY-3 Year
All residents in SUNY Downstate Medical Center GMEC approved programs are required to successfully complete and pass USMLE Step 3 or COMLEX Part 3 examinations by November 1st in the second post-graduate year of training. Failure to demonstrate passage within the stated time line will result in a notice of non-renewal of training which may be rescinded by the program if the resident passes the required examinations by the end of the academic year. Individual residents who have received a statement of non-renewal are entitled to due process, which includes criteria established by each training program for remediation and withdrawal of the notification. In addition, individual training programs reserve the right to establish more stringent written criteria as a determinant of eligibility for applicants to be selected for placement in a training program or for promotion. These requirements apply to residents transferring into GMEC approved core residency programs and residents entering into GMEC approved fellowship programs.
Exceptions to this policy require approval by GMEC which shall not be unreasonably withheld.
Approved by GMEC 3/8/2006

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POLICY ON RESIDENT APPOINTMENT, AND REAPPOINTMENT
All appointments (contracts) are for one year and each resident must be re-appointed for each subsequent year of training, contingent upon satisfactory completion of the current post-graduate year. All residents are appointed as Clinical Assistant Instructors at SUNY-Downstate but are salaried by an affiliated hospital

Recommendations for the appointment and reappointment of residents are initiated by programs and sent to the Office for Graduate Medical Education.

Deadlines Non-renewal of Appointment --A resident whose performance fails to meet the level of competence for reappointment shall be notified by his/her department in writing of the intent not to renew the contract. Residents who have July 1st appointments will be notified by November 15 (December 15th at PGY-1).

Specific guidelines for decisions on termination of contracts, or non-reappointment are found in the Due Process and Appeals Policy.

Residents are expected to notify their department sufficiently in advance if they do not intend to return the following year.

Appointment and/or reappointment do not constitute an assurance of successful completion of a residency program or post-graduate year. Successful completion is based on performance as measured by individual departmental standards.

Revisions approved by GMEC 4/11/2001



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CREDENTIALING

It is SUNY Downstate's policy, in compliance with the regulations of the New York State Health Codes (Part 405.4) that all residents accepted into SUNY Downstate programs must provide credentialing documentation prior to their appointment as house staff physicians.

Each year during the third week of June a credentialing fair is held for all new residents regardless of pay source. For those unable to attend the credentialing fair it is imperative that they contact the GME House Staff Office at (718) 270-4221 or contact their program director to try to reschedule. (See Section II for a list of required documents.)

Residents’ files are reviewed on an annual basis and are required to maintain an updated credentialing file each year.



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NAME CHANGE
Residents must notify the GME Office within 30 days of a name change. In order to officially change a name original legal documentation must be submitted to the GME Office.



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CHANGING RESIDENCY PROGRAMS BY SUNY RESIDENTS
It is recognized that residents may change their career plans during their residency. When such changes occur, residents are expected to honor the full year of commitment to their originally chosen residency program. In addition, as soon as a resident is very seriously considering changing training programs, he or she should notify the current Program Director so that the maximum possible lead-time is allowed for that program's planning and recruitment. Program Directors who have agreed to accept into their programs current residents in other SUNY-Downstate residencies should also respect the concept that commitments should be honored for the full year. Only if both the affected Program Directors agree should a different timetable be used. Program Directors should not actively seek to recruit residents from other SUNY Downstate programs to their residency. However, when there is reason to believe that there is mutual interest, exploratory contact may be appropriate. Residents considering a career change should feel free to obtain advice and counsel from any faculty member. If and when such discussions move to consideration of action regarding career change, early notification of the current Program Director is strongly recommended; preferably, both the involved resident, AND the discussant/confidante/advisor should contact the home Program Director. Any SUNY-DOWNSTATE program Director considering acceptance of a transferring resident from another program should inform the home Program Director in a timely fashion, irrespective of when the proposed change is to take place. All reasonable efforts should be made to honor prior commitments fully. All discussions and communications beyond the exploratory stage should be documented, including written approval between the two Program Directors if a transfer is made. If agreement cannot be reached between the two Program Directors, an ad hoc committee of two Program Directors and one resident will be formed to decide the issue.

Approved by GMEC 4/11/2001



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RESIDENT EVALUATION POLICIES AND PROCEDURE

1. Each graduate medical education program determines its methods of evaluation (i.e. clinical, in-service, chart review, observed clinical exam, and oral exams) consistent with sound pedagogical practice and the requirements of its Residency Review Committee (RRC).
   
   
2. Each program must establish a Resident Evaluation Committee that monitors the progress of each resident and makes recommendations to the Program Director. This committee should meet at least two times per year. This committee or a departmental sub-committee serves as the first step in the program's academic appeals process.
   
   
3. Each program should institute an advisory system assigning each resident to an advisor. This advisor will become a liaison between the resident and the evaluation committee and will meet for follow-up with the residents at least twice yearly.
   
   
4. The Chairman/Program Director or designee must meet with each resident at least every 6 months to review progress and discuss future promotion in the residency program.
   
   
5. All meetings related to formal evaluation between resident and representatives of program must be documented, signed and dated by resident and representative, and placed in resident's academic file immediately. (See academic file policy)
   
   
6. If a resident is subject to any type of adverse action (suspension, letter of warning, probation, termination, non-renewal of contract), the Office of the Associate Dean for GME must be notified. (See Due Process Policy Below)
   
   
7. A Resident Promotion Form must be completed at the end of the academic year on each resident.
   
   
8. In discussing adverse actions with residents, the Program Director or designee must outline specific problem areas, define with the resident the methods that will be used to address these, and determine a timetable for improvement. Clear criteria for determining improvement must be articulated. A follow-up meeting should be scheduled to determine status. These meetings must be documented and signed by both parties and placed in the resident's evaluation file with a copy to the GME Office. (See Due Process Policy below).
   
   
9. All evaluation documentation should be open for direct review, in the departmental office, by the resident when requested.
   
   

Evaluations of Resident Performance

1. Evaluations should be in writing and completed at the end of each month or rotation or when appropriate. Evaluations should be discussed with the resident. All evaluations that are marginal or unsatisfactory, must be discussed with the resident in an exit interview at the end of the rotation and signed by both the resident and the evaluator or referred to the program’s resident evaluation committee for review and action.
   
   
2. Programs are required to prepare evaluation forms that address areas of knowledge, skills and attitude and contain space for comments at each evaluation point. The form should also have an overall evaluation rating and space for defining strengths and weaknesses and suggestions for future remediation. There should be space for resident signature and date of review. An updated copy of the form must be on file in the GME Office.
   
   
3. Completed evaluation forms should be returned by the evaluator to the departmental office within a reasonable time after the resident completes the evaluation period.
   
   
4. The forms should be reviewed for completeness by the Program Director and followed-up in cases of inadequate documentation.
   

In cases where the evaluator has not sufficiently documented his/her evaluation, the evaluator should be called by the program director to correct deficiencies. (i.e. no comments for below average performance, inconsistency between written and numerical evaluation).

Resident Evaluation of Program and Faculty
Residents must be given the opportunity to evaluate their program and teachers at least
once a year. This evaluation must be confidential and anonymous.

Approved by GMEC 1996
Revisions approved by GMEC 4/11/01



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GRIEVANCE AND DUE PROCESS
The SUNY-Downstate GME Committee monitors, oversees and facilitates individual program compliance with institutional, ACGME, and RRC guidelines for due process in regard to:

(1) Review and Evaluation of Resident Performance: academic or other disciplinary actions taken against residents that could result in dismissal, nonrenewal of a resident's agreement or other actions that could ignificantly threaten a resident's intended career development; and,

(2) Adjudication of resident complaints and grievances related to the work environment or issues related to the program or faculty.

(1) Review and Evaluation of Resident Performance: Adverse actions and decisions in all SUNY-Downstate programs are based on department specific educational requirements and expectations for resident performance. Departmental guidelines and procedures for resident review and evaluation must be explicit and in written form and consistent with RRC requirements. These guidelines and procedures must meet the Downstate standards set below. An evaluation of program due process procedures is a part of the GME Committee internal review protocol and subject to audit by the GME Office.

(i) Letter of Warning --When a resident's performance is not adequate, notification of the deficiencies must be made in a “letter of warning” to the resident by the program director with copies to the GME Office. A plan to correct deficiencies, which include the manner and time frame in which the deficiencies will be corrected, and the consequences of not correcting the deficiencies within the time frame, should be a part of this notice. This plan may or may not include a period of monitored performance. A letter to the resident, which specifies the corrective action, must indicate that possible outcomes of failure to fully satisfy the terms of the corrective action may include probation, contract nonrenewal or termination. Residents who successfully correct deficiencies according to terms described in a “letter of warning” must be so notified in writing.

(ii) Probation – Probation may include a plan to correct deficiencies but is distinguished by being a reportable status in the resident’s permanent academic file. A letter to the resident, which specifies probation, must indicate that possible outcomes of failure to fully satisfy the terms of probation may include, contract non-renewal or termination of the resident’s appointment at the end of the period of probation.

(iii) Suspension-- If, in the judgment of the program director or department chairman, a resident’s professional competence or behavior may endanger patients or disrupt the educational process; the resident may be suspended immediately pending investigation and application of due process. In such cases, the GME Office and the affiliate hospital that salaries the resident must be notified prior to the suspension if possible, or, if this is not possible, on the next regular business day following suspension. Written confirmation of the suspension and planned review shall be given to the resident as promptly as possible.

(iv) Notice of adverse action -- Any notice of probation, suspension, termination, or nonpromotion of a resident must be in writing, must generally state the reasons for the action, and must be reviewed with the resident, who must sign and date the notice indicating its content has been reviewed with him/her. It must also inform the resident of his/her right to appeal as described below. Copies of program and GMEC grievance policies and procedures should be appended to the notice. A copy of this signed notice must be sent to the Associate Dean for Graduate Medical Education and the affiliate hospital that salaries the resident.

SUNY-Downstate Due Process and Grievance Policies and Procedures are independent (and complementary to those set forth by HHC CIR- Collective Bargaining Agreement, the Brooklyn VA and other affiliated hospital procedures.

(v) Resident appeals of adverse action Residents who challenge an evaluation of their academic performance in a required educational activity, or who challenge an unfavorable academic standing or status assigned to them because of inadequate evaluations of their performance may request a review of the evaluation or of the academic status, or both.

Each residency program has established procedures for considering such requests.Residents who wish to request a review of an academic grievance should submit such a request in writing to the program Director within 15 days of the grieved action.

If the issue is not resolved through completion of the program's grievance procedure, residents may then address a petition to the GME Committee for a review of their case and of the program's decision's on it. The GME Committee may appoint and refer such petitions to an Ad Hoc Resident Grievance Sub-committee.

To initiate the appeal process, the resident shall notify the Associate Dean for Graduate Medical Education. This notice shall be in writing, and must be delivered to the Graduate Medial Education Committee (GME Office 270-1984 fax 270-2408) within 15 working days of the resident's notification by the Program Director. Such notification must include the reasons for the requested appeal. Upon receipt of the appeal, the GME Office will request the program director to submit the resident's departmental file and any other materials on which it bases its decision to the Office for Graduate Medical Education, for distribution to the committee.

Within ten working days of receipt of the request for appeal, the GMEC Chair will appoint an ad hoc committee, and will notify the resident and the members of the ad hoc committee in writing of the committee's appointment with a copy to the program director and chair. The chair of said ad hoc committee will be a member of the Graduate Medical Education Committee, and one additional faculty member, and one resident will comprise the committee.

Eligible faculty for the ad hoc committee are defined as full-time physician faculty members of clinical departments in the College of Medicine with the rank of Assistant Professor or higher, and may not be members of the department which sponsors the resident's program. The resident member of this committee must be from a department other than that which sponsors the aggrieved resident's program. The appealing resident may request replacement of an ad hoc committee appointee with cause. The ad hoc committee will determine the process. If the process includes an appeal hearing it must occur within 30 days of the committees’ appointment.

Upon written request, the resident will be provided with a photocopy of summary academic evaluations and photocopies of any correspondence to the resident from the program, before the hearing is held.

If a hearing is deemed appropriate by the ad hoc committee, the process of the hearing will not be rigidly prescribed, except that, the resident shall be given the opportunity to appear before the committee and will be allowed to be accompanied by an advocate who is not an attorney. The resident should be prepared to present evidence for rescinding the action. The program director should appear and be prepared to present evidence for upholding the action.

The hearing shall be confidential and open only to the committee members, the resident, and if invited, by an advocate. If either the program director or resident would desire individuals with factual information regarding the decision of the department, above and beyond information in the file, to appear before the committee, the interested party may make the appropriate arrangements. The hearing may only be rescheduled under extraordinary circumstances at the discretion of the chair of the ad hoc committee. At the discretion of the chair, the program director and resident may question their own witnesses. If the committee decides that additional information is required, the chair may request written materials and additional meetings, which may occur beyond the 30-day time period referenced above.

The ad hoc committee's scope of review shall be to determine: whether there was adequate documentation on which to base the decision, and whether the appropriate procedures (e.g. notice of deficiencies, plan of remediation) were followed. The preparation of the committee's final report shall be the responsibility of the Chair of the ad hoc committee.

The Associate Dean/DIO for Graduate Medical Education shall make notification to the resident of the GMEC’s decision verbally and in writing with a copy to the Program Director and Chair.

The Ad Hoc Subcommittee’s decision is final and is not subject to further formal review within the University.

(2) Adjudication of resident complaints and grievances related to the work environment or issues related to the program or faculty.

Residents are expected to address complaints and grievances to their program director. If this fails to resolve the issue, or if the resident does not wish to discuss the matter within the program, the resident may speak directly and confidentially to the Associate Dean/DIO who serves as Ombudsman for GME. Residents are assured that nothing can be communicated about what they say to the Ombudsman without their expressed permission. Referrals as well as problem solving interventions are provided in strict confidence.

Formal charges of discrimination based on race, sex, age, religion, national or ethnic origin, disability, marital status, sexual orientation, or veteran status, should be filed with the campus Affirmative Action Office.

After consultation with the Associate Dean/DIO and Ombudsman for GME, residents may formally seek adjudication through the GME Committee. Within ten working days of receipt of the request for adjudication, the GMEC Chair will appoint an ad hoc grievance committee to consider the grievance or complaint for appropriate action.

The chair of said ad hoc committee will be a member of the Graduate Medical Education Committee, and one additional faculty member, and one resident will comprise the committee. Eligible faculty for the ad hoc committee are defined as full-time physician faculty members of clinical departments in the College of Medicine with the rank of Assistant Professor or higher, and may not be members of the department which sponsors the resident's program. The resident member of this committee must be from a department other than that which sponsors the aggrieved resident's program. The grieving resident and the defendant(s) may request replacement of an ad hoc committee appointee with cause. The ad hoc committee will determine the process. If the process includes a hearing it must occur within 30 days of the committees’ appointment.

If a hearing is deemed appropriate by the ad hoc committee, the process of the hearing will not be rigidly prescribed, except that, the resident and defendant(s) shall be given the opportunity to appear before the committee and will be allowed to be accompanied by an adviser who is not an attorney. The resident and the defendant(s) should be prepared to address or respond to the grievance or complaint in writing.

The hearing shall be confidential and open only to the committee members, the resident, and any invited adviser(s). If the defendant(s) or resident would desire individuals with factual information regarding the grievance to appear before the committee, the interested party may make the appropriate arrangements. The hearing may only be rescheduled under extraordinary circumstances at the discretion of the chair of the ad hoc committee. At the discretion of the chair, the defendant(s) and resident may question their own witnesses. If the committee decides that additional information is required, the chair may request written materials and additional meetings, which may occur beyond the 30-day time period referenced above.

The Ad Hoc Subcommittee’s adjudication is final and is not subject to further formalreview within the University.
Revisions approved by GMEC 2/14/07



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APPEALS PROCESS
Residents who challenge an evaluation of their academic performance in a required educational activity, or who challenge an unfavorable academic standing or status assigned to them because of inadequate evaluations of their performance may request a review of the evaluation or of the academic status, or both.

Each residency program has established procedures for considering such requests. Residents who wish to request a review of an academic grievance should submit such a request in writing to the program Director within 15 days of the grieved action.

If the issue is not resolved through completion of the program's grievance procedure, residents may then address a petition to the GME Committee for a review of their case and of the program's decision's on it. The GME Committee may appoint and refer such petitions to an Ad Hoc Resident Grievance Sub-committee.

To initiate the appeal process, the resident shall notify the Associate Dean for Graduate Medical Education. This notice shall be in writing, and must be delivered to the Graduate Medial Education Committee (GME Office 270-1984 fax 270-2408) within 15 working days of the resident's notification by the Program Director. Such notification must include the reasons for the requested appeal. Upon receipt of the appeal, the GME Office will request the program director to submit the resident's departmental file and any other materials on which it bases its decision to the Office for Graduate Medical Education, for distribution to the committee.

Within ten working days of receipt of the request for appeal, the GMEC Chair will appoint an ad hoc committee, and will notify the resident and the members of the ad hoc committee in writing of the committee's appointment with a copy to the program director and chair. The chair of said ad hoc committee will be a member of the Graduate Medical Education Committee, and one additional faculty member, and one resident will comprise the committee.

Eligible faculty for the ad hoc committee are defined as full-time physician faculty members of clinical departments in the College of Medicine with the rank of Assistant Professor or higher, and may not be members of the department which sponsors the resident's program. The resident member of this committee must be from a department other than that which sponsors the aggrieved resident's program. The appealing resident may request replacement of an ad hoc committee appointee with cause.

The ad hoc committee will determine the process. If the process includes an appeal hearing it must occur within 30 days of the committees’ appointment.

Upon written request, the resident will be provided with a photocopy of summary academic evaluations and photocopies of any correspondence to the resident from the program, before the hearing is held.

If a hearing is deemed appropriate by the ad hoc committee, the process of the hearing will not be rigidly prescribed, except that, the resident shall be given the opportunity to appear before the committee and will be allowed to be accompanied by an advocate who is not an attorney. The resident should be prepared to present evidence for rescinding the action. The program director should appear and be prepared to present evidence for upholding the action.

The hearing shall be confidential and open only to the committee members, the resident, and if invited, by an advocate. If either the program director or resident would desire individuals with factual information regarding the decision of the department, above and beyond information in the file, to appear before the committee, the interested party may make the appropriate arrangements. The hearing may only be rescheduled under extraordinary circumstances at the discretion of the chair of the ad hoc committee. At the discretion of the chair, the program director and resident may question their own witnesses. The note taker will make written minutes of the hearing. If the committee decides that additional information is required, the chair may request written materials and additional meetings, which may occur beyond the 30-day time period referenced above.

The ad hoc committee's scope of review shall be to determine: whether there was adequate documentation on which to base the decision, and whether the appropriate procedures (e.g. notice of deficiencies, plan of remediation) were followed. The preparation of the committee's final report shall be the responsibility of the Chair of the ad hoc committee.

The Chair will present the ad hoc committee’s report to the GMEC at its next regularly scheduled meeting. The GMEC will consider the ad hoc committee's report. The Associate Dean for Graduate Medical Education shall make notification to the resident of the GMEC’s decision verbally and in writing with a copy to the Program Director and Chair.

Action accepted by the GMEC is final and is not subject to further formal review within the University.

Revisions approved by GMEC 4/11/2001



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RESIDENT RESPONSIBILITIES, DUTIES AND PRIVILEGES
Residents shall perform their duties and at all times conduct themselves in compliance with all applicable program and departmental rules and regulations, as well as applicable affiliated hospital policies and procedures, both personnel and operational and such specific rules and regulations as from time to time may be established for residents. (See Section II for further details).

In accordance with the requirements of the Accreditation Council for Graduate Medical Education (ACGME), and the SUNY-Downstate Graduate Medical Education Committee (GMEC), residents will be provided with an opportunity to:

- develop a personal program of learning to foster continued professional growth with guidance from the teaching staff.

- participate in safe, effective, and compassionate patient care, under supervision, commensurate with their level of advancement and responsibility

- participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other residents and students.

- participate on institutional committees and councils whose actions affect their educational and/or patient care.

- submit to the program director or to designate institutional official at least annually confidential written evaluations of the faculty and of the educational experiences.

Procedure Privileging for Subspecialty Fellows
Approved at GME Committee Meeting – April 5, 2006
(a) All fellows must be privileged in procedures required of graduating residents in their core discipline.

• Fellows who successfully completed their core discipline residency at SUNY Downstate will have their core’s privileges recorded in their fellowship Web Esprit procedure file.

(b) Fellows who have completed their prior core discipline residency training at a non-SUNY Downstate institution, must present verifiable documentation of the privileges granted by their prior core discipline residency program(s) to the GME Office and to the Fellowship Director for certification before fellowship training can begin at any SUNY Downstate affiliate hospital.

• Any SUNY Downstate core discipline procedures not privileged in prior training at a non-SUNY Downstate program must be approved for privileging by the Fellowship Program Director and the core discipline Program Director before fellowship training can begin at any SUNY Downstate affiliate hospital.

• If the advanced resident has not been privileged by another institution, the Program Director has the right to modify that resident’s procedure credentialing process after reviewing the nature of that resident’s prior training and clinical experience.

(c) Procedure Privileging Specific to Subspecialty Programs

• Fellowship Program Directors must formally notify the GME Office if their subspecialty program does or does not require approval for privileging of procedures specific to the subspecialty.

o If the fellowship program requires approval for privileging of procedures specific to the subspecialty, the procedures and the requirements for privilege approval must be submitted to the GME Office. The GME Office will issue Procedure “chit” Booklets and enter the procedures for tracking in Web Esprit.

o If the fellowship program does not require privileging approval for any subspecialty specific procedure, the Fellowship Program Director must formally inform the GME Office that no procedure privileges are required.

(d) Though the manner in which the advanced resident is privileged may be different than a resident entering at the first year level, it will still be necessary for the Program Director to maintain on file any internal or external documentation of the privileging process for that resident and to provide the resident with a letter stating that they have been privileged for performing procedures. A copy of that letter must be sent to the Office of Graduate Medical Education.

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CERTIFICATES OF TRAINING
Each year the departing residents receive certificates indicating the length and scope of residency training. The certificates are issued at the request of the resident's training program.

— Diplomas are issued twice each year: June and December
— Diploma list deadline for diploma issuance in June is March 1
— Diploma list deadline for diploma issuance in December is October 1
— Duplicate diplomas can be ordered for a fee of $30.00 which includes a certified mail fee.
— A notarized letter explaining the reason for the request is required.

A check or money order should be made out to "SUNY" and submitted with the letter to the GME Office:

State University of New York
Health Science Center @ Brooklyn
450 Clarkson Avenue, Box 1229
Brooklyn, NY 11203



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VERIFICATION OF TRAINING
The Office for Graduate Medical Education will keep a record of each resident's appointment indefinitely.

The GME Office conducts primary source verifications of Medical School, prior training, ECFMG certification and NYS license.



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IDENTIFICATION BADGES
http://138.5.102.101/fsa/pages/fsa17.htm

All Residents irrespective of salary source are required to carry a SUNY-DOWNSTATE Identification Badge. This badge will allow you to utilize the University’s Medical Library as well as other campus facilities.

To obtain a SUNY-DOWNSTATE picture I.D. - call the GME Office, 270-4221, Monday - Friday 9:00 AM to 3:30 pm. The GME Office will check your file to ensure that it is complete and arrange for a SUNY-DOWNSTATE badge to be issued. ID cards are issued to Residents only if their credentialing file is complete.



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RESIDENT SUPPORT, BENEFITS, AND CONDITIONS OF EMPLOYMENT
All residents in SUNY-DOWNSTATE sponsored residency program are provided with appropriate financial support and benefits. Compensation of residents and distribution of resources for the support of education is carried out with the advice of the GMEC.

Professional Liability Insurance
All residents hold the title of “Clinical Assistant Instructor” and are indemnified in accordance with the provisions of the New York State Public Officers Law while at SUNY-Downstate facilities. (See Appendix)

Institutions affiliated with SUNY-DOWNSTATE shall defend, indemnify and hold harmless medical residents and fellows who hold the SUNY faculty title of “Clinical Assistant Instructor” and rotate to the Affiliate as part of their training in integrated clinical programs, in connection with any and all claims, suits, actions, proceedings, expenses, including reasonable attorney’s fees, costs, liability, loss or damage arising out of the residents’ activities at the Affiliate.

SUNY-DOWNSTATE shall defend and indemnify, in accordance with the provisions of the New York State Public Officers Law, those residents who hold the SUNY faculty title of “Clinical Assistant Instructor” and are on the payroll of the Affiliate while they are on rotation to SUNY-Brooklyn facilities as part of their training in integrated clinical programs in connection with any and all claims, suits and actions arising out of the residents’ activities at SUNY-DOWNSTATE

Residents should be aware that professional liability insurance coverage might not include practice conducted at unaffiliated sites, including private office locations, even under the direct supervision of attending SUNY faculty. Special arrangements must be made for appropriate coverage through the resident’s SUNY graduate medical education program.



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VACATION /SICK LEAVE POLICY
Specific details of leave benefits vary according to pay source, but are considered in establishing compensation comparability. However, at minimum, residents are afforded 20 working days of vacation time and up to 20 days of sick leave per year.



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POLICY ON LEAVES OF ABSENCE
A leave of absence, which is defined as an excused absence without pay, is a privilege that may be granted to SUNY-DOWNSTATE residents at the discretion of the program director.

Reasons for a Leave of Absence: A leave of absence may be granted for personal reasons such as dependent or elder care, or community service. Dependent care is covered under the Family and Medical Leave Act, in the case of serious health conditions.

Length of Leave: A leave of absence may be granted for not more than 12 months. Leaves granted for less than 12 months may be extended, if requested prior to expiration, for up to a total absence of 12 months.

Return from Leave: A resident on leave is assured of their position at the conclusion of the leave. The resident must keep the program appraised of his/her plans periodically, and in a timely fashion so as not to interfere with the scheduling of rotation assignments.

When a date of return is known, the resident must notify the Program Director to confirm arrangements for return to active status. Required length of notice may vary widely by program and it is the responsibility of the resident to provide notice in accordance with individual program requirements. A minimum notice of one month is desirable and is requested if feasible. A resident's failure to return from a leave will result in termination of employment. It is up to the individual programs to determine if any portion of an extended leave of absence must be made up, either in accordance with the RRC Requirements of that discipline or at the program director's discretion.

Leave Application: The resident will present to the Program Director in writing a formal request for a leave of absence no less than thirty (30) days prior to the beginning date of the leave. In the case of an emergency, this time period may be waived. This request will include reason for leave, dates of leave, and expected return date. The Program Director, acting for the Department/training program, will decide and notify the resident in writing as to whether or not the request has been approved.

Family Medical Leave Act
Under the Family Medical Leave Act (FMLA) a resident may be entitled to 12 weeks of unpaid leave for any of the following reasons: to care for the employee’s child after birth, or placement for adoption or foster care; to care for the employee’s spouse, son or daughter, or parent, who has a serious health condition; or for a serious health condition that makes the employee unable to perform his/her job.

The program director will consider the applicable ACGME and RRC Requirements in determining whether such leave may be granted. It is possible that additional training after such leave may be needed for board certification requirements. However, no assurances can be given that the resident will be entitled to compensation during this additional period.

Revisions approved by GMEC 4/11/01



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RESIDENT DRUG AND ALCOHOL TESTING
Some SUNY Downstate affiliates require that employment be contingent upon completion of a drug and alcohol test with a negative result.

A positive screening result must be confirmed by a method free of interferences using a specimen for whom the chain of custody can be documented.

Residents with positive results must be referred for counseling as described in this document, and cause for termination will be handled on a case by case basis using guidelines described under the Policy On Impaired Residents.

Approved by GMEC 4/11/2001



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POLICY ON IMPAIRED RESIDENTS
Location: HSEB RM 312 - Ext. 7550

Physician Impairment: The GME Committee has adopted the following policy that describes how physician impairment, including that due to substance abuse, will be handled. Educational programs for residents regarding physician impairment, including substance abuse are given at orientation for new residents and also during the academic year by Committee for Physicians Health (CPH) staff at program grand rounds.

Impairment is defined as "the inability to practice medicine with reasonable skill and safety due to physical or mental illness, loss of motor skills or abuse of drugs including alcohol" (American Medical Association).

It is professional misconduct to practice medicine while impaired. New York State includes within the definition of professional misconduct the following: (1) practicing the profession while the ability to practice is impaired by alcohol, drugs, physical disability, or mental disability; and (2) being habitually drunk or being dependent on, or a habitual user of narcotics, barbiturates, amphetamines, hallucinogens, or other drugs having similar effects.

The SUNY Downstate Medical Center recognizes that drug addiction, mental disability and alcoholism are illnesses. The University will take all reasonable steps to protect the confidentiality of the employee who seeks voluntary treatment or is referred for treatment by his/her supervisor subject to applicable legal constraints and the provisions of this policy.

The CPH will provide confidential evaluation, treatment planning, and monitoring for physicians who voluntarily enroll. CPH generally does not report participating physicians to the Office of Professional Medical Conduct (OPMC) of the New York State Department of Health unless 1) on initial evaluation the physician is an imminent danger to the public, 2) the physician refuses to cooperate with CPH, or 3) the physician does not follow the treatment plan and/or does not respond to treatment.

Voluntary Self Referral for Drug/Alcohol Treatment in the Absence of Performance Issues A resident who is concerned that he/she may have a problem with impairment may contact CPH directly (1-800-338-1833) or may discuss the issue with a faculty member, the program director, the Department Chair or the Associate Dean for GME (ADGME).

If a resident brings a concern about his/her own potential impairment to the attention of any of these individuals, the individual so notified must notify at least one of the others, and at least two of these individuals must meet with the resident to determine an appropriate course of action. The meeting with the resident must occur as soon as possible but within two business days.

For residents who require further voluntary evaluation and possibly treatment, the Program Director and/or Chair should notify the Associate Dean who will arrange for referral to CPH. A resident who has enrolled in a CPH approved treatment program may be permitted to return to work with agreement of CPH and in accordance with the "Return to Work Section" of this policy.

Referral for Drug/Alcohol Treatment by Others in the Context of Performance Related Concerns When a resident is experiencing performance related problems or engaging in suspicious behavior, and impairment is suspected, the program shall have the right to require the resident to undergo further evaluation. Suspicious behavior is defined as any instance in which another resident, faculty member, other hospital employee, patient or patient's family, or other person witness’s inappropriate behavior by a resident during the exercise of his/her professional duties. These incidents may include, but are not limited to, perceived problems with judgment, behavior, speech, emotional outbursts, depression, alcohol odor or other evidence of substance abuse.

Suspicious behavior may be reported to the resident's attending physician, residency program director, Department Chair or CPH. Reports to the resident's attending physician should be brought to the attention of the residency program director and Department Chair.

Upon receiving such a report, the residency program director and Department Chair should conduct an interview with the resident within 2 business days. If both the program director and Department Chair agree that the report has no foundation and that there are no performance concerns with respect to the resident, no further action will be taken.
If the program director and Department Chair believe the report has foundation, they shall further evaluate the situation. In assessing the situation, the program director and Chair may require the resident to undergo further testing (psychiatric evaluation and/or drug or alcohol testing). If a decision to require testing is made, the program director or Department Chair should contact the ADGME to arrange for this testing. Results of the tests will be reported directly to the Department Chair.

The program director may allow the resident a personal leave (Leave of Absence) or if necessary the program director may suspend the resident from clinical duties while the situation is investigated if it is felt that further training will put patients, the resident, or other hospital staff at risk. If a decision to suspend the resident during the investigation and evaluation period is made, this should be communicated in writing to the resident with a copy to the GME Office. A suspension or restriction of clinical privileges must be reported to the New York State Health Department. If, after evaluation, it is believed that the resident needs further evaluation to eliminate the concern, the matter will be referred to the GME Office. The resident will be offered the opportunity to voluntarily enroll with CPH, which will arrange for an intake evaluation. The GME Office will assist the resident in enrolling in CPH. If, after evaluation, both the program director and Department Chair determine that the resident does not require treatment or rehabilitation, they shall address the resident's performance problems in accordance with departmental evaluation standards and related institutional policies (Evaluation Policy and Disciplinary Procedures and Appeals Policy).

Return to Work If treatment or rehabilitation is recommended by CPH, and the resident enrolls in a CPH-approved treatment program, the resident will be required to waive his/her right to confidentiality to the extent that: the ADGME will be notified as to whether the proposed treatment plan limits the resident's ability to work, and if so, will be provided with a description of the limitations, the ADGME will be notified periodically whether the resident is participating in the treatment plan and whether treatment has been successful; and any other information needed by the ADGME to assess the resident's continued fitness to work. Whether a resident will be allowed to return to work or complete his/her residency will be evaluated on a case-by-case basis, taking into consideration the recommendations of the treatment program, the limitations, if any, on the resident's ability to practice and expected duration of the limitations, whether reasonable accommodations can be made by the residency program, the circumstances that give rise to the initial report of potential impairment (i.e. whether any serious incidents or violations of law occurred), and whether patient and staff safety can be maintained.

Refusal to Cooperate If a resident who self-reports potential impairment or is determined by his program director and Department Chair to require further evaluation refuses to enroll with CPH, the ADGME will be obligated to report the resident to the OPMC. In addition, the ADGME may terminate the resident's clinical privileges and may terminate the resident from the residency program. The resident shall have the right to appeal the decision to terminate him/her from the program pursuant to the appeal procedures set forth in the Resident Disciplinary Procedures and Appeals Policy.

Approved by GMEC 9/12/96
Revised Policy approved 4/11/2001



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GME POLICY AND PROCEDURE FOR ASSISTING RESIDENTS WHO ARE IN NEED OF PSYCHOLOGICAL SERVICES
The Department of Psychiatry provides residents from all Departments with information about referrals for psychiatric treatment. Such information can be obtained through the office of the Chairperson of the Department of Psychiatry (270-2022).

The Department of Psychiatry provides urgent psychiatric evaluation, counseling and referral for residents of all Departments, in cases where a resident is having a psychiatric problem which cannot be adequately addressed by the resident with the resident’s Advisor or Training Director. An urgent evaluation should be initiated by the resident’s Training Director, with the resident’s agreement, and with the understanding that the evaluation will be time-limited, will be conducted with due respect for the resident’s right to confidentiality, and will not influence in any way the resident’s academic or employment status. The Training Director should discuss the resident’s situation with the Chairperson of the Department of Psychiatry who will, if warranted, designate a senior faculty member to evaluate and counsel the resident and make recommendations to the resident for further treatment. NO RESIDENT SHALL BE REQUIRED TO UNDERGO SUCH AN EVALUATION, WHICH SHALL BE ENTIRELY VOLUNTARY; AND NO INFORMATION ABOUT THE EVALUATION SHALL BE COMMUNICATED TO THE RESIDENT’S TRAINING DIRECTOR OR DEPARTMENT WITHOUT THE EXPRESS CONSENT OF THE RESIDENT.

In cases where a resident needs to be evaluated psychiatrically on an emergency basis, during regular working hours the person requesting the evaluation should discuss the situation with the Chairperson of the Department of Psychiatry, or the Chairperson’s designee, who will, if warranted, arrange for an emergency evaluation. Between 5:00 P.M. and 9:00 A.M., on weekends, and on holidays, the situation should be discussed with the “Bell” attending (beeper 917-760-0091) on call for the Department of Psychiatry. Whenever possible, emergency evaluation and treatment of a resident should be carried out in a facility that is not affiliated with the Health Science Center provided this does not place the resident at risk clinically.

Senior faculty members in the Department of Psychiatry are available, through the office of the Chairperson, to talk with and meet with selected faculty members and residents of other Departments, to help clarify psychological issues that arise in the course of training residents, and to suggest methods of handling residents’ behavioral problems within their own Departments.

When a psychiatric or psychological evaluation is required as part of a determination of a resident’s academic or employment status, the evaluation should be arranged through outside consultants or agencies, in conformity with relevant policies of GME and Human Resources.

Approved by GMEC: March 3, 1999



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POLICY ON PROFESSIONAL MISCONDUCT
"For purposes of this policy, professional misconduct is defined as any behavior that is defined as professional misconduct under New York Public Health and Education Laws.

Residents are held to the same standards of conduct as other physicians and dentists, whether or not they are licensed in New York State. Professional misconduct includes but is not limited to the following:

• Obtaining a license fraudulently Practicing fraudulently, beyond authorized scope, with gross incompetence, with gross negligence on a particular occasion or negligence or incompetence on more than one occasion
  
  
• Practicing while impaired by alcohol, drugs, physical disability, or mental disability (See policy on impairment below)
  
  
• Being convicted of a crime under New York State law, Federal Law, or the law of another jurisdiction which would constitute a crime in New York State
  
  
• Accepting or performing professional responsibilities which the practitioner knows he/she is not competent to perform
  
  
• Delegating professional responsibilities to a person when the practitioner knows or has reason to know that such person is not qualified to perform them
  
  
• Refusing to provide professional services because of a person's race, creed, color, or ethnic origin
  
  
• Abandoning or neglecting a patient in need of immediate professional care
  
  
• Performing professional services which have not been authorized by the patient or his/her representative
  
  
• Willfully harassing, abusing, or intimidating a patient, either physically or verbally
  
  
• Altering or falsifying medical records in such a way that needed information for patient care is omitted or falsified
  

The Office of Professional Medical Conduct (OPMC) of the New York State Department of Health investigates professional misconduct by physicians.

While anyone may report possible professional misconduct by physicians to the appropriate New York State Office, Public Health Law requires that physicians report suspected cases of misconduct. Reporting to the hospital's peer review mechanism or reporting directly to the OPMC will satisfy this obligation. Or when appropriate, referral to CPH may satisfy this obligation in cases of physician impairment. A resident who is concerned about professional misconduct on the part of another health care provider, or anyone with concerns about professional misconduct on the part of a resident, is encouraged to report the concerns to the Department Chair, Program Director, Associate Dean for GME or directly to CPH.

The Office of Counsel of the Medical Center will work with the department chair or Chief Medical Officer to investigate the concern. If it is determined that misconduct has occurred on the part of a resident, the residency program director, department chair, and Associate Dean for GME (ADGME) will meet to determine appropriate disciplinary action, which will be communicated to the resident in writing. The resident shall have the right to appeal termination or non-promotion. The appeal process shall be as described in the Disciplinary Procedures and Appeals Policy. If it is determined that misconduct has occurred on the part of a medical resident as described above, the ADGME will report such misconduct to the OPMC and to the affiliate hospital in which the misconduct occurred.

In addition, the ADGME will report to the OPMC or the OPD, as appropriate, if it is determined that any of the following occur:

1. The suspension, restriction, termination or curtailment of the training employment, association or professional privileges related in any way to:
   -Alleged mental or physical impairment
   -Incompetence
   -Malpractice
   -Misconduct, or
   -Impairment of patient welfare.
   
   
2. The denial of certification of completion of training for reasons related to those listed
   in 1.
   
   
3. The voluntary or involuntary resignation or withdrawal of association, or of privileges,
   to avoid the imposition of disciplinary measures.
   
   
4. The receipt of information that indicates a resident has been convicted of a crime.
   

Approved by GMEC 4/11/200




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RESIDENCY PROGRAM CLOSURE AND REDUCTION POLICY
Residents must be informed as soon as possible of any plans to reduce the size of a residency program or closure of a residency program. Residents are not at risk for losing their positions as a result of a reduction in program size-- only the number of future positions to be offered will be reduced and all current residents will be allowed to complete their programs. In the event that a program is closed SUNY-Downstate must allow residents already in the program to complete their education or assist them in enrolling in an ACGME accredited program in which they can continue their education.

Approved by GMEC 4/11/2001






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RESTRICTIVE COVENANTS PROHIBITED
SUNY Downstate does not require residents to sign a non competition guarantee. SUNY Downstate prohibits any restrictive covenant to be included in resident contracts or agreements on the terms and conditions of appointment to an educational program. All resident contracts must be reviewed and approved by the GME Office to assure full compliance with this policy.

Approved by GMEC 4/11/2001




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RESIDENT SUPERVISION, DUTY HOURS AND WORK ENVIRONMENT

Work Environment
The GMEC Resident Subcommittee and the Subcommittee on Resident Working Conditions monitor the residents work environment through site visits of each program in conjunction with Internal Reviews and. Each program, through it‘s annual report, submits an evaluation of the on call rooms, food services, medical records, lab systems, radiological information retrieval system, safety and security of persons and property, phlebotomy services as well as messenger and transporter services at each teaching site

Work Hour Surveys
Affiliate hospitals and the Office for GME surveys residents about their working hours periodically. The survey is confidential and residents are required to complete the survey accurately. Summary information is used by the GME Office, the residency program directors and affiliate hospitals to monitor compliance with the work hours policy and the laws of New York State.



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POLICY ON RESIDENT WORK HOURS
The following GME Committee policy has been approved by the New York State Department of Health and conforms to 405 regulations.

The scheduled workweek shall not exceed an average of 80 hours per week over a four-week period. Residents/fellows shall not be scheduled to work for more than 24 consecutive hours.

A maximum 3 additional hours for transfer of information about patients is allowed in connection with a consecutive 24-hour shift if 1) the resident/fellow assumes no new patient care responsibilities during this time, and 2) the transition time is included in the 80-hour work week. The 3-hour transition time shall not be scheduled as part of assigned duties. Scheduled activities, which count in the 80-hour workweek and for the 24-hour consecutive work rule, include inpatient assignments, outpatient clinic, required conferences and other required educational activities, and on-site activity/direct patient care that occur when a resident/fellow is on beeper call.

Each program shall maintain records of direct patient care by residents/fellows on beeper call and adjust call schedules if direct patient care during beeper call regularly causes residents/fellows to exceed the 80-hour workweek. Scheduled on-duty assignments shall be separated by not less than 8 non-working hours. Residents/fellows shall have at least one 24-hour period of scheduled, non-working time per week. This means no scheduled activities including beeper call.



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SPECIAL PROVISIONS FOR SURGERY RESIDENTS/FELLOWS
On call duty in the hospital during the night shift hours shall be included in the 80-hour workweek and the 24-hour consecutive work limit unless all of the following four conditions are met:

— the program can document that during such night shifts residents/fellows are generally resting and that interruptions for patient care are infrequent and limited to patients for whom the resident/fellow has continuing responsibility;

— and such duty is scheduled for each resident/fellow no more often than every third night;

— and a continuous assignment that includes night-shift "on call" duty is followed by a non-working period of no less than 16 hours;

— and the department has written policies and procedures to immediately relieve a resident/fellow from a continuing assignment when fatigue due to an unusually active "on call" period is observed.

Each resident/fellow shall notify his/her department of any employment outside of assigned program duties (i.e., moonlighting). Residents/fellows are prohibited from working outside of the training program if the addition of such hours will exceed the 80-hour maximum workweek or the 24-hour consecutive work limit. The hours devoted to moonlighting must be added to the training program work hours and must be reported on the Office for Graduate Medical Education work hours survey, and to the Chairman and Program Director on any departmental work hours surveys. For departments other than Anesthesiology, Family Practice, Medical, Surgical, Obstetrical, Pediatric or other services which have a high volume of acutely ill patients, and where night calls are infrequent and physician rest time is adequate, the department may develop other scheduling arrangements with approval of the GME Committee.

As required by section 405.4(b) (6) (v), of the NYS DOH Hospital Code, each Program Director shall take appropriate action to ensure that trainees who have worked the maximum number of hours permitted are prohibited from working additional hours as physicians providing professional patient care services.

Approved by NYS DOH 6/2/98
Approved by Graduate Medical Education Committee 3/28/01



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POLICY ON RESIDENT SUPERVISION
The following GME Committee policy has been approved by the NYS DOH and conforms to New York State Health Code. A member of the Medical Staff or qualified attending physician must supervise all residents. The attending physician must be in the hospital, or he/she must be immediately available by telephone and readily available in person (within 20-30 minutes) at all times.

All residents will consult with the attending physician regarding the assessment and treatment of a patient's illness. Treatment plans will be in accordance with the attending physician's recommendations. When attending physicians are immediately available by telephone and readily available in person when needed, the onsite supervision of routine hospital care and procedures in the acute care specialties of anesthesiology, family practice, medicine, obstetrics, pediatrics, psychiatry and surgery may be carried out by postgraduate trainees who are in their final year of training, or who have completed at least three years of training in their program.

For non-acute care specialties, onsite supervision of routine hospital care and procedures may be performed by a resident who is not in the final year of training if the department has specifically credentialed that individual resident to work in that capacity and supervise other residents.

The department must maintain written documentation of such credentialing for each resident who assumes such responsibility. Attending physician supervision in surgery must be direct personal supervision of all surgical procedures requiring general anesthesia or an operating room procedure. All supervision must be documented in the resident rotation schedules and