Advanced Search
Phone Directory

Home > Otolaryngology > Residency Policies

Department of Otolaryngology

General Residency Policies

• Guidelines
• Policy on Resident Work Hours
• Department Policy for Patient Care Coordination
• General Information
  • Prescription Stamps
  • Lab Coats
  • University Privileges
  • On Call Schedule
  • Slide Reproduction
  • New York State License Requirements
  • DEA Numbers
  • Mailboxes
  • Paychecks
• Evaluations
  • Faculty Evaluations
  • Resident Evaluations
  • Faculty Advisors
  • Resident Role in Departmental Policy-Making
  • Resident Education in Quality Assurance Program
• Clinical Evaluations
• Travel Reimbursement Guidelines
• Disciplinary Action
• Resident Due Process, Grievance Policies and Procedures

Supervision of residents during their performance of clinical duties is critical element of our training program. Progression of responsibility will occur during the course of the training program. It is the policy of the Department of Otolaryngology that resident supervision will be fully in compliance with regulations of the Accreditation Council for Graduate Medical Education, Joint Commission for Accreditation of Healthcare Organizations and New York State Department of Health Regulations.

The following guidelines for resident supervision have been established.

• Residents will only be assigned to hospitals and offices where the department has determined that there is sufficient support for the training program by both the otolaryngology staff and by the institution itself.
• All attending physicians who participate in resident supervision must be board-certified or board-eligible in their specialty.
• All attending physician who participates in resident supervision must have a current and valid license in the State of New York.
• All attending physicians who participate in resident supervision must have privileges at the hospital at which supervision will take place.
• The attending physician assigned to cover any resident surgical procedure must have privileges for performing that procedure.
• The attending physician must be present during major portions of the surgical procedure.
• The attending physician responsible for supervision in the clinic must be available throughout the clinic session and supervise actively during major portions of physical examination.
• The Chief Resident (PGY-5) may supervise junior residents in the clinics but not in the operating room unless the attending physician is present.
• Consultations on service patients may be performed by residents without the attending physician being present. However, the proposed plan of action must be discussed with the attending before it is undertaken. The attending physician is responsible for signing the consultation report with 48 hours.
• The following activities do not require on-site attending supervision, although attending co-signature is required within a suitable interval: chart documentation, dictation of operative needs, discharge summaries.
• No attending supervision is required for writing routine order, performing dressing changes, venipuncture, tracheotomy changes, and other routine aspects or patient care.
• The responsibility for monitoring resident supervision and assuring compliance withall regulations resides with the Departmental Chair/Program Director with assistancefrom the Director of Resident Training and Associate Director of Resident Training.
• The departmental policies for resident supervision are to be reviewed at least annually with all residents and attending physicians. The policies are also included in the orientation process for new residents.

« Back to Top

Policy on Resident Work Hours

Department of Otolaryngology

On-call requirements are essential for an optimal educational environment and to assure the continuity of patient care. It is the policy of the Department of Otolaryngology that resident work hours will be fully in compliance with regulations of the Accreditation Council for Graduate Medical Education, Joint Commission for Accreditation of Healthcare Organizations and New York State Department of Health regulations.

The following guidelines have been established:

• Total weekly work hours, including formal didactic education activities, shall not exceed 80 hours per week, averaged over a two-week interval.
• Continuous time on duty should not exceed 24 hours (except 3 additional hours beyond 24 hour limit permitted if. (1) the purpose is for the transfer of patient information "shift change": (2) patient care activity is not assigned, or (3) additional time is accommodated in the 80 hour schedule.
• There must be a minimum of eight hours free of clinical and formal educational activities between assignments.
• The frequency of on-call duty for residents should be no more than every third night when averaged over a two week interval.
• Residents must have at least one full day (24 hours) free of clinical and educational duties each week.
• Each service chief is responsible for determining whether a resident who has been on Call on the previous night or weekend day is capable of carrying out his/her duties on the following day. If the resident requires additional rest, it is expected that the service chief will make suitable arrangements.

The monitoring of compliance with this policy is the responsibility of every service chief at each of our affiliated hospitals.

« Back to Top

Department of Otolaryngology Policy for Patient Care Coordination

I. Patient access to the appropriate type of care

When the hospital accepts a patient for entry into a particular service or setting its decision to do so is based on the outcomes of its assessment procedures.

Patients will enter medical care in the Department of Otolaryngology by the following methods:

1. Direct admission by attendings:
   • The attending is responsible for communicating diagnostic and treatment plan. Orders are written for in-patient care by the attending physician or directly communicated to the resident on-call. It is recommended that the attending communicate directly with the resident for all admissions. Alternatively, residents are to contact the attending physician to discuss each case.
2. Emergency department (E.D.) admission:
   • If the E.D. staff (resident or attending) requests an otolaryngology consult, a response is expected: (a) immediately if called stat or (b) within 1 _ hours if urgent. Residents who evaluate emergency department patients must consult with an attending physician who is on-call. An admission decision will be made by Otolaryngology Resident, Attending and E.D. attending. Diagnostic and management decisions including setting for care (i.e. need for ICU care) will be made prior to hospital admission. Orders will be determined at this time. Admissions occurring at night must be seen by the chief resident. Attending contact is required prior to any admission. Attendings are required to examine patients within 24 hours of their admission. In the case of a disagreement, the E.D. attending and the otolaryngology attending will discuss the care of the patient to determine appropriate care. If disagreement persists, the Chairman of the E.D. and Otolaryngology are to be notified.
3. Post-surgical admission:
   • Planned: all patients admitted on a "day of surgery" admission basis will be admitted following surgery with orders and management decisions determined by the attending and resident involved in the care. Direct communication of post-operative wound care, IV fluids, medications and all other aspects of management must be discussed and approved by the attending.
   • Unplanned: If surgical patients require unexpected admission, complete evaluation by the attending and resident involved is required. Diagnostic and management decisions including need for consultation should be discussed at the time of admission. The resident is responsible for writing appropriate orders and arranging consults as needed. The level of service should be determined with respect to critical care units and clinical parameters to be monitored.
4. Transfer from another service:
   • Transfers will be accepted after complete evaluation by admitting resident and direct communication with attending has been completed. Discussion between the two services will take place to determine the appropriateness of transfer. A determination of level of care will be made prior to transfer. In the case of a disagreement, the attending of each service will discuss the case. If disagreement persists, the chairman of each service is to be notified.

II. Patients and Families receive information about proposed care during the entry process

The attending is responsible for communication of medical information to patients and families. The attending may assign the resident involved in the care to this duty after giving specific instructions.

Information regarding a patient's condition should be made available to those identified by the patient – or immediate family members if patient is unable. This must include updates throughout the patient's care regardless of care setting (O.R., ICU, etc.) If the attending is not available, the covering attending is responsible for communication with patients and family members.

III. Coordination among the health professions and services or settings involved in a patient's care (in-patient)

Appropriate consultations are made to ancillary services such as home-care, nutrition or other clinical departments. Based on clinical assessment and consultation responses, plans for treatment and ultimate discharge are continuously updated. Communication of this information should be clear in all hospital entries. Both, in the in-patient and out-patient settings, review of pertinent laboratory and radiologic studies is acknowledged in the patient chart. Appropriate contact with the patient is made as necessary from these results.

For procedures of transfers see above.

IV. An established procedure is used to resolve denial or conflicts over care, services or payment

For conflicts between services and care, the attendings responsible from each service are to address the issues. If conflict persists, the chairman of each service is to confer for final resolution. If hospital care-delivery or payment is involved, the hospital administrator will be asked to participate in all decisions.

All activities in the Department of Otolaryngology regarding the clinical care of patients which includes admission and transfer procedures is reviewed on a monthly basis during a continuous quality improvement departmental meeting. Adjustments in protocol are discussed and distributed to all departmental members.

« Back to Top

General Information

« Back to Top
« Back to Top
« Back to Top
« Back to Top
« Back to Top
« Back to Top
« Back to Top
« Back to Top
« Back to Top

Evaluations

Faculty Evaluations

Residents are required to evaluate all full-time faculty members and those voluntary faculty with whom they have contact. Evaluation forms will be distributed by Dr. Gady Har-El's office directly to the residents. The forms are to be completed and returned to the Department of Otolaryngology, Long Island College Hospital, 134 Atlantic Avenue, Brooklyn, New York 11201, Attention: Ms. Rosalie Incorvaia, Residency Secretary. These evaluations are compiled in confidence and transmitted to the Department Chairman for review and action as appropriate. Every effort is being made in this process to ensure confidentiality in handling these forms.

« Back to Top

Resident Evaluations

The continuing evaluations of the performance of the resident are carried out as a very close working relationship with the full-time and part-time teaching faculty and the resident staff. Each resident is reviewed by one or more attendings at the conclusion of each rotation. This procedure is also followed during the rotations in general surgery, and copies of the reports are sent to the otolaryngology office for incorporation in the permanent report. These are compiled and retained as a permanent part of the resident personnel file. Evaluations are discussed with the resident during meetings with their advisors and during periodic evaluation meetings with the Department Chairman. Advancement is predicated on satisfactory reviews.

« Back to Top

Faculty Advisors

Each resident chooses a faculty advisor each year. This advisor is responsible for meeting frequently with the residents to review academic development, research projects, and career plans. Faculty advisors are also needed for research projects. Service chiefs act as a faculty advisors at each institution. Since the research program begins in the first year and since faculty meets with residents every 6 months, we are able to point them toward faculty advisors for any projects.

« Back to Top

Resident Role in Departmental Policy-Making

The residents have an important role in departmental policy-making. All major administrative and educational policies are discussed with residents at selected conferences before they become official. Resident feedback on departmental functions is actively sought and respected.

« Back to Top

Resident Education in Quality Assurance Program

In addition to participation in the Quality Assurance Conference which is held monthly, and for which the residents prepare the protocols for each institution, the residents also receive two introductory lectures on the QA process from both the Chairman and the Director of the departmental Quality Assurance program.

« Back to Top

Clinical Evaluations

1. Should be in writing and completed at end of each month or rotation or when appropriate. In general, evaluations should be discussed with the resident. All evaluations that are marginal or unsatisfactory should be discussed with the resident in an exit interview and signed by both the resident and the evaluator.
2. The evaluation form should address areas of knowledge, skills and attitude and provide space for comments at each evaluation point. The form should also have an overall evaluation rating and space for defining strengths and weakness and suggestions for future remediation. There should be space for resident signature and date of review.
3. Completed evaluation forms should be returned by the evaluator to the departmental office within one week after the resident completes the rotation period.
4. The form should be reviewed for the completeness by the Residency Secretary and followed-up in cases of inadequate documentation.
   • In cases where the evaluator has not sufficiently documented, the evaluator should be called to correct deficiencies. (i.e. no comments for below average performance, inconsistency between written and numerical evaluation). The Residency Secretary should also show below-average evaluations to Program Directors or designee for immediate follow-up.
5. Residents must be given the opportunity to evaluate their rotation and teachers, preferable on a monthly (or appropriate interval) basis. This evaluation is confidential and need not be signed by the resident.

« Back to Top

Travel Reimbursement Guidelines

Prior to submitting an abstract for consideration, the resident must have the abstract reviewed by the Director of Residency Training and the Chairman of the Department. If the abstract is approved for submission by the Chairman and is accepted by the appropriate society, the resident must supply the Chairman with a copy of the acceptance letter. Airline, hotel and car rental accommodations will be arranged by the resident within the departmental guidelines. Reimbursement will be made upon completion of the trip and, if applicable submission of a completed paper for publication in the appropriate journal.

— All travelers must submit a completed "Travel Pre-Approval and Reimbursement" Form to the Department Chairman for review and approval. Residents must submit the form directly to the Vice-Chairman/Director of Resident Training, who will forward reviewed and approved requests to the Chairman for additional sign-off. (Forms are available in the Administrative Offices at SUNY and at LICH)

— All categories of expenses must be justified, and a copy of the program/conference announcement must be attached.

— Since reimbursement is paid promptly by the Department, no travel advances are provided.

— Air/Ground Transportation is reimbursed as follows:

• Coach airfare will be paid. Advance arrangements are strongly encouraged so discounted airfares can be obtained. Those who choose to travel in first or business class will be reimbursed at the equivalent of the coach fare rate.
• Routine cab fare reimbursement is provided. Limousine fares will be reimbursed at the routine cab fare rate if used for transportation to and from airports.
• First class train travel will be reimbursed.
• Use of your own automobile for transportation to local conferences will be reimbursed at the rate of $0.33 per mile (rate for 2001).
• For local transportation at the conference site, the cost of a rental car versus taxi cabs or other forms of transportation will be considered on a case by case basis.
• Airport parking will be reimbursed.
• Meal/Lodging costs are reimbursed as follows:
  • Meals are reimbursed at the rate of up to $60 per day (documented, with original receipts) unless higher expenses are justified and approved in advance.
  • When attending a conference, hotel accommodations should be carefully evaluated. In most cases, the main hotel for the conference will be approved at the lowest room rate.
• Those intending to make a presentation of any kind must submit a copy of the presentation materials (research paper, etc.) along with the travel request.
• Once approved, travelers will receive a copy of the approved form, with approval signature(s), which must be resubmitted upon return with documented expenses in order to be reimbursed.
• Residents who have papers or posters reporting original scholarly research accepted for the AAOHNSF Annual Meeting will have documented expenses up to $1000 reimbursed by the department. An additional reimbursement of up to $200 will be made for Instruction Courses.
• Residents who have papers or posters reporting original scholarly research accepted for the COSM and other Spring meetings will have documented expenses up to $1000 reimbursed by the department.
• Residents who have papers or posters reporting original scholarly research accepted for the Eastern Section Meeting and other Triological Section Meetings will have expenses up to $500 reimbursed by the department. All other Resident travel will be considered on an individual basis.
• Any travel grants made payable to residents will be used to offset departmental reimbursements.
• All travelers are required to submit original receipts along with a copy of the approved "Travel Pre-Approval and Reimbursement" form (which will now have the "Actual Expense" column filled in) in order to be reimbursed. Photocopies are not accepted; please provide your Social Security # to process the reimbursement.
• Original receipts and related documentation must be submitted to the Administrative office (either at SUNY or at LICH) within 3 weeks of return date in order to be reviewed, approved, and reimbursed by the department. Reimbursement is usually available in two weeks or less.
• Visiting Faculty traveling to our institutions are subject to the guidelines listed above for travel and reimbursement of expenses. Any faculty member arranging for a visiting professor is expected to ensure that these guidelines have been communicated to the visitor once the visit has been approved by the Department Chairman.

Effective June 12, 2001
SUNY-HEALTH SCIENCE CENTER AT BROOKLYN
Department of Otolaryngology

« Back to Top

Disciplinary Action

If a resident commits an act that significantly jeopardizes a patient's health, immediate suspension by the service Director is possible pending a complete hearing. In the absence of the service Director (e.g. on nights, weekends, or holidays), the physician in-charge may suspend the resident, and notify the Director subsequently as well as the Director of Medical Education and the Department Chairman.

If a more serious violation of institutional or departmental rules has occurred, or if the Departmental Chairman has reasonable doubt that a resident has the desirable characteristics of a physician as outlined in the preceding pages, he may create a panel to hear testimony, examine documents, and recommend further action including, if necessary, termination of the resident's appointment in the department. The panel will be composed of:

1. Director of Resident Training
2. Two attendings appointed by the Chairman
3. The Administrative Chief Resident
4. The person who has made the allegation of wrongful action

Each member of the panel will have one vote. A minority report, if deemed necessary, is possible. If the Director of Resident Training brings charges against a resident, he will not sit on the panel, and his position will be filled by a designee of the Department Chairman. This panel will create its own rules of procedure. It will act expeditiously to ascertain the facts and present a recommendation to the Department Chairman. Final disposition will be the decision of the Department Chairman in conformity with the institutional rules.

Disposition may include:

1. Termination of the appointment as resident.
2. Suspension for a period of time including all clinical duties, and teaching and learning responsibilities. However, suspension may be ended by the Chairman upon the recommendation of the investigative panel.
3. Probation period without eliminating clinical or learning responsibilities. The probationary status will be noted in the resident's file and will indicate the need for close scrutiny. The status will be reviewed quarterly by the Resident Evaluation Committee, which can recommend continuation or suspension of probationary status.

The resident may appeal any disciplinary action directly to the Departmental Chairman

Beyond the program and department, the provost may convene an ad-hoc committee to review whether due process procedures were followed in any case of suspension, probation or dismissal, and to make recommendations for corrective actions where necessary. The ad-hoc committee may also be convened to carry out sporadic reviews (not triggered by adverse actions) of departmental documentation and compliance with their due process guidelines.

Whenever an adverse action is taken the department notifies the Provost in accordance with the "Resident Due Process and Grievance Policies and Procedures" issued by the Graduate Medical Education Committee (GMEC).

« Back to Top

Resident Due Process, Grievance Policies, and Procedures

The SUNY-HSCB GME Committee will serve to monitor, oversee, and facilitate individual department compliance with institutional and RRC specific guidelines for due process.

Due process in all SUNY-HSCB programs will be 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 HSCB standards set below. An evaluation of departmental due process procedures will be a part of the GME internal review protocol.

1. The Chairperson of the GME Committee (the Provost) or a delegate must be notified by the Department Chair or Program Director of any action leading to the suspension, probation or dismissal of a house staff. In all instances documentation of evaluation and attempted intervention must be in place prior to any action.
2. The Provost may convene an ad-hoc committee to review whether due process procedures were followed in any case of suspension, probation or dismissal, and to make recommendations for corrective actions where necessary. The ad-hoc committee may also be convened to carry out sporadic reviews (not triggered by adverse actions) of departmental documentation and compliance with their due process guidelines.
3. Where requested, resident staff members of the GME Committee may serve as peer advocates/counselors to residents engaged in appeals.
4. All SUNY-HSCB clinical programs should establish a sub-group of the Evaluations Committee. The committee should be formally charged with reviewing a resident's record and deciding on the merits of adverse actions. In addition, the committee will:
   1. Meet a minimum of every four months and review all house staff evaluations. At this time the group will review any problem residents that have been identified by evaluations or comment. Written reports will be prepared on each of the discussed residents and a plan to deal with any problems will be recommended. Feedback of this information to the residents is important so they may use this information for their educational growth.
   2. Require residents to review and sign their evaluations at least every four months. In the event of a refusal to sign evaluations, the resident must sign a document indicating that access was granted to his/her files.
   3. Submit recommendations on residents to the Chairman and Residency Program Director and Service Chiefs. These recommendations will be written and a copy will be placed in the resident's file. These files will be open and residents and attendings will be encouraged to review these files on an ongoing basis.
   4. Review at least yearly, all residents' files and make written specific suggestions regarding improvement/continuation/progress. Complete a Resident Promotion Form and return to the Office of Provost/GME.
   5. Problems that have been identified will be compiled, and the resident will be called in and informed in writing, and will meet with the Chairman, Program Director, and a committee member. All meetings will have a written report documenting the meeting and specific recommendations. This report will be placed in the resident's file.
   6. Discuss issues of evaluation in an attempt to improve the quality of evaluations and the educational process. Documentation of these discussions and outcomes must be maintained in the committee's files.
   7. In the event of a need for support services (psychologist, counselors, family support, drug intervention, learning disabilities, etc.) document evidence of making these services available, either directly or by written referral to an institutional source.
5. Departmental due process procedures must be consistent with SUNY-HSCB Resident Evaluation Policies and Procedures.
6. SUNY-HSCB Due Process and Grievance Policies and Procedures are independent (and complimentary) to those set forth by HHC-Collective Bargaining Agreement, the Brooklyn VA, and other affiliated hospital procedures.

« Back to Top

DEPARTMENT OF OTOLARYNGOLOGY
phone: (718) 270-1638 fax: (718)270-3924

Webmaster: J. Zubrovich
Last updated March 19, 2008

Campus Calendars | Education | Research | Health Care | Patients
Students | Prospective Students | Faculty & Staff | Alumni | Community
News and Events | Library | Computing | Employment | Contact Us

Copyright © 2008 SUNY Downstate Medical Center. All rights reserved.

Policies and Procedures - Compliance Line - FOIL