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Department of Otolaryngology

General Residency Policies

• Policy on Resident Supervision Guidelines
• GME Policy on Resident Duty Hours
• Policy on Resident Duty Hours Monitoring
• Policy on Communication and Escalation Guidelines
• Policy for Patient Care Coordination
• General Information
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  • Resident Evaluations
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  • Resident Role in Departmental Policy-Making
  • Resident Education in Quality Assurance Program
• Travel Reimbursement Guidelines
• GME Disciplinary Due Process Policy
• GME Miscounduct Due Process Policy

Resident Supervision Guidelines

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 physicians 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 within 24 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 orders, performing dressing changes, venipuncture, tracheostomy changes, and other routine aspects or patient care.
• The responsibility for monitoring resident supervision and assuring compliance with all regulations resides with the Departmental Chair and Program Director.
• 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.

 

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GME Policy on Resident Duty Hours

Department of Otolaryngology

Purpose:

To comply with New York Section Health Code Section 405 Regulations, ACGME Common Program Requirements and to establish a work environment with physicians fit for duty and conducive to resident/fellow education and the provision of safe and effective patient care.  The following GME Committee policy has been accepted by the New York State Department of Health and conforms to NYSDOH Section 405 regulations and ACGME requirements revisions which become effective July 1, 2011.

Definitions:

Attending Physician: An appropriately credentialed and privileged member of the medical staff who accepts full responsibility for a specific patient’s medical/surgical care.

Continuity clinic: Setting for a longitudinal experience in which residents develop a continuous, long-term therapeutic relationship with a panel of patients.

Duty Hours: time spent in all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

External moonlighting: Voluntary, compensated, medically-related work performed outside the institution where the resident is in training or at any of its related participating sites.

Faculty: Any individuals who have received a formal assignment to teach resident/fellow physicians. At some sites appointment to the medical staff of the hospital constitutes appointment to the faculty.

Fatigue management: Recognition by either a resident or supervisor of a level of resident fatigue that may adversely affect patient safety and enactment of a solution to mitigate the fatigue.

Fitness for duty: Mentally and physically able to effectively perform required duties and promote patient safety.

Night shift or night float:  A duty assignment which takes place during night time hours and is distinct from on-call assignment.

On-Call: A period during which a resident is assigned to be in-house or available at home in addition to the regularly scheduled duty activities.

Residents or Fellows:  Physicians engaged in a program of graduate medical education under the tutelage and supervision of appropriately qualified faculty and attending staff.

Scheduled duty periods: Assigned duty within the institution encompassing hours which may be within the normal work day, beyond the normal work day, or a combination of both.

Strategic napping: Short sleep periods, taken as a component of fatigue management, which can mitigate the adverse effects of sleep loss.

Transitions of care: The relaying of complete and accurate patient information between individuals or teams in transferring responsibility for patient care in the health care setting.

The following guidelines have been established:

Maximum Hours of Work per Week

Duty hours will not exceed 80 hours per week, averaged over a four week period inclusive of all in-house call activities, clinic assignments and all moonlighting (if approved).  Any exception to this maximum must be approved by the GMEC and DIO and then submitted for approval to the ACGME Review Committee.  Activities, which count in the 80-hour work week and for the consecutive duty hours work rules, include inpatient assignments, outpatient clinic, emergency and acute care assignments, required conferences and other required educational activities, program required research activities and on-site activity/direct patient care that occurs when a resident/fellow is called back while on beeper call from home.  In Emergency Medicine, residents should not work more than 60 hours per week seeing patients in the ED and no more than 72 hours per week.

Maximum Duty Period Length

Duty periods for PGY-1 residents will not exceed 16 hours duration total.

Duty periods for PGY-2 residents and above will not be scheduled to exceed a maximum of 24 hours of continuous duty on-site in the hospital.  During this period, residents must use alertness management strategies including opportunities for strategic napping after 16 hours.  After 24 hours of continuous in-house duty, residents can remain on-site for a maximum of 3 hours for effective transitions in care and educational activities such as rounds and conferences.  However, residents will not be assigned additional clinical responsibilities during this time, and this time can not be scheduled as part of assigned duties.  This period of transition time must be counted in the 80 hour weekly limit.  In Emergency Medicine settings, duty periods will not exceed 12 hours continuous duty.

In the infrequent event of unusual circumstances in which residents, on their own initiative, choose to remain beyond a scheduled duty period to assist in the care of a single patient due to severity of illness, instability, events of academic importance or humanistic needs, documentation of the reason must be submitted to the program director, and all other patients must be handed over to other team members responsible for their continuing care.  The program director must review each submission of additional duty time and track both individual resident and program-wide occurrences.

Maximum Frequency of In-House Night Float

Residents must not be scheduled for more than 6 consecutive nights of night duty. 

Maximum Frequency of In-House On-Call   

Maximum in-house call for intermediate and senior residents (PGY2 and above) is every third night, averaged over a four-week period.

Minimum Time Off between Scheduled Duty Periods

PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods.  Intermediate level residents, as defined by each Review Committee, should have 10 hours free of duty, and must have eight hours between scheduled duty periods, and they must have at least 14 hours free of duty after 24 hours of in-house duty.  Residents in their final years of education (as defined by each Review Committee) must have eight hours free of duty between scheduled duty periods.  For residents on-duty in Emergency Medicine,  there must be an equivalent period of time off-duty.

Mandatory Time Free of Duty

Residents/fellows are to be scheduled for a minimum of one day (24 hours) free of duty (non-working time) per week.  There must be no scheduled activities during this time and at-home call cannot be assigned on these free days. 

At-home Call

At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.  Time spent in the hospital by residents on at-home call must count toward the 80 hour maximum weekly limit, but each episode of this type of care will not initiate a new “off-duty period.”  The frequency of at-home call is not subject to the every third night limitation on calls, but it must satisfy the requirement for one-day (24 hours) per week free of duty.  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 work week.

Moonlighting*

Moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program.  As such, moonlighting is restricted as per GME Moonlighting Policy and it is prohibited without express written permission by program director and or chairperson and approval by the GME Office.  Said permission can be withdrawn at any time.  If approved, all moonlighting, internal and external, must comply with duty hours restrictions and be counted towards working hours limitations.  All moonlighting must be counted towards the 80 hour limit.  Trainees who have worked the maximum number of hours permitted are prohibited from moonlighting.  PGY1 residents are not permitted to moonlight at all.  Refer to GME Moonlighting Policy for further information.

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.  Resident/fellow duty hours will be monitored by the sponsoring institution, programs and affiliated sites as per Duty Hours Monitoring Policy

Failure to comply with duty hours limitations can result in corrective or disciplinary actions.  Resident or fellows who knowingly violate duty hours rules can be subject to disciplinary action which may include probation, nonrenewal or termination.  In the event of such actions, the resident/fellow will be entitled to due process and grievance proceedings as per GME policy.

This policy becomes effective July 1, 2011 and supersedes all previous Resident/Fellow Duty/Work Hours Policies.

Originally approved by NYS DOH 6/2/98  

Reviewed and re-approved by GMEC 6/16/10

Policy revised and approved by GMEC:5/18/11

*The Department of Otolaryngology does not allow moonlighting by its residents.

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Policy on Resident Duty Hours Monitoring

All residents are required to honestly and accurately complete surveys of duty hours using the web-based New Innovations Residency Management System.

All PGY-1 through PGY-5 resident MUST enter duty hours WEEKLY.  Although the SUNY GME office requires a minimum of 1 week entered monthly, this DOES NOT apply to the department of otolaryngology, for which duty hours must be entered for all days (similar to the Department of Surgery).

Residents will receive a weekly email reminder form New Innovations to enter duty hours.  Duty hours can be logged by accessing New Innovations through the website or uploading duty hours data through Smartphone apps provided by New Innovations.

Duty hours surveys will routinely be conducted by GME Office at SUNY Downstate on approximately a quarterly basis.  The program director for otolaryngology will review duty hour reports monthly.

Residents/fellows are required to report all work or profession related activity for all hours during the monitoring period.  Reporting categories include Routine Shift, On-call, Home-call, Non-patient Care Time, Vacation/Leave, Moonlighting.

To complete the duty hours survey submission, each resident must certify the accuracy and validity of their duty hours reported.  Failure of any party to comply with requirements for the honest and accurate reporting of duty hours can result in adverse action as described in the GME Misconduct Due Process Policy.  Completion of the survey is a professional duty obligation of each trainee which supports the institution in assuring a safe and effective patient care environment.  It is also an important function demonstrating competence in safe and effective patient care, systems-based practice and practice based learning and improvement, and professionalism.

Under no circumstances may anyone retaliate against, interfere with or discourage any party from participating in the good faith, accurate and honest reporting of duty hours.  A house staff physician who believes he/she may have been intimidated or retaliated against in violation of this policy should immediately report it to his/her supervisor, the GME Office, resident ombudsman or any other supervisor including the Program Director, Department Chairperson or institutional leadership.

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Communication and Escalation Guidelines

Guiding Principles

It is the goal of the Department of Otolaryngology to provide the finest possible care to our patients.  We also have the goal of providing the best Otolaryngology training for our residents and students, but this is always secondary to patient care.

Every encounter a trainee has with any patient as a member of the Department of Otolaryngology is performed under the auspices and supervision of an attending physician within the Department.  The moment to moment care of the patient may be delegated to the trainee, but the responsibility of the treatment always remains with the attending physician and is never delegated.

It is important for the trainee to always know who the responsible attending is on every patient.  For most patients in the hospital, it will be their admitting attending.  For patients in the Clinic, it is the attending that is supervising that clinic.  For inpatient and ER consults, it is the designated consult attending.  During call hours, it is the designated on-call attending.  When doubt exists as to whom is responsible, contact the Director of Service at the site in question.   

During on-call coverage, patient care functions are delegated by the attending physician to the resident trainees.  This includes not only the care of ENT post-operative and inpatients, but also inpatient and ER consultations.  The call schedule designates the junior and senior call residents and the responsible attending on call.  The in-house resident and the back-up senior resident must always know who the responsible attending is and how to contact them in the quickest manner (usually by cell phone). 

Departmental Practices

1. For patients Admitted to the Otolaryngology Service, the Attending must be contacted and notified within one hour for any critical change in the patient’s condition.  This includes, but is not limited to:
   • Admission to the hospital
   • Transfer to Intensive Care
   • Unplanned intubation or ventilatory support
   • Cardiac arrest, hemodynamic instabilities or called code “66” or “99”
   • Change in neurological status including seizures or new-onset paralysis
   • Development of major wound complication (dehiscence or fistula)
   • Medication or treatment error requiring clinical intervention
   • Blood transfusion without prior attending knowledge or instruction
   • Development of any problem requiring an invasive procedure or operation
2. The following need to be discussed with the attending and approved before they occur:
   • Discharge from the hospital
   • Transfer out of the IC
3. The attending should also be contacted if:
   • Any trainee feels the situation is more than he or she can manage
   • Nursing or physician staff request that the attending be contacted 
   • The patient or family requests the attending be contacted
   • The patient files a complaint with Patient Relations regarding their care
4. All consults are to be discussed in a timely manner with the senior backup resident and the attending.  When such a patient is first seen, the consult resident also needs to contact a representative of the consulting service to discuss the plan of care for the patient.  This contact needs to be documented, dated and timed.  For urgent consults (impending airway, etc.) the responsible attending should be contacted immediately, whereas routine consults may be discussed with and signed off by the attending at the next morning rounds.  All consults must be discussed, seen and signed off by an attending within 24 hours.
5. If the consultation requires further monitoring or follow-up, the residents should continue to see the patient on a regular basis as determined by the attending.  No consult may be “signed-off” of without discussion with and approval of the attending. 
6. The following issues should be dealt with by attending to attending communication:
   • transfer of care of a patient from one service to another
   • disputes among services as to the priorities in the treatment of a patient with multiple problems
   • questions of responsibility in patients mutually managed with another service
   • acceptance of transfer of a patient from another facility
7. If responsible attending is unavailable (e.g. out of town) they must designate another attending to be responsible for the care of their patients. 
8. The Director of Service and/or Chairman needs to be notified when the above recommendations are not followed.

Approved December 17, 2010

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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 ½ 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 elective “same day admission“ patients will have 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.

 

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General Information

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Evaluations

Faculty, Training Program and Rotational Evaluations

Residents are required to evaluate all full-time faculty members and those voluntary faculty with whom they have contact.  Additional evaluation forms are provided after each clinical rotation and annually to evaluate the training program in general.  All forms are accessible through the New Innovations website. The forms are to be completed, electronically signed and submitted through New Innovations. Questions regarding New Innovations should be directed to the Educational Coordinator, Nicole Fraser at 718-270-1638.

All resident evaluations of the faculty, training program, and clinical rotations are confidential.  The Educational Coordinator is the only individual in the department with access to individual evaluations in New Innovations, for purposes of monitoring the completion (not content) of material.  The Coordinator compiles de-identified summary reports for review by the Program Director, who will share the information (in the de-identified format) with teaching faculty.

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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.

Evaluations are compiled and retained as a permanent part of the resident personnel file, which is available at any time for resident review in the Educational Coordinator’s office.  Residents must also electronically sign-off and acknowledge evaluations in New Innovations.  Evaluations are discussed with the resident during meetings with their advisors and during biannual evaluation meetings with the Department Chairman.  Advancement is predicated on satisfactory reviews.

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Faculty Advisors/Mentor

Each resident is assigned a faculty mentor at the start of training.  This mentor is responsible for meeting periodically with the residents to review academic development, research projects, and career plans, including fellowship training.

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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.

Residents are appointed to committees such a curriculum development and resident selection recruitment. 

A resident designated as Liaison to the department communicates directly with the Program Director and Department Chair regarding issues of concern to the residents.

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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.

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Travel Reimbursement Guidelines

Prior to submitting an abstract for consideration, the resident must have the abstract reviewed by the associated faculty member.  If the abstract is approved for submission and is accepted by the appropriate society, the resident must supply the Chairman with a copy of the acceptance letter.  Hotel and car rental accommodations will be arranged by the resident within the departmental guidelines.  Travel arrangements must be made through the SUNY Administrative Office.  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 at least 12 weeks prior to the meeting.  Only early registration fees will be paid. 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 and first class train travel will be covered.  Advance arrangements are to be made via the SUNY Administrative Office.
• 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.
• Use of your own automobile for transportation to local conferences will be reimbursed at the current State-approved rate.
• 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 per diem rate determined by the State (according to city of meeting), (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 necessary expenses 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 necessary expenses 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 necessary expenses 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) and proof of manuscript submission to a peer-reviewed journal 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 30 days of return date in order to be reviewed, approved, and reimbursed by the department.  Reimbursement is usually available in two weeks or less, dependent upon manuscript submission.

• 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 27, 2008

Reapproved January 15, 2011

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GME Disciplinary Due Process Policy

Purpose:

To establish a policy for all post-graduate medical programs of SUNY Downstate Medical Center for use in addressing all actions that can result in altering the intended career path of a resident or fellow.  To provide residents and fellows with fair, reasonable and readily available policies and procedures for grievance and due process through a decision-making process while minimizing conflict of interest by adjudicating parties.

Scope:

This policy applies to all programs and house officers (residents and fellows) participating in graduate medical education programs sponsored by SUNY Downstate.  This policy applies to actions taken as a result of academic deficiencies or misconduct.

Definitions:

Due Process:  an individual’s right to be adequately notified of any changes or proceedings involving him or her, and the opportunity to be meaningfully heard with respect to those proceedings.

House Staff or House Officer:  refers to all interns, residents or fellows enrolled in post-graduate medical training or research program or activity

GME Program:  refers to a residency or fellowship educational program

Adverse Action:  disciplinary actions taken against a resident which alter the intended career development or timeframe.  Such actions are reportable and allow a request for review and due process Adverse actions include the following:

• Dismissal:  act of terminating a house officer participating in a GME program prior to successful completion of the course of training whether by early termination of a contract or by non-renewal of a contract.
• Non-renewal:  act of not reappointing a house officer to subsequent years of training prior to fulfillment of a complete course of training.
• Non-promotion:  act of not advancing a house officer to the next level of training according to the usual progression through a program
• Extension of Training:  act of extending the duration of time required by a house officer to complete a course of training generally resulting from repeating unsatisfactory rotation assignments or remediating poor performance or needing additional time to demonstrate achievement of required competence in one or more domains.
• Probation:  placement of a resident under close monitoring for specific performance concerns which if not successful resolved may result in other adverse actions including dismissal.  This action is reportable to state licensing authorities and health care institutions.
• Suspension: Withdrawal of privileges for participating in clinical, didactic or research activities associated with appointment to the training program or hospital staff.  This action is taken if, in the judgment of the Program Director, Department Chairperson or institutional leadership (Associate Dean, Dean, Medical Director) a resident’s or fellow’s competence or behavior is such that patients may be endangered, the educational process disrupted or other peers, staff, faculty are subjected to an adverse and unacceptable work environment.  Under such circumstances, suspension may be implemented immediately pending further investigation and determination of other appropriate action.  Suspension may be with salary or salary may be withheld after consultation with the labor relations department of the employing facility.

Policy:

Academic Matters:

The SUNY Downstate GME Academic Performance Policy affords due process to residents/fellows who are subject to adverse actions or whose intended career development is altered by an academic decision of a program.  See Academic Performance Policy for delineation of specific processes provided.

Misconduct Matters:

The SUNY Downstate Resident/Fellow GME Misconduct Policy affords due process to residents/fellows who are subject to adverse actions or dismissed from a GME program in a manner that alters their intended career development.  See Resident/Fellow GME Misconduct Policy for delineation of specific processes provided.

Policy revised and updated on 5/13/2011.  This Policy supersedes all prior, similar and/or related versions and revisions.  Revisions approved by GMEC 5/18/11.  Effective immediately upon approval.

 

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GME Misconduct Due Process Policy

Purpose:

To establish a policy and procedure for all post-graduate medical programs of SUNY Downstate Medical Center to use in addressing allegations of misconduct made against a house staff officer.  To provide fair, reasonable and readily available policies and procedures regarding charges of misconduct.

Scope:

This policy applies to all programs and house officers (residents and fellows) participating in graduate medical education programs sponsored by SUNY Downstate.  This policy applies to any actions taken as a result of allegations of misconduct or serious departure from standards of professionalism or professional expectations.  This policy describes minimum expectations providing residents with an opportunity to be notified of allegations and an opportunity to be heard and respond to such allegations and any proposed action taken as a result.

Definitions:

Due Process:  an individual’s right to be adequately notified of any changes or proceedings involving him or her, and the opportunity to be meaningfully heard with respect to those proceedings.

House Staff or House Officer:  refers to all interns, residents or fellows enrolled in post-graduate medical training or research program or activity at SUNY Downstate or as a visiting rotator to SUNY Downstate.

GME Program:  refers to a structured educational experience in graduate medical education designed to conform to the Program Requirements of a particular specialty/subspecialty

Misconduct: refers to improper behavior; intentional wrongdoing; violation of law, rule, standard of practice, or policy of the program, department, institution or agency including NYS Education Law Section 6530 (synopsis attached as appendix 1).  Misconduct may also constitute unprofessional behavior, which may also trigger action under the GME Academic Deficiencies Policy, not to the exclusion of any action resulting from this GME Misconduct Policy.  These actions may proceed simultaneously.

Monitored Performance: an academic function involving the heightened level of monitoring and assessment of house officer performance in the course of training program activities usually used to further assess for improvement in noted areas of deficiency, often as a part of a program for remediation.  This is not an adverse action and it is not reportable.

Adverse Action:  disciplinary actions taken against a resident which alter the intended career development or timeframe.  Such actions are reportable and allow a request for review and due process.  Adverse actions include the following:

Dismissal:  act of terminating a house officer participating in a GME program prior to successful completion of the course of training whether by early termination of a contract or by non-renewal of a contract.

Non-renewal:  act of not reappointing a house officer to subsequent years of training prior to fulfillment of a complete course of training.

Non-promotion:  act of not advancing a house officer to the next level of training according to the usual progression through a program.

Extension of Training:  act of extending the duration of time required by a house officer to complete a course of training generally resulting from repeating unsatisfactory rotation assignments or remediating poor performance or needing additional time to demonstrate achievement of required competence in one or more domains.

Probation:  placement of a resident under close monitoring for specific performance concerns which if not successfully resolved may result in other adverse actions including dismissal.  This action is reportable to state licensing authorities and health care institutions.

Suspension: withdrawal of privileges for participating in clinical, didactic or research activities associated with appointment to the training program or hospital staff.  This action is taken if, in the judgment of the Program Director, Department Chairperson or institutional leadership (Associate Dean, Dean, Medical Director) a resident’s or fellow’s competence or behavior is such that patients may be endangered, the educational process disrupted or other peers, staff, faculty are subjected to an adverse and unacceptable work environment.  Under such circumstances, suspension may be implemented immediately pending further investigation and determination of other appropriate action.  Suspension may be with salary or salary may be withheld after consultation with the labor relations department of the employing facility. 

Structured Feedback:  routine feedback regarding a trainee’s performance or behavior and consistent with the educational program.  Structured feedback can consist of verbal feedback, rotational and summative evaluations, spontaneous or “on-the-fly” formal evaluations, memos or letters to a resident’s record or to the Program Director and shared with the resident, discussion and recommendations of a Program’s Clinical Competence or Resident Performance or other similar committee.

Policy:

A house officer, employee of the hospital, attending physician, patient, or any other person who believes that a house officer has engaged in misconduct of any kind should immediately report his/her concern to his/her supervisor, or any other supervisor in the institution, who in turn should communicate the allegations to the house officer’s Program Director.  Upon receipt of a complaint regarding the conduct of a house officer, the Program Director should conduct an initial inquiry, as follows:

• Review documentation of and in support of the complaint
• If possible, meet with the person complaining of misconduct
• Meet with the house officer to advise the house officer of the existence of the complaint, to notify him or her and provide an opportunity to respond to the allegations, and to identify any potential witnesses or other information relevant to the alleged misconduct
• Consult with GME Office to determine whether the Dean, Associate Dean for GME, Department Chairperson, Legal Affairs and/or Human Resources and/or Labor Relations should be contacted as appropriate based on the issues and the people involved
• Upon the request of the house officer, or if the Program Director, Associate Dean for GME/DIO, Department Chairperson or Human Resources decide the incident warrants more investigation, then a “Full Inquiry” must be done
• All allegations of sexual harassment, disruptive behavior or violence must be reported to Human Resources/Labor Relations in accordance with the Institution’s policies.
• Upon consensus of the Program Director and the Associate Dean for GME/DIO or designee, the accused house staff officer can be removed from duty (with or without pay) pending the outcome of a full inquiry

Full Inquiry:

A full inquiry is an internal investigation of the allegations/incident by a committee of appropriate individuals appointed by the Department Chairperson from within the Department/Institution.  This may include GME staff or leadership, Program Director, Department Chairperson, key faculty, Human Resources, Legal Affairs, Labor Relations, Hospital Administration, or others.  The inquiry process is administered by the Department Chairperson in consultation with the GME Office.  Factual results of the inquiry along with recommendations for action will be prepared by the Chairperson and/or other responsible faculty or staff participating in the full inquiry and reported back to the Program Director and the house officer for appropriate action.  A copy of this report will be submitted to the GME Office and Associate Dean for GME/DIO.  If the full inquiry results in a finding that no misconduct occurred, no action will be taken against the house officer.  If the house officer was suspended pending the inquiry, the house officer will be reinstated with full benefits and pay without prejudice.  If the full inquiry results in a finding that the house officer engaged in misconduct, the Program Director shall determine, in consultation with the Department Chair, Human Resources, Legal Affairs, Labor Relations or other appropriate individuals, what action is appropriate under the circumstances, to remedy the situation.  At all times, quality of patient care, safety of patients, staff, faculty and house officers, and integrity and security of the work and education environment must be assured.  The Program may take actions including, without limitation, the following:

• Verbal or written warning or reprimand
• Election to not promote to the next training level
• Non-renewal of contract
• Suspension
• Probation
• Immediate termination or dismissal from residency or fellowship program

Reportable Actions:  The decision not to promote a house officer to the next PGY level, to extend training, to deny credit for a previously completed period of training, suspension, probation, and/or terminating a house officer’s participation in  a residency or fellowship program are each considered “reportable  actions.”  Such actions must be disclosed to others upon request, including without limitation, future employers, privileging hospitals, and licensing and specialty boards.  House Officers who are subject to a reportable action are permitted to request a review of the decision and seek to appeal that decision.

For all such actions, the resident must be notified verbally, when possible, and in writing.  A copy of the notification signed and dated by the Program Director with documentation that it was received by the resident (resident signed acknowledgement or witnessed or other receipt verification) must be included in the resident’s record and copied to the GME Office.  Notice of adverse action or any action which can interfere with the resident’s intended career development must inform the house officer of his/her right to review and appeal of such adverse action. The house officer should be provided with or referred to applicable policies and procedures regarding due process, review and appeal.  Notifications of adverse action should be done in consultation with the GME Office.  Note that performance evaluations and assessments, even when unsatisfactory, are standard procedures in a training program and in and of themselves are not considered adverse actions, are not reportable actions and are not subject to appeal under this policy.  Verbal or written warnings and/or reprimands are also not considered adverse actions, are not reportable and are not subject to appeal under this policy.

Request for Review and Appeal:

A review and appeal of a Program’s decision to take a Reportable Action or any action interfering with the resident’s intended career development may be requested by the house officer.  The request must be made in writing, addressed to the Associate Dean for GME, signed and dated, and submitted to the Director of Graduate Medical Education within 14 calendar days of the house officer learning of the Reportable Action.  The request should clearly describe the reason for requesting the review and any basis upon which an appeal is being made.  Upon receipt of a Request for Review and Appeal, the Associate Dean for GME will determine whether the matter is subject to review under this Policy.  If so, the Associate Dean for GME will direct the Director of GME to appoint an ad hoc Review and Appeal Subcommittee of the GME Committee.  This subcommittee will be composed of neutral reviewers from Departments other than the one in which the requesting house officer is appointed.  The subcommittee will consist of at least two SUNY Downstate faculty members and one resident or fellow.  Additional committee members may be assigned at the discretion of the Associate Dean for GME/DIO.  The subcommittee may also include institutional GME Department leadership such as the Vice Dean for GME, Associate Dean for GME, the DIO or GME Office administrative officers.  SUNY Counsel may serve in an advisory capacity.

The ad hoc Review and Appeal subcommittee will:

• Conduct confidential meeting(s) open only to committee members, GME Office and GMEC staff, and any participants invited by and approved by the Committee.
• Identify one faculty member who will serve as Chairperson of the subcommittee.  The subcommittee Chairperson should be a participant on the SUNY Downstate GME Committee.
• Arrange for an individual to take notes and document a summary of minutes of meetings held.
• Committee meetings will be scheduled at the discretion of the committee Chairperson.
• Establish a process for the review.  Such process will not be rigidly prescribed and is not conducted in the manner of a legal hearing process.  No legal representation will be permitted.  No opportunity for cross examination or questioning is offered.   
• Review the resident/fellow complaint and request for review/appeal.
• Provide the house officer requesting the review or appeal the opportunity to appear before the committee to make a statement and/or present evidence of relevance for rescinding the action under review.  The committee may also require the house officer to respond to questions posed by the committee.  As an academic review panel and not a legal hearing, when appearing before the committee, the house officer may be accompanied by an advocate who is not an attorney.  Failure of an appealing house officer to appear as scheduled before the committee without just cause could result in a summary determination against the house officer.
• If applicable, review relevant records and documentation such as the house officer’s file, program records, policies, meeting minutes, etc.
• Consider any extenuating circumstances.
• The committee may meet with the Program Director or other program representative(s) and request presentation of evidence for upholding the proposed action.
• The committee may request statements from or interview other house officers, faculty, staff, administrators or members of the academic or health care team in order to gather additional information.
• The committee may consult with others, as appropriate, to assist in the decision making process.
• Determine whether this Policy was followed, the house officer received notice and an opportunity to be heard, and the decision to take the reportable action was reasonably made.
• The subcommittee Chairperson is responsible for preparing the committee’s report summarizing findings and making recommendations to the Associate Dean for GME/DIO regarding the review and request for appeal of reportable actions.
• The subcommittee Chairperson or designee will report the outcome of the review and appeal process to the GME Committee.

Upon receipt of the Chairperson’s report from the ad hoc Review and Appeal Subcommittee, the Associate Dean for GME shall review said findings and recommendations.  The Associate Dean for GME/DIO finding the committee’s review process to have followed procedure and be fair, reasonable and appropriate shall make notification to the resident of the Review and Appeal subcommittee’s decision in writing with a copy to the Program Director, Department Chairperson, the employing institution, if applicable, and others as appropriate.

The decision resulting from this review is a final and binding decision.  It is not subject to further formal review within the State University of New York Downstate Medical Center (Health Science Center at Brooklyn).

No Retaliation:  Initial and full inquiries will be conducted with due regard for confidentiality to the extent practicable. Under no circumstances may anyone retaliate against, interfere with or discourage anyone from participating in good faith in an initial inquiry or full inquiry conducted under this policy.  A house staff officer who believes he/she may have been retaliated against in violation of this policy should immediately report it to his/her supervisor, the Director of GME, resident ombudsman, Associate Dean for GME, DIO or other any other supervisor. 

Original policy completed on 5/13/2011.  This Policy supersedes all prior, similar and/or related versions and revisions.  Reviewed and approved by GMEC 5/18/11.  Effective immediately upon approval.

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