F S U

FLORIDA STATE
UNIVERSITY
College of Medicine
PEDS Policy & Procedure Manual
2011-2012
1
PEDIATRIC RESIDENCY
2011-2012 Policy & Procedure Manual
MAIN SECTIONS:
PAGE(S):
Introduction
3
Our Residents
4
Statement of Commitment to Graduate Medical Education (GME)
5
Florida State University (FSU) Pediatric Residency Goals and Objectives
(Incl. Background Checks/Drug Screens)
I.
Support Systems
II.
Residency Policies
III.
Required Conferences & Attendance Policy
IV.
Continuity Clinic
V.
Duty Hours
VI.
On-Call Activities
VII.
Night-Time Phone Calls
VIII.
Medical Records
IX.
Evaluations
X.
Practice Based Learning and Systems Based Practice
XI.
Accreditation Council for Graduate Medical Education (ACGME)
Essentials of Accredited Residencies
XII.
Code of Conduct
XIII.
Duration of Appointment
XIV.
Certificate of Completion
XV.
Institutional GME Policies
6-9
Educational Information
57-66
Appendix
Appendix
Appendix
Appendix
Appendix
67-68
70-71
72-73
74-75
76-81
I
II
III
IV
V
FSU SHH Moonlighting Policy
Programmatic Moonlighting Approval Form
Non-Programmatic Moonlighting Approval Form
SHH Policy on Internet Social Networking/Blogging
Support for Resident Physicians with Impairments
2
10-12
12-15
15-16
16
17-18
18-20
20
20-21
21-23
24-25
25-26
26-27
28
28
28-56
INTRODUCTION
This Resident Policy and Procedure Handbook is designed to improve quality of patient
care, minimize conflicts, display responsibilities and duties, and allow you to spend
more time and energy on your basic goal -- that of learning the art and science of
Pediatrics. That is why we are here. “Training begins with a task, and learning begins
with a question.”
In this program, you will find both with abundance.
We are available and we will be happy to talk with you about anything at any time. As
faculty of the Pediatric Residency Program, it is our responsibility to provide the
opportunities for your education and to finally place the stamp of completion on your
residency documents.
We look forward to the coming year.
Peter Jennings, MD
Program Director, Pediatric Residency
Anthony “Gus” McDavid, MD
Associate Program Director
Erica Whittingham, MD
Assistant Professor
James Burns, MD
Director of Adolescent Medicine
Director of Pediatric Program Research
D. Gary Griffin, MD
Asst. Dir., Pediatric Care Center
Jason Foland, MD
Medical Director
Pediatric Respiratory Care
Ryan Hahn, DO
Clinical Asst. Professor/Intesivist
PICU
Rob Patterson, MD
Medical Director
Sacred Heart Children’s Hospital
PICU
Rex Northup, MD
Co-Medical Director
Diane M. Wilkinson, MD
Medical Director
Pediatric Care Center
Jesse Walck, MD
Medical Director,
Pediatric Emergency Dept.
Martin I Herman, MD
Pediatric Emergency Medicine
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OUR RESIDENTS
Resident Physicians -
July 1, 2011 - June 30, 2012
PGY 3 YEAR
Lisa Hills, M.D.
Amy Lee, M.D.
Haendel Munoz, M.D.
Jennifer Panganiban, M.D.
Grisset Rivera Diaz, M.D.
Jennifer Walker, M.D.
Stamatia Alexiou, M.D.
American University of the Caribbean
Ross University
Univer. Peruana Cayetano Heredia
University of Santo Tomas
Ross University
Florida State University
Akademia Medyczna Im Karola
Marccinkowskiego (Poland)
PGY 2 YEAR
Anacani Fonseca, MD
Peter Michael Mangubat, MD
Nam Nguyen, MD
Courtney Shipon, MD
Rohini Singh, MD
Sneha Taylor, MD
Musab Al-Yahia, MD
Universidad Autonoma de Cludad Juarez
University of Santo Tomas
Ross University
Jefferson University
Louisiana State University/New Orleans
Smt. N.H.L. Municipal Medical College
St. Christopher’s Medical University
PG 1 YEAR
Tangra Broge, MD
Ashley Duray, MD
American University of the Caribbean
Rosalind Franklin University of Medicine
Science
University of Texas Medical Branch
University of Aleppo
Mercer University
St. George’s University
University of Arkansas for Medical Science
Jagiellonian University Medical College
Christopher Healey, MD
Salim Hommeida, MD
Patricia Onuegbu, MD
Sona Patel, MD
Jason Straub, MD
Magdalena Struk, MD
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STATEMENT OF COMMITMENT TO GRADUATE
MEDICAL EDUCATION
The Florida State University College of Medicine (FSU COM) is committed to GME as
central to its mission to maintain a scholarly environment that is dedicated to
excellence in education, medical care and research. The FSU COM seeks to educate
tomorrow's physicians and medical scientists and will financially support our
infrastructure to do so. We will maintain necessary partnerships to provide educational
and human resources to in order to achieve, at a minimum, substantial compliance with
the Accredited Council for Graduate Medical Education (ACGME) Institution, Common
and Individual Program Requirements. We further commit ourselves to doing regular
assessments (Internal Reviews) of the quality of the GME programs, the performance of
their residents, and the use of outcome assessment results for program improvement.
The FSU COM provides an environment of organized GME programs in which residents
develop personal, ethical, clinical and professional competence under careful guidance
and supervision. Programs will assure the safe and appropriate care of patients and the
progression of resident/physician responsibility consistent with each trainee’s
demonstrated clinical experience. The Graduate Medical Education program is designed
to provide residents and fellows with the knowledge, skills and values that can serve as
the basis for competent and compassionate clinical practice, scholarly research and
public service.
Residents are encouraged to develop a process for self-evaluation and moral reflection
to sustain a lifetime of responsible and committed practice of medicine. The educational
program prepares residents to continue their own education and to teach their patients,
colleagues and medical students throughout their careers. We are committed to
ensuring that our graduates understand the scientific foundation of medicine and apply
that knowledge to clinical practice and extend that knowledge through scholarly
activities. In addition, we provide the experience necessary for residents to master the
clinical skills necessary to evaluate and care for their patients.
The FSU COM is committed to having an organized administrative system, including
a Graduate Medical Education Committee (GMEC) and a Designated Institutional
Official (DIO) that complies with the ACGME Institutional Requirements.
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GOALS AND OBJECTIVES
The primary program goal of the Florida State University (FSU) College of Medicine
(COM) Pediatric Residency Program at Sacred Heart Children’s Hospital is to achieve
and maintain excellence in the education and training of pediatricians by assuring an
organized educational experience with increasing responsibilities over three years in a
setting where mutual respect between learners and teachers is fostered, where there is
a diverse patient population, and where the teaching staff is enthusiastic and
committed to teaching. This experience is designed to promote the acquisition of
knowledge, skills, and attitudes needed to practice pediatrics, to develop the
progressive autonomy of residents, and to provide them with appropriate levels of
supervision.
The program’s objectives are defined under the ACGME six core competencies: Patient
Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism,
Practice Based Learning and Improvement, and Systems Based Practice.
OBJECTIVES
Achieve competency in patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents must be
able to provide family centered patient care that is developmentally and age
appropriate, compassionate, and effective for the treatment of health problems and the
promotion of health.
Achieve competency in medical knowledge and the application of this knowledge in
patient care. Residents must demonstrate knowledge about established and evolving
biomedical, clinical, epidemiological and social-behavioral science, and demonstrate the
ability to apply this knowledge to patient care.
Achieve competency in interpersonal and communication skills which results in effective
information exchange when working with patients, their families, and other health
professionals.
Achieve competency in practice-based learning and improvement. Residents must
demonstrate competence in the use of scientific methods and evidence to investigate,
evaluate, and improve their patient care practices. The goal of this being to create an
inquisitive, life-long learner, knowledgeable in the processing of medical information
which can be utilized in care of patients now and in the future.
Achieve competency in professionalism as manifested through a commitment to
carrying out professional responsibilities, adherence to ethical principles, and sensitivity
to a diverse patient population.
Achieve competency in systems-based practice. This includes developing a working
knowledge and comfort in the role of pediatrician as advocate for child health related
issues.
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PATIENT CARE
Patient care is the cornerstone of pediatric residency training, Under the supervision of
attending faculty, the resident assumes responsibilities for safe, effective and
compassionate care of patients, consistent with the resident’s level of education and
experience. The resident is expected to adhere to the established policies, procedures,
and practices of the department, hospital and its affiliated institutions.
Elements of patient care include:
1. Gathering essential and accurate information about the patient using the following
clinical skills:
• Medical interviewing
• Physical examination
• Diagnostic studies
• Developmental assessment
2. Making informed diagnostic and therapeutic decisions based on patient information,
current scientific evidence, and clinical judgment:
• Use effective and appropriate clinical problem-solving skills
• Understand the limits of one’s knowledge and expertise
• Use consultants and referrals appropriately
3. Developing and carrying out patient care management plans.
4. Performing all medical procedures required for the scope of practice.
5. Counseling patients and families:
• To take measures needed to enhance or maintain health and function, and
prevent disease and injury
• To encourage them to participate actively in their care by providing
information necessary to understand illness and treatment, share decisions,
and give informed consent
• To provide comfort and allay fear
6. Providing effective health care services and anticipatory guidance.
7. Using information technology to optimize patient care.
MEDICAL KNOWLEDGE
Each resident is expected to participate fully in the educational and scholarly activities
of the residency program and, as required, assume responsibility for teaching and
supervising other residents and medical students.
Elements of medical knowledge include:
1. Reading and following the goals and expectations of each rotation, which will be
provided and discussed with the resident at the beginning of the rotation.
2. Seeking feedback from faculty particularly at the midpoint of a rotation and at the
end of a rotation.
3. Developing and participating in a personal program of self-study and professional
growth with guidance from the teaching staff.
4. Participating in institutional programs, committees, councils, and activities involving
the medical staff of the hospital as assigned by the program director/chief residents.
5. Attending all educational conferences, lectures, and Grand Rounds unless the
resident is on vacation or has another compelling reason.
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6. Understanding the principles of health maintenance and the influence of the
environment on health.
7. Performing and documenting all procedures (required and exposure) as outlined in
the program’s Procedure Log Policy (Section II., pg. 14).
INTERPERSONAL AND COMMUNICATION SKILLS
Residents must be able to demonstrate interpersonal and communication skills that
result in effective information exchange and in teaming with patients, their families,
and professional associates.
Elements of interpersonal and communication skills include:
1. Communicating effectively in a developmentally appropriate manner with patients
and families to create and sustain a professional and therapeutic relationship across a
broad range of socioeconomic and cultural backgrounds. Residents should be able to
demonstrate the ability to avoid being judgmental, and to respect the beliefs and
values of patients’ families when those beliefs and values differ from their own.
2. Communicating effectively with physicians, other health professionals, and health
related agencies.
3. Working effectively as a member or leader of a health care team or organization.
4. Acting in a consultative role to other physicians and health professionals.
5. Maintaining comprehensive, timely, and legible medical records.
PRACTICE-BASED LEARNING AND IMPROVEMENT
Elements of practice based learning and improvement include:
1. Participating in the journal club curriculum.
2. Developing an Individualized Education Plan (ILP) using www.pedialink.org.
3. Taking primary responsibility for lifelong learning to improve knowledge, skills, and
practice performance.
4. Analyzing one’s practice experience to recognize one’s strengths, deficiencies, and
limits in knowledge and expertise.
5. Using evaluations of performance provided by peers, patients, superiors, and
subordinates to improve practice.
6. Locating, appraising, and assimilating evidence from scientific studies related to
health problems of patients.
7. Using information technology to optimize lifelong learning.
8. Actively participating in the education of patients, families, students, residents, and
other health professionals.
9. Demonstrating the ability to utilize community resources to embrace the
effectiveness of community service to children and their families.
10. The above assimilation of this competency will be, in part, exemplified in the
completion and presentation of a pediatric research project (Section X. A.).
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PROFESSIONALISM
Residents must demonstrate a commitment to carrying-out professional responsibilities,
adherence to ethical principles, and sensitivity to diversity.
Elements of professionalism include:
Demonstrating respect for responsiveness to the needs of patients and society by:
• Accepting responsibility for patient care including continuity of care;
• Demonstrating integrity, honesty, compassion, and empathy in one’s role as a
physician;
• Demonstrating respect of the patient’s privacy and autonomy;
• Demonstrating appropriate professional boundaries;
• Demonstrating accountability and commitment;
• Demonstrating a responsiveness to the needs of patients and society that supersedes
self-interest;
• Demonstrating high standards of ethical behavior; and,
• Demonstrating sensitivity and responsiveness to patients’ and colleagues’ gender,
age, culture, disabilities, ethnicity, and sexual orientation;
SYSTEMS-BASED PRACTICE
Residents will practice quality health care and advocate for patients in the health care
system.
Elements of systems-based practice include:
1. Understanding how types of medical practice and delivery systems differ from one
another in areas such as methods of controlling health care costs, assuring quality, and
allocating resources.
2. Practicing cost-effective health care and resource allocation that does not
compromise quality of care.
3. Developing and demonstrating basic understanding of the various health care
delivery models, payment structures, and insurance issues.
4. Advocating for quality patient care and assisting patients in dealing with system
complexities.
5. Collaborating with health care managers and health care providers to assess,
coordinate, and improve patient care.
6. Advocating for the promotion of health and the prevention of disease and injury in
populations.
7. Acknowledging medical errors and developing systems to prevent them.
8. The above assimilation of this competency will be exemplified in the completion of
second and third year advocacy projects (Section X. B.).
BACKGROUND CHECKS/DRUG SCREENS
The Sacred Heart Health System, like many hospitals and other facilities to which
residents rotate, requires a criminal background check and drug screen of all individuals
working, training, or volunteering in their institution(s). In addition, application to the
Florida Board of Medicine as an intern/resident/fellow, as well as for unrestricted
licensure, requires self-disclosure of criminal convictions and of prior substance abuse
and/or treatment.
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I. SUPPORT SYSTEMS
ADMINISTRATIVE OFFICES
The following is a list of initial contact people within the program who can help, or direct
you to people who can help, with any problem or question you may have.
1. Procedural or policy questions:
Amy Lee, MD., Chief Resident - pager 406-4529, cell 309-333-4082
E-mail: [email protected]
Haendel Munoz, MD., Chief Resident- pager 406-2991, Cell 850293-4246
Email: [email protected]
Danika Talbert, Program Coordinator, E-mail: [email protected]
Residency Office:
5151 N. 9th Ave., Pensacola, FL. 32504
(850) 416-7658
Connie Donohoe, FSU COM Coordinator, E-mail: [email protected]
Office Phone: (850) 645-6867
2.
Sick day, serious illness, death in the family, or anything that will keep
you from your schedule:
Ward, NICU, PICU, and Nursery: It is the resident's responsibility to notify the
Residency Office, ward senior, and/or chief resident and attending.
Subspecialty services: It is the resident's responsibility to notify the Residency
Office and the attending physician.
Clinic: It is the resident's responsibility to notify the chief resident and your clinic
attending.
Note: After 5:00 p.m. or on weekends, leave a message at the Residency Office,
and contact the chief resident
Switches in the call schedule: (See Section V. Call and Back-up call
responsibilities)
Notify the residency office of any changes in the original rotation schedule.
Phone calls should be made as soon as possible preferably before 8:00 a.m. A
maximum of ten sick days over the year, any further sick days will
require a written doctor's excuse. In the event that the ill resident is unable
to notify all of the appropriate individuals listed above, he/she should
communicate with the chief resident to inform the other parties. Failure to
comply with this policy will result in a review by the Residency Training and
Evaluation Committee (TEC) and a possible additional night of call assigned to
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the resident.
3.
Personal Problems and/or Interpersonal Difficulties:
Amy Lee, MD
Chief - pager 406-4529, cell 309-333-4082
Haendel Munoz, MD
Chief – pager 406-2991, cell 850-293-4246
Danika Talbert
Coordinator - 416-7658, cell 850-375-3155
Anthony “Gus” McDavid, M.D. Associate Residency Director – pager 443-1118
Peter J. Jennings, M.D.
Residency Director – 416-6912; pager 506-0292
Alma B. Littles, M.D.
Sr. Assoc. Dean/DIO, FSU COM (850) 644-5905
4.
Court Summons/Subpoena regarding a patient, notify the following
individuals:
Peter J. Jennings, M.D.
Residency Director 416-6912, pager 506-0292
Mr. Charles J. Portero, JR
Legal Counsel, FSU COM *SIP - (904) 244-9076
Alma B. Littles, M.D.
Sr. Assoc. Dean/DIO, FSU COM (850) 644-5905
*Self Insurance Program
(see Section II, Residency Policies, pg. 11)
5.
Communication, management problems with any hospital department:
Peter J. Jennings, M.D.
Residency Director – 416-6912; pager 506-0292
Anthony “Gus” McDavid, M.D. Associate Residency Director – 416-7713;
pager 443-1118
ACADEMIC SUPPORT
1.
Big Sibling - Prior to coming to the Program, each resident is assigned a Big
Sibling. The Big Sibling is a resident who has completed at least one year in the
program. The Big Sibling is available to answer questions about the program,
help the new resident get settled and generally play a supportive role. The
amount of contact the resident has with the Big Sibling is open, and will be
decided by the individuals involved.
2.
Mentor/Advisor - Each resident is expected to select a faculty mentor to whom
they may turn to for support and advice. The mentor counsels and supports the
professional growth of the resident. The program director needs to be informed
of your prospective mentor. If a resident does not choose a mentor by the end of
rotation #4, the program director will assign one to the resident.
Responsibilities of the Resident
1.
Select a mentor by the end of rotation #4
2.
Meet with the mentor on a regular basis (at least twice per year) as
mutually agreed upon.
Responsibilities of the Mentor/Advisor
1.
Meet with the resident on a regular basis (at least twice per year) as
mutually agreed upon.
2.
Review evaluations with the resident.
3.
Serve as resident's counsel in issues of professional growth, progress in
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4.
5.
the training program, and future educational and career opportunities.
Help with developing a plan of action to alleviate any difficulties or
problems.
Be available, as needed, for meeting with the Resident Evaluation and
Training Committee, to help with any remedial plan, and for progress
reviews with the Residency Director.
Objectives of Resident/Mentor Meetings
1.
Discuss the resident's work and evaluations
2.
Develop plans to alleviate any problems or difficulties
3.
Counsel on career planning
4.
Submit documentation of Resident/Mentor meeting at each bi-annual
meeting with residency directors. This will become part of your resident
portfolio.
3.
Resident Training and Evaluation Committee (TEC) - This committee
handles matters related to promotion, remedial, disciplinary action, and
dismissal. This committee meets quarterly or more often as needed.
4.
Residency Curriculum Committee - This committee meets quarterly to
discuss issues of the program's curriculum and is advisory to the director. There
is an elected resident representative that serves on this committee.
5.
Graduate Medical Education Committee (GMEC) – This committee meets
quarterly, with a monthly teleconference in between meetings, to discuss issues
pertaining to graduate medical education and the teaching of the resident in
both Pediatrics and OB/Gyn.
II. RESIDENCY POLICIES
The pediatric residency program requires Pediatric Advanced Life Support (PALS) and
Neonatal Resuscitation Certification (NRP) certifications of all pediatric residents.
Because this is a residency requirement, the residency program shall provide the initial
fee for the courses. If a resident fails to appear, to complete, or fails the course, the
repeat of the course will be at the resident's expense. Re-certifications for Basic Cardiac
Life Support (BCLS), PALS and NRP will be at the expense of the pediatric residency
program.
LEGAL LIABILITIES – Contact with Attorneys, Insurance Companies, and
News Media regarding testimony, statements, or reports regarding patients
If you receive such a request, report it to the proper attending physician, your
Residency Director, and the Legal Counsel for FSU COM. DO NOT discuss any situation
with lawyers, the press, insurance agents, or others until you have cleared this with
your Program Director and the Legal Counsel for FSU COM.
If at any time you receive a summons to appear in court, immediately notify:
1. Your Residency Director
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2. Legal Counsel for FSU COM SIP, (904) 244-9076
3. Sr. Associate Dean/DIO for Graduate Medical Education FSU COM, (850) 644-5905
4. Risk Management of Sacred Heart, 416–7864
You will be advised as to what action to take. It must be emphasized that such a
summons cannot be ignored. If it is necessary to obtain legal advice, Legal Counsel
for FSU COM will arrange this. In addition, you may secure your own legal counsel at
your own expense.
If you are contacted by representative of the media (newspapers, TV, radio, etc.),
notify your Residency Director, and the Marketing & Public Relations Department of
Sacred Heart Health System. We will work with you to arrange appropriate interviews
as needed. All information shared with the media must be HIPAA compliant.
These guidelines are for your protection, the protection of our patients, and to ensure
the effective operation of the entire hospital.
HIPAA PRIVACY AND SECURITY
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is an
important federal law that affects how you and the Florida State University College of
Medicine must handle confidential patient health information. The fundamental premise
under the Privacy Rules is to protect ‘Patient Health Information.’
‘Patient Health Information’ is broadly defined in the Privacy Rules to include any oral,
written or electronic individually identifiable information relating to (a) the past,
present, or future physical or mental health of an individual; (b) the provision of health
care to the individual; and/or (c) the payment for health care. This means that virtually
all patient related information is subject to the protections of the Privacy Rules.
Consequently, it is vital that you fully comprehend your obligations to protect this
information in accordance with HIPAA Policies and Procedures. The Sacred Heart Health
System requires training in this area.
VACATIONS
Please refer to Section XV, Institutional GME Policies, regarding number of vacation
days per year. Vacations may not be taken while on Ward, RNICU, or PICU.
Vacations are to be taken in one-week blocks. No vacation time will be granted in July
to first year residents unless there is an extenuating circumstance authorized by the
program director. ACGME Residency Review Committee and American Board of
Pediatrics (ABP) requirements must be considered when approving vacations during
certain rotations. Residents from other programs who are rotating to the WARD,
RNICU, & PICU may be granted vacation. In some instances, rotators who are granted
vacation during these periods will receive a reduction in the number of nights they are
expected to be on call during the rotation.
Vacation Request Forms
A.
Residents’ requests for vacation time are submitted to the residency office, at
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B.
C.
D.
E.
F.
least three four-week rotations prior to the requested time off.
Include on the vacation requests all days the resident wishes to be off duty.
Failure to include the weekend days may result in the resident being on call the
weekends prior to or following the requested vacation time.
Once vacations are approved they become difficult to change.
Per FSU COM policy and compliance with the ABP, vacation time not used during
the academic year is not carried over to the following year.
Three senior residents can be approved for vacation time per week. Included in
this number is anyone on a Leave of Absence or Continuing Medical Education
(CME). The resident's needs and the needs of the entire program are taken into
account when approving vacations for junior residents.
Only a medical Leave of Absence (LOA) will be granted for rotations one or
thirteen (i.e. No planned LOA will be granted). For all other rotations, no more
than one resident will be granted a planned LOA at any given time.
CONFERENCE TIME OFF (CME)
CME is granted for attending conferences. Requests are submitted on the same
schedule as vacation requests--three four-week rotations in advance. If planning to use
CME funds to attend a conference, contact the residency coordinator. To receive
approval, submit to the program coordinator a completed Conference Travel Form and
information about the conference prior to any arrangements being made. Approval is
usually made in a 1-2 week's time. Unused CME time or funds cannot be carried over
into the next academic year.
PERSONAL DAYS
Personal Days are made in advance, unless unforeseeable emergencies. The same
vacation form is filled out. Notify the residency, the attending physician of the service,
and the senior and/or chief resident.
INTERVIEW DAYS
Interview Days are personal days and are requested in the same manner as a vacation.
The residency director must approve any additional time.
CAMP REQUESTS
Camp requests can be taken from PGY2 and PGY3 residents and are generally in
conjunction with the subspecialty you are involved with. Fill out the appropriate form
and send it to the Residency Office well in advance.
OUT-OF-TOWN ROTATIONS
Residents are allowed one out-of-town elective rotation during their three years of
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training. The Residency Office should be notified of out-of-town rotation requests by the
end of their first rotation of the academic year. A Letter of Agreement between the FSU
COM and the external institution must be in place prior to starting the rotation. The
resident must have written goals and objectives for the rotation, and provide the lead
supervisor’s name and contact information. That individual will be responsible to
complete an evaluation on the resident that will be sent to the Program Director.
If no-call is required to accommodate an out-of-town elective, notify the Residency
Office three rotations prior to beginning the out-of-town elective. No out-of-town
electives will be granted during rotation #7.
REASONABLE MEDICAL LEAVE
Reasonable medical leave will be granted as approved by the Program Director and
based on FSU COM policies. Maternity and paternity leave is considered sick leave. If
extended leave is necessary, the resident's total length of residency training will be
extended to meet the program's requirements and the requirements of the American
Board of Pediatrics.
Sick leave, maternity and paternity leave, and leave for family medical emergencies
follow the requirements of the Family Medical Leave Act. (Section XV, Institutional GME
Policies)
PROCEDURE LOGS
Procedure Logs is a requirement by the pediatric RRC and this residency. Keep a log of
pediatric experiences related to technical procedures (lumbar punctures, umbilical
artery, catheterization, etc.). Record procedures as accurately as possible, including the
date and supervising physician, on the ACGME website. Documentation of your skills
will be required by accrediting bodies, hospitals that you intend to have privileges at,
and by the American Board of Pediatrics for Board Certification. The residency director
at each six-month review will look at procedure logs and recommend ways of meeting
the requirements. A copy of the ACGME procedure log will be pulled and placed in the
resident’s portfolio at each biannual evaluation.
III. REQUIRED CONFERENCES AND ATTENDANCE POLICY
Lecture topics for educational conferences reflect ACGME, and ABP requirements.
Suggestions for lecture topics or speakers may be given to the chief resident
responsible for scheduling. Lecture topics are on an 18 month rotation and are based
on Pediatrics in Review.
All educational conference time is protected from patient care responsibilities. For this
reason an 80% attendance is mandatory for all residents. A sign in sheet will determine
attendance. Failure to sign in (or sign in in the appropriate time-frame…5
minutes of the start of noon conference and 10 minutes of the start of morning
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report) will result in lack of credit for that particular conference. Leaving any
conference without an excuse will be considered a failure to attend. Residents
unable to attend a scheduled conference for any reason are required to leave a
message with Danika Talbert (416-7658).
Exceptions:
1 Approved vacation, CME time, personal day, or leave of absence.
2 One senior resident on the ward rotation is expected to cover emergency and
admits 7:00-8:00 a.m. (7:00-9:00 a.m. on Tuesdays, and during noon
conference).
3 Residents on night float will be excused from any conferences after Morning
Report is completed at 8:00 a.m. each day for that week of float.
4 Residents on out-of-town rotations will be excused for that rotation.
Failure to comply will result in a pre-probation warning. The first infraction will result
in an additional ward call to be assigned on a Friday, Saturday or Sunday. The second
infraction will result in an additional ward call plus a five-page paper on an assigned
topic by the Program Director with at least five citations. The third infraction will result
in the resident's probation and being brought before the TEC for disciplinary action
including consideration for dismissal.
One noon conference each rotation is a Residency Business Meeting. Issues of
importance to the residents and to the program are discussed at this meeting. All
residents are expected to make a special effort to attend this business meeting.
Forum for Inter-program Communication
Bi-annually all FSU COM residents and LECOM residents, pediatric, obstetrics &
gynecology and internal medicine, participate in a Forum for Inter-program
Communication. This meeting provides residents the opportunity to jointly express
views and concerns as related to the Residency Program as a whole.
IV. CONTINUITY CLINIC
There is one all-day resident continuity clinic site. The clinic provides the resident with
an opportunity to become skilled in primary care outpatient pediatrics. Beginning in the
first year, residents are encouraged to develop and treat a panel of patients who will
look to them for continuity of their medical care and treatment of acute illness.
Attendance at all assigned clinics is required. If a resident is unable to attend clinic as
scheduled due to an emergency, the resident must notify the Residency Office, and the
attending physician for that clinic as soon as possible.
There is to be no change/switching of clinics once they have been scheduled.
This is a resident continuity clinic and in order to maintain maximal continuity, no
changing or altering the clinic schedule in any way will be allowed, pending
family/personal emergency. All requests for changing clinic days must be approved by
Dr. McDavid and by your clinic attending. Failure to comply will result in being asked to
discuss this infraction with Dr. McDavid. A repeat offence will result in a letter of
reprimand regarding unprofessional behavior being permanently placed in you file. A
third offence will result in being brought before the Residency TEC for consideration of
dismissal.
16
V. DUTY HOURS
Duty hours are defined as all clinical and academic activities related to the residency
program; i.e., patient care (both inpatient and outpatient), administrative duties
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.
Duty hours must be limited to 80 hours per week, averaged over a four-week period,
inclusive of all in-house call activities including programmatic moonlighting (see
below). This includes for PL1 residents no more than 16 consecutive hours of patient
care responsibilities (see On-Call Activities pg. 17). For PL2 and PL3 residents, no more
than 24 hours of new patient care responsibilities. An additional 4 hours may be
provided for transfer of patient care responsibilities.
Residents must be provided with 1 day in 7 free from all educational and clinical
responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as
1 continuous 24-hour period free from all clinical, educational, and administrative
duties. Adequate time for rest and personal activities must be provided. This should
consist of a 10-hour time period provided between all daily duty periods and after inhouse call.
The residency will require that all residents submit their prior week's duty
hour sheet to the residency each Monday by 5:00 p.m. Failure to complete
(with the exception of vacation) will result in suspension until such time as
the duty hour sheet is submitted and will result in a bi-annual review
reflecting issues with professionalism. Repeat offenders may have a letter
placed in their file regarding unprofessional behavior. Third-time offenders
will be brought before the residency TEC for consideration of suitable
punishment measures including consideration for dismissal.
Without exception, the resident is to be honest and truthful in his/her documenting of
all duty hours. Any misrepresenting of duty hours will result in the resident being
placed on immediate suspension. The resident will then be brought before the TEC of
the residency for consideration of further disciplinary action, including consideration of
dismissal for violation of professional behavior.
MOONLIGHTING
a. Moonlighting is discussed in greater detail in Section XV (Institutional GME
Policies, pg. 30). Please note that all moonlighting counts toward the duty
hours and is held subject to these requirements. No PL1 residents are
allowed to moonlight. Under federal statues no moonlighting is
permissible for residents holding a Visa.
In addition, for the Pediatric Residency moonlighting is contingent upon:
17
b. The resident must sign a Programmatic Moonlighting Approval Form stating
they will follow the FSU GME guidelines for moonlighting. (Refer to Section
XV).
c. All moonlighting must have the full knowledge and approval of the Residency
Director and/or Pediatric Chief Resident; and the resident must record all
moonlighting activities for monitoring by the residency. All moonlighting logs
will be kept on file in the Pediatric Residency Office.
d. Only those residents in good standing will be allowed to moonlight.
That is, only those residents who have average to above average
evaluations, have not had issues with medical records within the last
six months, and have taken and passed step 3 of the United States
Medical Licensing Examination (USMLE).
e. No resident shall moonlight while on back-up call, post-call, nor pre-call.
f. No resident shall moonlight while on the PICU, NICU, Pediatric Ward
rotations, nor while on Float
g. Under no circumstance is a resident allowed to moonlight while on medical
leave nor after calling in for a sick day.
h. The resident must bear in mind that all moonlighting constitutes part of the
80 hr. work week. Under no circumstance is the resident to exceed the 80 hr.
total.
i. The RRC very clearly stipulates that under no circumstance is moonlighting to
interfere with the resident’s responsibilities to their residency. Moonlighting is
a privilege, which can and will be permanently revoked if a resident is found
to be derelict in their responsibilities as listed above. Continuing to moonlight
after this privilege has been revoked will constitute grounds for immediate
dismissal from this residency program.
VI. ON-CALL ACTIVITIES
PL1 residents are not to exceed 16 hours of continuous patient care
responsibilities; this includes night float and night shift work. PL2 and PL3 residents
will also have primarily night call responsibilities in the form of night shifts, and night
float, but may on occasion have the 24 hours of on-call responsibilities.
Night Float is defined as call outside the normal rotational requirement. Ex. Floor night
float, while on a cardiology rotation. There is to be no more than 6 consecutive nights
of night float and no more than 4 night float “weeks” per year. Night shifts are call
consistent with the rotation. Ex. Floor night shift while on the floor rotation. We will also
limit the number of consecutive nights to 6 nights while on night shift for a rotation.
For those rotations that have in-house call of the more traditional 24 hours
structure, this call structure is limited to the PL2 and PL3 resident and must
occur no more frequently than every third night, averaged over a 4-week period.
Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours.
Residents may remain on duty for up to 4 additional hours to participate in didactic
activities, transfer care of patients. (see Section V, Duty Hours, pg. 16). No new
patients may be accepted after 24 hours of continuous duty.
At-home call (or pager call) is defined as a call taken from outside the assigned
institution. The frequency of at-home call is not subject to the every third-night
18
limitation. Residents taking at-home call must be provided with 1 day in 7 completely
free from all educational and clinical responsibilities, averaged over a 4-week period.
When residents are called into the hospital from home, the hours residents spend inhouse are counted toward the 80-hour limit.
Night Float/Night Shift
The Schedule is as follows:
• Sunday through Saturday morning (6:00 p.m. to 7:00 a.m.)
Senior Level Night Responsibilities:
1. Pediatric floor admits and care of pediatric patients.
2. Senior level resident is responsible for supervising, teaching, and assigning duties to
both interns and medical students at night.
3. In charge of organizing morning report for assigned night week.
4. Does not attend Grand Rounds nor Noon Conference for assigned night week.
5. No vacation granted during rotation assigned night week.
6. Will have no Continuity Clinic during night week.
7. When possible, the senior resident is to allow the intern is to do a complete history
and physical, and generate an assessment and plan for patients, prior to themselves
evaluating the patient.
Junior Level Night Float Responsibilities:
1. Pediatric floor admits and care of pediatric patients.
2. The Junior level resident is responsible for supervising, teaching and assigning duties
to medical students at night.
3. Does not attend Grand Rounds nor Noon Conference for assigned night week
4. Will have no Continuity Clinic during night week.
5. No vacation granted during rotation assigned night week.
6. When possible, the intern is to do a complete history and physical, and generate an
assessment and plan for patients, prior to having the senior level resident evaluating
the patient.
Pediatric Ward-Call
If an on-call pediatric senior becomes ill or unable to attend the assigned call, he or she
is to call the chief resident. The ill resident is to “pay-back” the covering resident within
one month. The on call senior also needs to inform the pediatric residency office. If the
senior is not able to call because of a severe illness or an emergency, the closest family
member should inform the pediatric chief in charge of scheduling and notify the
pediatric residency office if before 3:30 p.m. weekdays.
If an on-call pediatric junior calls in sick, he or she is to notify the chief resident to find
a substitute junior. The ill resident is to “pay-back” the covering resident within one
month. If a covering junior is not found, then the chief may have to contact a senior
resident to cover the junior to call. (In lieu of the intern covering a senior call, the chief
will keep a running tally of call for the year and balance all senior call equally)
In the event of leave of absence or death in the family, any resident who is able to help
in facilitating pediatric floor operation, when asked by either the chief resident or
19
Residency Office, will be awarded one less night of call for each day of facilitating the
operation on the pediatric floor. This is at the discretion of the pediatric residency
director and pediatric chief resident.
VII. NIGHT-TIME PHONE CALL
ALL PATIENT RELATED TELEPHONE CALLS RECEIVED AT NIGHT BY THE
RESIDENT MUST BE DOCUMENTED.
Forms to be used for recording the content and consequences of the phone call are
widely available. The next morning after the phone call is received, the information is
forwarded to the clinic for review by the clinic attending and then placement in the
patient's file.
PHONE CALLS TAKEN BY INTERNS ARE DISCUSSED WITH THE SENIOR OR
ATTENDING AS NECESSARY.
It is permissible to take the history from the caller, hang up, discuss the case with the
senior resident, and call the caller back.
VIII. MEDICAL RECORDS
Discharge Summaries
1.
2.
3.
4.
5.
Discharge Summaries on patients followed by residents are to be done by the
intern assigned to that patient.
For patients admitted on a weekend (Friday/Saturday/Sunday) and discharged
the same weekend, the admitting intern would be expected to dictate the
Discharge Summary.
PICU Transfers: If a patient transferred from the PICU goes home less than 48
hours after transfer to the floor, the PICU resident should dictate the Discharge
Summary.
There are times when the senior resident is responsible for assigning an intern
other than the admitting intern to dictate the discharge summary and would
indicate so in the discharge orders.
At the end of a rotation, all patients remaining in the hospital should have an off
service note written by the assigned resident. The note should summarize the
important components of the hospital course and be in the medical record by the
last weekend of each rotation.
Guidelines for PICU Residents
20
A.
Patients transferred to the pediatric floor following PICU admission of 14 days or
more should have a dictated Interim Summary or a dictated Transfer Summary.
B.
Transfers from PICU should be communicated to the Senior Resident on the
floor.
C.
PICU Transfers: If a patient transferred from PICU goes home less than 48 hours
after transfer to the floor, the PICU resident is required to dictate the discharge
summary. Otherwise the senior resident will be responsible to assign the task to the
appropriate resident and will indicate so in the discharge orders.
DELINQUENT MEDICAL RECORDS POLICY
The Delinquent Medical Records Policy follows the Sacred Heart Health System Policy.
IX. EVALUATIONS
ABP AND ACGME ACCREDITATION REQUIREMENTS
ABP and ACGME accreditation requirements are both met by this pediatric
residency program. Residents who successfully complete the residency curriculum
are eligible for certification by the American Board of Pediatrics.
The following six clinical competencies are the required criteria used to
evaluate residents:
•
Patient Care - Gathers essential and accurate information. Performs a
complete history and physical examination. Orders appropriate diagnostic
studies. Makes informed diagnostic and treatment decisions. Analyzes and
synthesizes information. Knows limits of knowledge and expertise. Develops
and carries out patient care management plans. Prescribes and performs
procedures completely. Effectively counsels patients and families and allays
fears and provides comfort.
•
Medical Knowledge - Knows, critically evaluates, and uses current
medical information and scientific evidence for patient care.
•
Interpersonal and Communication Skills - Demonstrates interpersonal
and communication skills that result in effective information exchange and
teaming with patients, their families, and professional associates.
•
Professionalism - Demonstrates a commitment to carrying out
professional responsibilities, adherence to ethical principles, and sensitivity to
diversity.
•
Practice-Based Learning and Improvement - Investigates and
evaluates patient care practices, appraises and assimilates scientific evidence,
21
and uses these to improve patient management. Demonstrates a willingness
to learn from errors.
•
Systems-Based Practice - Practices quality health care that is costeffective and advocates for patients within the health care system.
ATTENDING EVALUATION
Attendings evaluate residents using a standardized electronic evaluation form. A
nine-point scale with nine (9) being an outstanding graduating resident, is used to
measure the six competencies. For every rotation there is a designated faculty
member, or members, to complete evaluations for that rotation. Completed
evaluations including comments become a part of the resident’s permanent record.
When a resident is displeased and/or fails a rotation, he/she with input from his/her
mentor does have an opportunity to respond in writing and to request a meeting
with the Program Director. The response, if provided, can be included in the
resident's evaluation file. If no response is received in writing, this will be
interpreted as accepting the evaluation as complete. The Evaluation & Training
Committee (ETC) may review evaluations and the resident files at any time.
CONTINUITY CLINIC
The Continuity Clinic attending completes the electronic standardized evaluation
form on a quarterly basis.
PEDIATRIC WARD
When on the Pediatric Ward aside from the usual attending evaluation of residents
(interns and seniors), the supervising residents evaluate the interns and vice versa
the interns evaluate the supervising residents, using the same standardized
electronic evaluation form. In addition, the charge nurse evaluates the pediatric
resident’s performance.
RESIDENT EVALUATION
Residents Evaluate the Rotation and the rotation attending using an electronic
standardized form. Evaluating the rotation includes the ability to meet the given goals
and objectives. Evaluating the teaching attending, includes providing feedback about
other attendings with which contact during the rotation is given.
ATTENDING PHYSICIAN FEEDBACK
Attending physicians are encouraged to provide feedback to residents during (ideally
mid-rotation) the rotation, and it is required at the end of each rotation (except in the
primary care clinics when attending feedback is provided on a quarterly basis).
22
Feedback is particularly important for interns, and for residents whose performance is
viewed by the attending as below the expected level in any area. Residents who wish to
insure that they receive the appropriate feedback are responsible for asking the
attending both during and at the end of the rotation.
Semi-ANNUAL REVIEWS
Semi-annual reviews of your performance with the residency director is required.
Areas covered in the review include all of the above evaluations, as well as review of
your procedure logs, ILP, Mentor Meeting Minutes, and progress regarding your
research and child advocacy project(s).
ROTATION PRE/POST TESTS
In keeping with the core competencies and in order to facilitate learning, the residency
requires its residents to take pre- and post-tests on rotations. The goal is to evaluate
resident learning on rotations and to assure adequate medical knowledge regarding the
rotation has been achieved, as well as improving any noted deficiencies in the rotation.
(There are some rotations which as of yet there are no tests available, however we will
be working on these). Once these tests become available, they will also be required.
Failure to take the required tests at the appropriate time will result in a CP for the
rotation. This CP is only remediable by taking the post-test within two weeks and
achieving a minimal pass of 80%.
PEDIATRIC IN-TRAINING EXAMINATION
The Pediatric In-Training Examination is a required Board exam to provide you with
feedback about your progress and about areas in which you will benefit from increased
study. It will not be used to determine whether you move on in the program. Keep in
mind that there is clear correlation between performance on the in-training examination
and later success on the pediatric boards.
APPEAL
Any resident who is unhappy with the outcome of his/her evaluation has a right to
appeal to the Program Director, who may channel such appeal for determination by the
appropriate grievance committee. Hereafter, further action(s) will follow the grievance
procedure of the FSU COM (see pg. 27).
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X. PRACTICE BASED LEARNING AND SYSTEM BASED PRACTICE
A. Scholarly Project (Practice Based Learning):
Residents are required to produce and present at Grand Rounds a scholarly product
by the time they finish the residency. Generally, residents will work on their scholarly
project during their third year; however, they may work on it and submit it at any
time during their residency. (Refer to guidelines).
What is a scholarly product?
•
A data based research article, which appears in a scholarly journal. It may
be based on original data or on secondary analysis of existing data.
•
A clinical research article that appears in a clinical or scholarly journal.
•
A case study which adds to the knowledge of a particular disease, which
appears in a referred journal.
•
A meta-analysis of existing studies, which draws new conclusions from a
review of a large number of studies.
•
A literature review of a specific area, which may gather information
together in a single place in useful way. Such reviews may often be used for
teaching purposes.
•
A data based information booklet to distribute to parents to increase their
understanding of a specific disease, selected aspects of child development,
etc.
•
Other and similar products.
How
•
•
•
•
do you pick a topic?
It should be of interest to you, the first and most important criteria.
Something for which you have, or can learn the requisite skills.
Something for which you have, or can obtain, the requisite resources.
Resources include: time, money, materials, space, etc.
A project that is do-able in the time and effort you have available.
How do you pick a research mentor?
•
Someone you can work with, i.e. whose work you respect, and with whom
you can interact in a professional manner.
•
Someone who has time and interest in working with you.
•
Someone who has the skills to help with your project.
•
If they have resources they can give you, all the better.
•
Someone working in your area of interest, or has an on-going activity in
which you can participate, this may be an advantage.
B. Child Advocacy (Systems Based Practice):
1. Residents are required to participate in Child Advocacy over the three years and
present a scholarly product at the time they finish the residency.
2. The requirements are as follows:
a. During the course of residency -- home visit, conversation with legislators,
24
community meeting, inter-agency meeting, and attend residency
educational conferences.
b. Second-year residents - Advocacy project for an individual patient and a
brief write-up.
c. Third-year residents - Team-up with one agency for a community-level
advocacy project, write a fact sheet, brief report, or other written product,
and present the project at Child Advocacy Day in June.
d. Any questions may be addressed to Dr. Peter J. Jennings, M.D. at 4166912.
XI. ACGME ESSENTIALS OF ACCREDITED RESIDENCIES
The ACGME is composed of representatives of five national associations interested in
medical education. Its component Residency Review Committees (RRC’s) set the
specialty-specific standards by which individuals programs are judged and considered
for accreditation. Residency programs must meet the general and specialty-specific
requirements as set forth by the ACGME and the specialty RRC in order to be deemed
accredited.
RESIDENT RESPONSIBILITIES
The position of resident involves a combination of supervised, progressively more
complex and independent patient evaluation and management functions, and formal
educational activities.
Among a resident's responsibilities in a training program of the University are
the following:
1) to meet the qualifications for resident eligibility outlined in the ACGME Essentials of
Accredited Residencies in Graduate Medical Education in the American Medical
Association (AMA) Graduate Medical Education Directory;
2) to develop a personal program of self-study and professional growth with guidance
from the teaching staff;
3) to provide safe, effective, and compassionate patient care, commensurate with the
resident's level of advancement, responsibility, and competence, under the general
supervision of appropriately privileged attending teaching staff;
4) to participate fully in the educational and scholarly activities of their program and, as
required, assume responsibility for teaching and supervising other residents and
students;
5) to participate in institutional orientation and educational programs and other
activities involving the clinical staff;
6) to submit to the program director confidential written evaluations of the faculty and
the educational experiences;
7) to participate on institutional committees and councils to which the resident is
appointed or invited, especially those that relate to their education and/or patient care;
25
8) to adhere to established practices, procedures, and policies of the University and of
affiliated institutions as applicable, including among others, duty hours regulations and
state licensure requirements for physicians in training, and to apply cost containment
measures in the provision of patient care;
9) to develop an understanding of ethical, socioeconomic, medical/legal issues,
communication skills and cost containment issues that affect graduate medical
education and medical practice; and
10) to develop an understanding of research design, statistics, and critical review of the
literature necessary for acquiring skills for lifelong learning.
XII. CODE OF CONDUCT FOR PROFESSIONAL BEHAVIOR
Objective
The FSU Pediatric Faculty and the Medical Staff of Sacred Heart Health System are
strongly committed to providing high quality patient care in a work environment that
fosters teamwork and respect for the dignity of each patient, visitor, employee,
volunteer, resident, student, referring physician and member of the Medical Staff. The
goal of the Code of Conduct for Professional Behavior (“Code”) is to define expectations
for Pediatric Resident behavior that promotes a safe and professional health care
environment.
Appropriate Conduct
Residents are expected to conduct themselves in a professional manner. Appropriate
professional behavior is outlined below:
1. Residents will treat patients, staff, faculty and colleagues with dignity and empathy.
2. Residents will be honest—honorable in all encounters, principles, intentions, and
actions – with all colleagues and others they encounter.
3. Residents will uphold and comply with all ethical and legal standards that apply to
the FSU COM and Sacred Heart Health System.
4. Residents will respect the privacy and confidentiality of patients and their protected
health information such as is contained in the patient’s medical record while in clinical
and public areas.
5. All verbal, nonverbal and written communication will be conducted in a mutually
respectful manner.
6. Residents will make every reasonable effort to communicate with referring or
other treating practitioners promptly.
7. A resident who is “on call” for clinic patient concerns must answer pages promptly (at
no time should this exceed 60 minutes for routine calls and 30 minutes for emergent
calls).
8. The resident or “covering” colleague must round on all patients under his/her care
every day and be available to address problems at all times.
9. Residents are required to attend all their scheduled clinics.
26
Unacceptable Conduct
Residents are expected to behave in a professional manner, showing respect to
patients, visitors, employees, volunteers, other residents, students, referring
physicians, faculty, and other members of the medical and dental staff. Conduct that is
disruptive or harassing is unacceptable and is outlined below.
1. Disruptive behavior is an act, or pattern of actions by a resident which adversely
affects the medical center’s health care team to the degree it may impede the team’s
ability to deliver quality patient care. Unacceptable disruptive conduct includes, but is
not limited to, behavior such as:
•
•
•
•
•
•
•
•
Conduct that interferes with the provision of quality patient care;
Attacks (verbal, written or physical) directed at others which are personal or go
beyond the bounds of fair professional conduct;
Shouting or using vulgar or profane or abusive language;
Writing of malicious, or inappropriate comments (or illustrations) made in the
patient medical record or other written documents;
Making public derogatory comments about the quality of care being provided by
other practitioners or nursing personnel, rather than working through peer
review/quality review processes or other avenues to address the issues;
Inappropriate expressions of anger such as destruction of property or throwing
objects;
Physical assault; and,
Conduct that demeans the dignity of any person(s) or disrupts the orderly
operation of the facilities of the FSU Pediatric Residency or Sacred Heart Health
System.
2. The FSU COM and Sacred Heart Health System prohibits all forms of harassment,
including harassment due to race, religion, sex, national origin, age, marital status,
sexual orientation and disability. Sexual harassment in the form of discrimination is
expressly prohibited pursuant to the FSU COM and Sacred Heart Health System
corporate policies. Conduct, which may constitute sexual harassment, includes
repeated, unsolicited verbal comments, gestures, drawings or physical conduct of a
sexual nature, which is unwelcome and damaging to the integrity of the employment
relationship.
Examples of such conduct include:
•
•
•
•
Unwelcome or unwanted physical advances of a sexual nature;
Requests or demands for sexual favors. This includes subtle or blatant
expectations, pressures, or requests for any type of sexual favor accompanied by
an implied or stated promise for preferential treatment or the risk of negative
consequences concerning one’s employment status.
Verbal abuse or joking that is sexually oriented and unacceptable to another
individual.
Any type of sexually oriented conduct that unreasonably interferes with
another’s work performance.
Nothing in the Code of Conduct is intended to replace, supersede or conflict with other
policies and standards of the FSU COM or Sacred Heart Health System.
27
XIII. DURATION OF APPOINTMENT AND CONDITIONS FOR REAPPOINTMENT and PROMOTION
Your initial appointment will begin on July 1, 2010; however, the beginning date of the
contract is contingent upon you receiving a Resident Training License. Appointments
are continuously reviewed and retention in the training program depends on your
satisfactory performance/training progress, including your adherence to acceptable
professional behavior. A resident's reappointment and progression to more advanced
levels will be based on the results of periodic reviews of the resident's educational and
professional achievement, competence and progress as determined by the program
director and teaching faculty. It is a requirement of this training program that its
residents must successfully complete USMLE Step 3 (or COMLEX Step 3 for
DO’s), prior to being promoted to their PL2 year. Any deviation from this policy
due to extenuating circumstances are subject to the approval of the TEC
committee and the program director. The program maintains a confidential record
of the evaluations.
The primary site of your graduate medical education training will be the Sacred Heart
Health System, Pensacola, and affiliates. All assignments and call schedules are made
at the discretion of your Program Director. In addition, should this residency program
be closed or downsized, the University will inform the resident as early as possible of
such events. Every effort will be made to complete the resident's course of training or
to find another site for the resident to complete training.
XIV. CERTIFICATE OF COMPLETION
A certificate of graduate medical education training (diploma) will be issued to a
resident on the recommendation of the University's Program Director only after
satisfactory completion of service and educational requirements and fulfillment of all
other obligations and debts, including completion of medical records and return by the
resident of State of Florida property, as well as property of any affiliated institution.
XV. INSTITUTIONAL GME POLICIES
DISCIPLINE POLICIES AND PROCEDURES
Grievances, Suspension, Non-renewal, Dismissal or Appeal of a Resident:
The position of the resident presents the dual aspect of learner in graduate training
while participating in the delivery of patient care. The Florida State University College of
Medicine is committed to the maintenance of a supportive educational environment in
which residents are given the opportunity to learn and grow. Inappropriate behavior in
any form in this professional setting is not permissible. A resident's continuation in the
training program is dependent upon satisfactory performance as a learner, including the
maintenance of satisfactory professional standards in the care of patients and
interactions with others on the health care team. The resident's academic evaluation
will include assessment of behavioral components, including conduct that reflects poorly
28
on professional standards, ethics, and collegiality. Disqualification of a resident as a
learner or as a member of the health care team from patient care duties disqualifies the
resident from further continuation in the program.
Grievances: A grievance is defined as dissatisfaction when a resident believes
that any decision, act or condition affecting his/her program of study is arbitrary,
illegal, unjust or creates unnecessary hardship. Such grievance may concern, but is not
limited to, the following: academic progress, mistreatment by any University employee
or student, wrongful assessment of fees, records and registration errors, discipline
(other than non-renewal or dismissal) and discrimination because of race, creed, color,
gender, religion, national origin, age, disability, veteran’s or marital status, or any other
protected group status, subject to the exception that complaints of sexual harassment
will be handled in accordance with the specific published policies of Florida State
University and the College of Medicine.
A resident who has a complaint or grievance may discuss this with the Program
Director. If, after discussion, the grievances cannot be resolved, the resident may
contact the Chairman of the Graduate Medical Education Committee (CGMEC). The
CGMEC will meet with the resident and will review the grievance. The decision of the
CGMEC will be communicated in writing to the resident.
Alternatively, the resident may utilize the University’s Mediation Program that is
administered by the Employee Assistance Program (EAP) prior to the filing of a formal
complaint or grievance. Additional information on the EAP may be obtained through
the Florida State University.
The Office of the University's Coordinator of Sexual Harassment Resolutions (the
"Coordinator"), within the Office of Audit Services, is designated to receive and
investigate sexual harassment complaints as set forth in the University's policy and to
maintain the records pertaining thereto.
Additional information may be obtained
through the Florida State University.
Suspension: The Chief of Staff of a participating and/or affiliated hospital where
the resident is assigned, the Dean, the Chief Executive Officer (CEO) of the Hospital, or
Program Director may at any time suspend a resident from patient care responsibilities.
The resident will be informed of the reasons for the suspension and will be given an
opportunity to provide information in response.
The resident suspended from patient care may be assigned to other duties as
determined and approved by the Program Director. The resident will either be
reinstated (with or without the imposition of academic probation or other conditions) or
dismissal proceedings will commence by the University against the resident within thirty
(30) days of the date of suspension.
Any suspension and reassignment of the resident to other duties may continue
until final conclusion of the decision-making or appeal process. The resident may appeal
to the Chair, Graduate Medical Education Committee (CGMEC), for resolution.
Non-renewal: In the event that the Program Director decides not to renew a
resident's appointment, the resident will be provided written notice no later than four
months prior to the end of the resident’s contract. However, if the primary reason(s)
29
for the non-renewal occurs within four months prior to the end of the agreement,
residents will be provided with as much written notice of the intent not to renew as the
circumstances will reasonably allow, prior to the end of the agreement. The notice of
intent will include a statement specifying the reason(s) for non-renewal.
If requested in writing by the resident, the Program Director will meet with the
resident; this meeting should occur within 10 working days of the written request. The
resident may present relevant information regarding the proposed non-renewal
decision. The resident may be accompanied by an advisor during any meeting held
pursuant to these procedures, but the advisor may not speak on behalf of the resident.
If the Program Director determines that non-renewal is appropriate, he/she will use
his/her best efforts to present the decision in writing to the resident within 10 working
days of the meeting; the resident will be informed of the right to appeal to the CGMEC.
Dismissal: In the event the Program Director of a training program concludes a
resident should be dismissed prior to completion of the program, the Program Director
will inform the CGMEC in writing of this decision and the reason(s) for the decision. The
resident will be notified and provided a copy of the letter of proposed dismissal; and,
upon request, will be provided previous evaluations, complaints, counseling, letters and
other documents that relate to the decision to dismiss the resident.
If requested in writing by the resident, the Program Director will meet with the
resident; this meeting should occur within 10 working days of the written request. The
resident may present relevant information regarding the proposed dismissal. The
resident may be accompanied by an advisor during any meeting held pursuant to these
procedures, but the advisor may not speak on behalf of the resident. If the Program
Director determines that dismissal is appropriate, he or she will use his/her best efforts
to present the decision in writing to the resident within 10 working days of the meeting.
Appeal: If the resident appeals a decision for suspension, non-renewal or
dismissal, this appeal must be made in writing to the CGMEC within 10 working days
from the resident's receipt of the decision of the person suspending the resident or the
Program Director. Failure to file such an appeal within 10 working days will render the
decision of the person suspending the resident or the Program Director the final agency
action of the University.
The CGMEC will appoint an ad hoc committee to conduct a review of the action, and
review the documents or any other information relevant to the decision. The resident
will be notified of the date of the meeting with the CGMEC and the committee; it should
occur within 15 working days of the CGMEC's receipt of the appeal. The CGMEC, along
with the committee, may conduct an investigation and uphold, modify or reverse the
recommendation for suspension, non-renewal or dismissal. The CGMEC will notify the
resident and the Residency Director in writing of the decision. If the decision is to
uphold a suspension, the decision of the CGMEC is the final agency action of the
University. If the decision is to uphold the non-renewal or dismissal, the resident may
file within 10 working days a written appeal to the Dean of the College of Medicine.
Failure to file such an appeal within 10 working days will render the decision of the
CGMEC the final agency action of the University.
The Dean will inform the CGMEC of the appeal. The CGMEC will provide the Dean
a copy of the decision and accompanying documents and any other material submitted
by the resident or considered in the appeal process. The Dean will use his/her best
30
efforts to render a decision within 15 working days, but failure to do so is not grounds
for reversal of the decision under appeal. The Dean will notify in writing the CGMEC,
the Program Director and resident of the decision. The resident will then be informed of
the steps necessary for the resident to further challenge the action of the University.
The President of the University will be the final agency action of the University.
OUTSIDE PROFESSIONAL ACTIVITIES
All programs have established rules regarding outside and extracurricular activities that
meet their RRC requirements and University's policy. All programs have established
rules regarding active voluntary, outside and extracurricular activities that meet their
RRC requirements and the University’s policy. There are two categories of such activity:
Programmatic Moonlighting
The Program Director must ensure, direct, and document supervision and faculty
support appropriate for the level of training of residents at all times. While performing
these services, residents are not to act as independent practitioners. Faculty schedules
must be structured to provide residents with continuous supervision and consultation.
Residents must be provided with efficient, reliable systems for communicating
with supervising faculty. Faculty are also responsible to recognize the signs of fatigue
and adopt and apply practices to prevent and counteract the potential negative effects.
Residents are required to complete the appropriate document with requested
signatures prior to participating in programmatic moonlighting (see attachment A).
Non-Programmatic Moonlighting
Residents must be licensed for unsupervised medical practice in the state where
such activity occurs, including DEA licensure as applicable and any other requirements
for clinical privileging at the employment site. There must be an exchange of
permission letters between the Program Director and appropriate staff at the institution
where the moonlighting will occur if the moonlighting is done externally.
Residents are not covered under the state’s sovereign immunity protection or the
University’s professional liability insurance program as the activity is outside the scope
of University employment. The resident is responsible for his/her own professional
liability coverage (either independently or through the entity for which the resident is
moonlighting) and must provide documentation of such.
Residents are required to complete the appropriate document with requested
signatures prior to participating in non-programmatic moonlighting (see attachment B).
Non-programmatic moonlighting hours must be documented (including days,
hours, location, and brief description of type of service[s] provided).
MEDICAL REQUIREMENTS
Screening of the resident for infectious diseases, prophylaxis/treatment for exposure to
31
communicable disease (including influenza), and immunizations will be provided by the
University or through arrangements with Sacred Heart Hospital. The resident will have
documentation of immunity to measles, mumps, and rubella (MMR), hepatitis B, polio;
diphtheria, tetanus, and pertussis (DTP series and Tdap as indicated); and varicella
(chicken pox). The resident will be required to have annual tuberculosis screening and
annual vaccination for influenza. The resident will comply with the infection control
policies and procedures of the institutions where the resident is assigned.
Florida State University conforms to the Florida Medical Practice Act (F.S. 458).
The rule calls for all licensed practitioners to report to the appropriate authority any
reasonable suspicion that a practitioner is impaired to practice. The legislation provides
for therapeutic intervention through the Professionals Recovery Network (PRN). This
organization works closely with the State Board of Medicine and is recognized as the
primary method of dealing with physician impairment in the state. Faculty, staff, peers,
family or other individuals who suspect that a member of the housestaff is suffering
from a physical, psychological or substance abuse problem that interferes with patient
care are obliged to report such problems. Reporting can be directly to the PRN or to
the Program Director. All referrals are confidential and there is early involvement of the
PRN. If the PRN feels intervention is necessary, they handle the situation and provide
for treatment and follow-up. Residents can only return to clinical duties with the
approval of the PRN. The PRN maintains contact with the program directors about
residents in the program of recovery.
RESEARCH
The Florida State University College of Medicine Office for Research (OFR) is responsible
for all matters pertaining to research proposals developed by College of Medicine faculty
members until such time as the contract, grant, or sub-contract is awarded (pre-award
procedures). Post-award procedures are handled by the Financial Affairs Office. It is
the responsibility of the OFR to assure compliance with college, university and grant
agency requirements. The OFR must review the proposal and the Associate Dean for
Research must sign approval for the College of Medicine prior to submission of the
proposal to the University Office of Sponsored Research.
1. Any contract or grant proposal by a member of the COM faculty/staff must be
submitted through the COM OFR if that faculty/staff member uses his or her
FSU title, or the college or university name on the proposal.
2. Proposals may be submitted only if a full-time FSU faculty member is listed as
Co-PI (university policy). Exceptions may be granted by the FSU Vice
President for Research.
3. Each PI should work with his/her Department Chair to determine a
reasonable percent effort for the proposal and include the corresponding
salary required for that percent effort, if the sponsoring agency allows PI
salary.
4. The COM does not permit cost-sharing in excess of that required by the
sponsoring agency. Exceptions to this policy must be approved by the
Associate Dean for Research, Dean of the COM, and the FSU Vice President
for Research.
5. If Recombinant DNA, Human or Animal Subjects, Radioactive/Hazardous
Materials, or Workshops/Conferences are involved, the project must be
approved by the appropriate FSU Compliance Officer (FSU Biohazard
32
Committee, FSU Human Subjects Committee, Animal Use and Care
Committee, Environment Health and Safety Director, Center for Professional
Development Director) prior to funding.
6. All graduate student Matriculation and Fee costs must be included in the
proposal budget or paid from an alternate source.
PROPER APPEARANCE FOR RESIDENTS
Residents are expected to dress in an appropriate manner at all times when engaged in
patient care. Florida State University nametags should be visible at all times. Scrub
suits are to be worn when on call and in the delivery room, ICN, NBN, Pediatric ER and
PICU areas only.
Note: The following is the Pediatric Residency Program Dress Code
o
o
o
o
o
o
o
o
o
o
o
o
o
o
FSU and Sacred Heart Hospital identification badges will be worn in plain sight
with the picture facing the front while on duty.
Clothing should be a conservative professional style appropriate for the
operational requirements of the rotation or department you are assigned to.
Scrubs may be worn when assigned to the Emergency Room, the ICN, the
PICU, or while on call.
Skirt hemlines should be no shorter than 2 inches above the knee and no
longer than ankle length. Skirt slits should be no higher than the allowable
skirt hemline.
Pants should be loose fitting. Leggings are not allowed. Jeans (of any color)
may not be worn.
Footwear should be a conservative style that is clean and safe for the
operational requirements of the rotation or department you are assigned to.
Socks or hosiery and closed toe shoes should be worn in clinical areas at all
times.
Tank tops, cropped tops, and spaghetti straps are not acceptable attire.
T-shirts worn with scrubs must be plain or with conservative logos only.
Jewelry should be a conservative, professional style and worn only on the
ears, neck, wrists, ankles, and hands. Body piercing on eyebrows, tongue,
nose and other exposed areas are not appropriate and are prohibited. Multiple
ear piercings (not in moderation) are not appropriate and are prohibited.
Hair should be well groomed and worn in a conservative, professional style.
Hair color must be a natural hair color. (Not purple, blue, etc.) Facial hair
must be trimmed and well groomed.
Fingernails should be clean and neatly trimmed. Artificial nails are not
permitted.
Make up, if worn, should be in moderation and in good taste.
Perfume and scented products, if worn, should be in moderation.
Tattoos that are offensive and that are not in moderation should be covered.
Two monogrammed laboratory coats and two sets of scrubs will be provided to each
incoming resident. One additional coat and one additional set of scrubs will be
provided at the start of each subsequent year of training. Anyone wishing to
purchase a more expensive coat may do so and be reimbursed the standard rate.
33
HARASSMENT
PURPOSE
The FSU COM is committed to the maintenance of a supportive and productive
environment for its students, staff, residents and faculty. In order to ensure that such
an environment exists, inappropriate professional behavior in all forms is not
permissible. As an attempt to clarify and unify policy and procedures related to a severe
form of inappropriate professional behavior, namely sexual harassment, the Florida
State University adopted the policy and procedures set forth in this document.
POLICY
POLICY STATEMENT. Sexual harassment is a form of discrimination based on a
person's gender. Sexual harassment is contrary to the University's values and moral
standards, which recognize the dignity and worth of each person, as well as a violation
of federal and state laws and University rules and policies. Sexual harassment cannot
and will not be tolerated by the Florida State University, whether by faculty, students,
residents or staff; or by others while on property owned by or under the control of the
University.
OFFICE OF AUDIT SERVICES. The Office of Audit Services (OAS) is charged with
receiving and investigating sexual harassment complaints as set forth in this policy and
shall maintain the records pertaining thereto. Within the OAS, the Coordinator of Sexual
Harassment Resolutions has primary responsibility for leading these investigations.
DEFINITION. Sexual harassment is defined as unwelcome sexual advances, requests for
sexual favors, and other verbal or physical conduct of a sexual nature directed at an
employee (or student) by another when:
a. submission to such conduct is made either explicitly or implicitly a term or
condition of employment, academic status, receipt of University services,
participation in University activities and programs, or affects the measure
of a student's/resident’s academic performance; or,
b. submission to or rejection of such conduct is used as the basis for a
decision affecting employment, academic status, receipt of services,
participation in University activities and programs, or the measure of a
student's/resident’s academic performance; or,
c. such conduct has the purpose or effect of unreasonably interfering with
employment opportunities, work or academic performance or creating an
intimidating, hostile, or offensive work or educational environment.
EXAMPLES OF SEXUAL HARASSMENT. Incidents of sexual harassment may involve
persons of different or the same gender. They may involve persons having equal or
unequal power, authority or influence. Though romantic and sexual relationships
34
between persons of unequal power do not necessarily constitute sexual harassment,
there is an inherent conflict of interest between making sexual overtures and exercising
supervisory, educational, or other institutional authority. Decisions affecting an
employee's job responsibilities, promotion, pay, benefits, or other terms or conditions of
employment, or a resident’s academic progress, evaluation, resident status,
recommendations, references, referrals, and opportunities for further study,
employment or career advancement, must be made solely on the basis of merit.
Examples of sexual harassment include, but are not limited to, the following, when they
occur within the circumstances described above:
a. use of gender-based verbal or written language, including electronic
communication, offensive or degrading to a person of that gender,
whether or not the content is sexual;
b. inappropriate display of gender-based pictorial images offensive or
degrading to a person of that gender, including but not limited to sexual
posters, photographs, cartoons, drawings, or other displays of sexually
suggestive objects or pictures;
c. use of inappropriate gestures or body language of a sexual nature,
including leering or staring at another;
d. unwelcome requests or demands for sexual favors or unwelcome sexual
advances;
e. inappropriate nonconsensual touching of another's body, including but not
limited to kissing, pinching, groping, fondling, or blocking normal
movement; or
f. sexual battery. (Note: some acts of sexual harassment may also
constitute violations of criminal law, e.g., sexual battery, indecent
exposure, sexual abuse, etc. In such instances, please refer to the
University's Sexual Battery Policy.)
DISCIPLINARY AND OTHER ACTIONS. Sexual harassment is prohibited by the Florida
State University. The University will take appropriate action against any person found to
be in violation of this policy. (Note: a person who has sexually harassed another or
retaliated against another may also be subject to civil or criminal liability under state or
federal law.)
a. Disciplinary Actions. Any employee who has sexually harassed another
employee or a student, retaliated against such person for bringing a
complaint of sexual harassment, or otherwise violated this policy shall be
guilty of misconduct and subject to disciplinary action up to and including
dismissal, in accordance with applicable law, rules, policies, and/or
collective bargaining agreements. In addition, any student who has
sexually harassed another student or an employee, retaliated against such
35
person for bringing a complaint of sexual harassment, or otherwise
violated this policy may be subject to disciplinary action up to and
including expulsion, pursuant to the Student Code of Conduct. The term
"employee" includes all persons employed by the University including
faculty, residents and graduate teaching assistants.
b. Other Actions. The University will take such corrective action against any
non-students or non-employees found to have violated this policy, as may
be appropriate under the circumstances.
RETALIATION. Retaliation against one who in good faith brings a complaint of sexual
harassment or who in good faith participates in the investigation of a sexual
harassment complaint is prohibited and shall be a violation of this policy and shall
constitute misconduct subject to disciplinary or other action as described above.
FILING OF FALSE SEXUAL HARASSMENT COMPLAINT. Knowingly filing a false sexual
harassment complaint is prohibited and shall be a violation of this policy and shall
constitute misconduct subject to disciplinary action as described above. A complaint
that is investigated and deemed unsubstantiated is not necessarily a false complaint.
REPORTING REQUIRED. Any student or employee who has witnessed what is perceived
to be a violation of this policy should promptly report that conduct to the OAS, who
then will proceed as appropriate. Any supervisor who has witnessed or becomes aware
of the alleged occurrence of sexual harassment by, or who receives a complaint of
sexual harassment involving a person within that supervisor's purview is required to
take prompt corrective action as appropriate, and to report the matter, if possible,
within two work days to the OAS. Failure of the supervisor to take appropriate
corrective action or to report the incident shall be a violation of this policy and shall
constitute misconduct subject to disciplinary action as described above.
COMPLAINT PROCEDURE.
a. Filing of Complaint. Any student or employee who believes that he or she
is a victim of sexual harassment in violation of this policy is encouraged to
promptly notify the alleged perpetrator (the "respondent") verbally or in
writing that his or her conduct is unwelcome. Such action may cause the
unwelcome conduct to cease as well as help to maintain an environment
free from sexual harassment. Assistance and support is available from the
Office of the Dean of the Faculties (for faculty), the Office of the Dean of
Students (for students), or the Department of Human Resources (for nonfaculty employees). Regardless of having given notice to the respondent,
the student or employee (the "complainant") may initiate a complaint
under this policy by promptly bringing the matter to the attention,
preferably in writing by completing the complaint form, of any of the
following:
1. The Office of Audit Services;
2. The Department of Human Resources;
36
3. The DIO; or,
4. An employee's immediate or next immediate supervisor.
All complaints should be filed in a timely manner. Complaints filed
for acts that occurred more than one year from the filing date of
the complaint will generally not be investigated unless appropriate
in the judgment of the OAS.
b. Preparing a Complaint. The complainant should provide the following
information to facilitate a prompt and thorough investigation:
1. The names, addresses, telephone numbers, administrative unit,
and position or status of the complainant and the respondent, if
known;
2. Specific acts alleged, including dates, times, and locations;
3. Names, addresses, and phone numbers of potential witnesses;
4. The effect the alleged acts have had on the complainant;
5. Actions the complainant may have taken to attempt to stop the
harassment;
6. Complainant's suggestion of proposed action to address or resolve
the harassment; and
7. Other
information
the
complainant
believes
is
relevant.
c. Transmitting a Complaint to the OAS. The complaint shall immediately be
forwarded to the OAS. If the complaint is verbal, the person receiving the
complaint shall make a written summary thereof on the complaint form
and request the complainant to sign it.
d. Reviewing a Complaint. The OAS will make an initial determination
whether the alleged perpetrator is a student or employee. If the alleged
perpetrator is identified, as one who is not a student or employee, then
the OAS will refer the matter to the Office of the General Counsel for
appropriate action. If the OAS determines that the alleged perpetrator is a
student or employee, the OAS will review the complaint to determine
whether the acts complained of, as stated by the complainant, constitute
a violation of this policy, and if not, the complainant will be so informed. If
the OAS determines the alleged acts may constitute a violation of this
policy, the investigation will proceed as set forth below, unless the matter
is satisfactorily resolved as in the following paragraph (e).
e. Notifying the Respondent and Supervisor; Informally Resolving a
Complaint; Withdrawing a Complaint. The OAS will notify the respondent
and his or her appropriate supervisor of the allegations contained in the
complaint. In an effort to informally resolve the complaint, the OAS will
37
elicit from the complainant, proposed actions the complainant believes are
necessary to address or resolve the alleged harassment. The OAS will
discuss these proposed actions with the respondent and with appropriate
levels of management. The respective parties will also have the
opportunity to propose other means of resolution. Thus, if the matter can
be resolved informally, or if the complainant chooses to withdraw the
complaint, the complainant will sign a statement outlining the informal
resolution and releasing the University from taking any further action. If
the matter is not resolved at this stage, the complaint will be investigated
as set forth in below.
INVESTIGATION. The following procedures will govern all investigations of complaints
alleging violations of this policy:
a. The OAS will thoroughly investigate complaints alleging violations of this
policy with the assistance, as needed, of the following: the Office of the
Dean of the Faculties, the Department of Human Resources, and/or the
respondent's supervisor(s), except in cases where the respondent is a
student. If the respondent is a student, the OAS will forward a copy of the
complaint and any associated materials to the Office of the Dean of
Students, which will, if appropriate, adjudicate the matter under the Code
of Student Conduct. The Dean of Students shall notify the OAS of the
outcome.
b. The investigation should include interviewing the complainant and
witnesses suggested by the complainant who may have knowledge of the
alleged offending behavior. Employees and students shall fully cooperate
in the investigation.
c. The respondent will be given an opportunity to respond to the complaint
verbally and in writing and may suggest additional witnesses.
d. The investigation should also include interviewing such other witnesses as
are deemed appropriate under the circumstances.
e. The investigation should include a review of any files and records of
previous sexual harassment complaints against the respondent and any
other documents deemed relevant.
f. All witnesses who provide relevant information should submit a written,
signed statement attesting to their knowledge of the subject
circumstances.
g. Confidentiality of the investigation will be maintained to the extent
allowed by law.
REPORT OF OAS. The OAS will prepare a report setting forth its findings and a
determination concerning violation of this policy. The report should be completed within
120 days following the filing of the complaint, where feasible, and will be submitted to
38
the appropriate vice president of the respondent's unit or department.
SUBSEQUENT ACTION. The vice president will make a determination, upon review of
the OAS's report, consultation with the Dean of the Faculties or the Director of Human
Resources, and consideration of any other relevant information, including aggravating
or mitigating circumstances, whether disciplinary action is warranted under the
circumstances. If the vice president determines that disciplinary action should be
initiated, then, consistent with due process requirements, the respondent will be
notified in accordance with applicable Florida Board of Education and University rules
and policies and collective bargaining agreements, and appropriate disciplinary
procedures as provided for therein will be followed. Regardless of whether formal
disciplinary action is initiated, the University may take such informal corrective action
as may be appropriate under the circumstances. The vice president will notify the OAS
of the outcome. The OAS will notify the complainant of the results of the investigation
and subsequent disciplinary or other corrective action taken, if any, to the extent
allowed by law. The OAS will notify the respondent of the results of the investigation
when no policy violation is found and no further action planned.
DISTRIBUTION OF POLICY. Copies of this policy are available to all current and future
employees and students at the Florida State University in hard copy (policy brochures,
student
handbooks,
The
Bulletin,
etc.),
electronic
format
(www.auditservices.fsu.edu/sh/policy), and will be made available in alternative format
upon request. Any person involved in the process under this policy needing
accommodations for a disability should notify the OAS.
APPLICABILITY. This policy supersedes any and all prior University policies regarding
complaints of alleged acts of sexual harassment.
RESIDENCY CLOSURE / REDUCTION
PURPOSE
The purpose of this policy is to protect the residents and provide for a smooth and
orderly transition in accordance with ACGME recommended guidelines should closure or
reduction of a program be required.
POLICY
All program directors must report to the DIO any plans for change in residency size.
Reductions should be designed to maintain a high standard of educational experience
that continues to comply with ACGME standards. Significant changes in program size
must be discussed at the GMEC regarding the educational impact on that program, as
well as other associated programs.
In the event that the FSU COM decides to reduce the number of residency positions in
and/or close any GME program, the residents will be notified as soon as possible.
Should a Residency Program downsize for any reason, it will make a good faith effort to
accomplish the reduction by accepting fewer residents into the entry level of the
program. Any such reduction must include provision for a continued training program
39
for existing residents/fellows. If necessary, the institution and the individual residency
program will assist residents in finding another residency position in the same specialty
at the appropriate PGY level; however, every effort will be made to allow residents in
the program to complete their training through the FSU COM Residency Program with
funding for their support remaining intact.
ACCOMODATION OF RESIDENTS WITH DISABILITIES
PURPOSE
The purpose of this policy is to outline the process whereby a resident in a graduate
medical education (GME) program sponsored by the FSU COM may request
accommodation for disability.
POLICY
The Florida State University (FSU) embraces the value of increasing knowledge and
awareness through diversity, which includes administration of the Americans with
Disabilities Act (ADA) program. This program ensures that faculty, staff, residents,
students and visitors with disabilities are included in the mainstream of University life.
As a public entity, FSU is required by Title II of the ADA to make all of its activities,
programs and services equally available to persons with disabilities. FSU has resources
available for those who have disabilities, which help ensure a quality, educational and
work environment.
If a resident wishes to request accommodation, he/she will submit the Employee
Request for Accommodations Under the American with Disabilities Act (ADA), form
ADA-99, to his/her residency program director, with copy to the DIO. The form is
available from the FSU Office of Diversity & Compliance. The program director and DIO
will review the request. If it is determined that additional medical information is
needed, the resident will be provided with any forms/questionnaires necessary for
his/her health care provider to complete. The Residency Coordinator will assist in the
evaluation of the information to determine eligibility within the guidelines of ADA.
The program director and DIO will then coordinate with the necessary institutional staff
and the resident to determine whether the requested accommodation would be
effective, reasonable, and enable the resident to perform the essential functions of the
position and achieve the essential educational goals and program objectives, or make a
good faith effort to negotiate another accommodation. The Residency Coordinator will
follow-up on employee's status/progress on annual basis, or earlier as need arises.
A request for accommodation may be made at any time during residency training. In
order for the resident to receive maximum benefit from his/her residency training time,
requests for accommodation should be made as early in the training process as
possible.
All medical-related information will be kept confidential and maintained separately from
other resident records. However, supervisors and managers may be advised of
information necessary to make the determinations they are required to make in
40
connection with a request for an accommodation. First aid and safety personnel may be
informed, when appropriate, if the disability might require emergency treatment or if
any specific procedures are needed in the case of fire or other evacuations.
Government officials investigating compliance with the ADA may also be provided
relevant information as requested. Form ADA-99 and attached documentation
submitted to the Residency Coordinator will be maintained in a confidential manner in
accordance with applicable federal and state mandated retention schedules.
PHYSICIAN IMPAIRMENT AND SUBSTANCE ABUSE
DEFINITION
For the purpose of this policy and procedure, impairment is defined as a condition which
is, or may be, adversely affecting patient care, including, but not limited to:
alcoholism/alcohol abuse, other drug addiction, sexual misconduct and/or harassment,
physical or medical conditions, psychiatric disorders, emotional disorders or behavioral
disorders.
PURPOSE
The purpose of this policy is:
1. To establish a process to identify and manage matters of individual resident
physician impairment, separate from the medical staff disciplinary function.
2. To establish a mechanism of reporting for any individual with a reasonable
suspicion that a resident physician is impaired.
3. To provide a process that offers support and compassion to the affected resident
physician.
POLICY
1. This policy places the highest priority on protection of the patient, while
promoting prompt referral for evaluation, treatment and support for resident
physicians.
2. The sponsoring institution and each program are responsible for monitoring
residents for signs of psychological, medical or substance abuse problems that
may be causing impairment, and for initiating appropriate interventions. The
FSU COM has contracted (via the Employee Assistance Program of Florida
State University) with LifeWorks, an organization that provides 24/7 access to
free confidential help with personal and work-related problems, and which can
assist residents with almost any issue, including: Life; Family; Money; Work;
and Health. Residents may phone toll-free to speak with a LifeWorks
consultant, or they may visit the website www.lifeworks.com to find the help
and resources needed. (See Attachment 1 for further details).
3. The FSU COM conforms to the Florida Medical Practice Act (F.S. 458), which
provides for the Impaired Practitioners Program, which is administered
through the Professionals Resource Network (PRN). PRN works closely with
the State Board of Medicine and is recognized as the primary mechanism for
providing assistance to impaired physicians in the state. Information on the
41
PRN and its program can be obtained by calling 1-800-888-8776 or by writing
to the PRN at P. O. Box 1020, Fernandina Beach, FL 32035-1020.
4. It is the intent of the FSU COM that all appropriate rules that govern the
practice of medicine and all FSU COM related polices be strictly enforced.
a. Each program will provide an educational program to its residents
regarding substance abuse and other impairment and available
assistance.
b. A resident physician whose behavior is consistent with substance abuse or
other impairment may be required by his/her Program Director to submit
to a drug screen. Drug screens will be performed by Sacred Heart Hospital
Human Resource Office Personnel.
i. Behavior indicating substance abuse may include:
1. Observed impairment of job performance.
2. Abnormal conduct or erratic behavior.
3. A serious workplace accident or number of minor workplace
accidents.
4. Evidence of drug tampering in the employee’s workplace.
5. Arrest or conviction on an alcohol- or drug-related offense.
c. All referrals to the PRN are confidential and are evaluated by the
professionals of the PRN. Decisions about intervention, treatment and
after care are determined by the PRN.
d. As long as the resident physician satisfactorily participates in the PRN
program, no regulatory action would normally be anticipated by the
Board of Medicine.
e. Resumption of clinical activity and residency program training will be
contingent upon the continued successful participation in the PRN and
continuation of the resident in the program will be determined in
consultation between the program director, DIO and the professionals
at the PRN.
PROCEDURE
1.
2.
3.
4.
Resident physicians with a past or current history of drug or alcohol addiction, or
mental or physical health condition that may impact patient care should report
such condition to PRN.
Faculty, staff, peers, family members or other individuals who suspect that a
member of the housestaff is suffering from a psychological, medical or substance
abuse problem impacting patient care are obligated to report such problems.
Individuals suspecting such impairment can discuss their concerns with the
Program Director, Chief of Medical Staff at SHH and/or the DIO, or may report it
directly to the Professionals Resource Network (PRN).
Residents meeting any of the above criteria in 4b, or other reasonable criteria
utilized by the Program Director, may be required by the Program Director to
submit to a drug test. Refusal or failure to submit to a timely drug test is
sufficient cause for termination of employment.
The resident will be relieved of his/her duties and will be given a specific time
(generally less than two hours) that he/she is to report to the testing facility.
Failure to report at the specified time, without pre-approval of the Program
42
5.
6.
7.
8.
9.
10.
11.
12.
Director, is sufficient cause for immediate termination. In the event that the
resident is obviously impaired, consulting staff members will make arrangements
to provide transportation to the testing facility.
The Designated Institutional Official should be promptly notified. Suspicious
behavior should be documented on the form appended to this policy (Attachment
2). This form is to be retained in the resident’s confidential personnel file.
The submitted sample (blood, hair and/or urine, as appropriate) will be
screened. If an initial screen returns a positive result, a confirmatory test on the
same sample will be conducted. If the confirmatory test is also positive, the
result will be turned over to the Program Director. All sample collections for drug
tests conducted for cause will be performed under observation.
Test results will be granted confidentiality in accordance with all federal and state
laws and residency policy. Tests will be performed at the Sacred Heart Hospital
Human Resource Office and will be paid for by SHH. Notification of any other
agency or licensing board will be accomplished by the Residency Director in
accordance with this policy.
Applicants may be asked to provide information as necessary to interpret drug
screen results. Such information will be considered confidential.
Attempts to alter or substitute a specimen will be cause for immediate
termination, even if the attempt is discovered at a later date.
The Program Director will schedule an appointment with the resident to discuss
with him/her the results and will inform the DIO and other hospital
administration as appropriate.
Along with the DIO and hospital administration as appropriate, the Program
Director will determine the appropriate action necessary which will include
prompt referral to with the Employee Assistance Program (EAP) / Lifeworks and
PRN, and depending upon the circumstances may include immediate termination,
while adhering to the ADA.
The Program Director will determine the resident’s ability to continue in the
program and/or remain in patient care activities after consultation with the
professionals at EAP and the PRN. Any resident terminated for cause will be
ineligible for rehire for a minimum of six months, may be more if situation
indicates longer term.
PHARMACEUTICAL/VENDOR INTERACTIONS
Purpose of Policy
The purpose of this policy is to establish guidelines to ensure that patient care and
medical education are not influenced by considerations other than what is in the best
interests of patients and/or trainees.
Statement of Policy
43
It is the policy of the FSU COM that pharmaceutical/industry access to students, faculty,
and residents, is prohibited on FSU COM property, including regional medical school
campuses However, discussion with representatives for the purpose of obtaining
unrestricted educational grants is allowed.
This policy applies to all FSU COM full-time faculty and part-time faculty (clerkship
directors, clerkship faculty, elective faculty) when performing their duties on FSU COM
property.
Scope of Policy
I. Accepting Offers
Gifts
Individuals subject to this policy (faculty, residents, students, and staff) may not solicit
or accept any gifts from pharmaceutical company/industry representatives.
Additionally, the use of any vendor’s material with the vendor’s name or logo is strongly
discouraged in public or patient care areas.
Food
The direct provision of any meals, desserts, etc. by pharmaceutical/industry
representatives on FSU COM property is prohibited. This includes the provision of meals
during any organized, scheduled educational activity (e.g., grand rounds, journal club,
faculty development, etc.) or reception. Industry representatives who wish to provide
support to the FSU COM may, however, do so in the form of an unrestricted educational
grant to the FSU COM. Such grants are expended for food solely at the discretion of
COM departments/divisions/regional campuses/residency programs.
Entertainment
Faculty members, residents, students, or employees of the FSU COM participating in
social events, including meals, funded directly by pharmaceutical company/industry
may not use their official status as FSU employees or students. Moreover, faculty and
employees of the FSU COM may not accept the use of supplier/vendor property,
airplane transportation, travel packages, or similar favors from industry as FSU
employees.
Compensation
Full time faculty or employees may not accept gifts or compensation for listening to a
sales talk by an industry representative, including the defraying of costs for simply
attending a CME or other activity or conference.
Honoraria provided directly by pharmaceutical/other industry are not allowed if faculty
or employment status with the FSU COM is acknowledged.
44
II. Site Access
Pharmaceutical/Industry Representatives are not allowed access to faculty, students,
residents or staff on FSU COM property, including its regional campuses, except for the
purpose of discussing/providing unrestricted educational grants.
III. Educational Funds
Industry representatives may provide support for medical educational purposes in the
form of unrestricted educational grants. Initial contact with industry representatives for
the purpose of discussing or obtaining unrestricted educational grants is permitted.
Scholarships / Educational Grants
No educational grant, financial award, donation, or expense reimbursement may be
given directly to a resident or medical student by an industry representative. Any
educational grant must be provided to the College of Medicine.
Faculty and staff who are invited to present or lead conferences or meetings funded
directly by pharmaceutical/other industry may not acknowledge their faculty status as
part of the program.
Note: These provisions do not apply to meetings of professional societies that may
receive partial industry support,
i.e., meetings governed by ACCME Standards.
IV. Disclosure of Relationships with Industry
All College, Program and Sponsoring Institution-sponsored medical education events
must include full and appropriate disclosure of sponsorship and financial interests above
and beyond those already governed by the Standards for Commercial Support
promulgated by the Accreditation Council for Continuing Medical Education. Department
Chairs, Program Directors and Faculty should disclose any financial relationships with
Industry, including but not limited to ownership of practice and hospital sites at the
time of appointment to these positions, annually through the FSU COM Personnel
Office, and as actual, potential, or the appearance of Conflicts of Interest arise.
Faculty with supervisory responsibilities for students, residents and/or staff should
ensure that the faculty’s conflict or potential conflict of interest does not affect or
appear to affect his or her supervision of the student, resident or staff member.
Individuals having a direct role making institutional decisions on equipment or drug
procurement must disclose to the FSU COM Administration / Personnel Office, prior to
making any such decision, any financial interest they or their immediate family have in
companies that might substantially benefit from the decision. Such financial interests
could include equity ownership, compensated positions on advisory boards, a paid
consultancy, or other forms of compensated relationship. They must also disclose any
research or educational interest they or their department have that might substantially
benefit from the decision. The administration will decide whether the individual must
remove him/herself from the purchasing decision.
45
Note: This provision excludes indirect ownership, such as stock held through mutual
funds.
V. Training/Communication Regarding Potential Conflicts of Interest
All faculty, attendings, residents, students and applicable staff shall be provided with
information regarding potential conflicts of interest in interactions with industry to
include:
•
•
•
A copy of these guidelines on vendor interactions.
Copies of the ethics statements of pertinent medical specialty societies and how
to apply those guidelines to practice.
Seminars and/or faculty development sessions describing:
o How activities can influence judgment in prescribing decisions and
research activities.
o How to manage encounters with Industry representatives.
o How to handle patient requests for medication, particularly regarding
direct-to-consumer advertising of drugs.
o The purpose, development, and application of drug formularies and
clinical guidelines and discussing such issues as branding, generic drugs,
off-label use, and use of free samples.
VI. Procedure, Monitoring and Responsibility
We want to ensure patients, students and residents know we are focusing on their
welfare, not on any commercial interest and eliminate the appearance of industry’s
inappropriate influence over the medical community. Therefore, all FSU COM faculty,
students, residents and staff will be given a copy of this Policy and Guidelines
document.
The Graduate Medical Education Committee (GMEC) must ensure that the Sponsoring
Institution monitors vendor interactions with residents and GME programs.
FSU COM administration, department heads, division heads, campus deans, program
directors, etc. are responsible for compliance with this policy and for ensuring the
personnel under their supervision understand and comply with this policy.
If FSU COM faculty and/or staff have any questions concerning the interpretation of this
policy and guidelines, or its applicability to a particular circumstance, they should first
consult with their supervisor. If their supervisor is unable to answer the question or
provide appropriate guidance, or if, because of the circumstances, it would be
inappropriate to discuss the matter with the supervisor, then the personnel and/or staff
member should contact the FSU COM Sr. Associate Dean’s office. If any FSU COM
personnel and/or staff member is aware of any violation or threatened or potential
violation of this policy, or suspects that a violation of this policy has occurred, they
must also refer to the FSU COM Sr. Associate Dean’s office.
VII. Exceptions
46
1. This policy does not apply to part-time faculty (clerkship directors and clerkship
faculty) engaged in their roles at venues other than FSU COM property; i.e., private
offices, hospitals or other sites.
2. This policy does not include faculty research and related activities, which are included
in the Florida State University Faculty Policies and Procedures for Dealing with
Misconduct
in
Research
and
Creative
Activity
(http://dof.fsu.edu/
facultyhandbook/Ch6/Ch6.20.html). Individuals should contact the FSU COM Office of
Research (http://med.fsu.edu/research/office/default.asp) with regard to publishing
articles under their name and FSU COM title, in disclosing their related financial
interests etc.
Pertinent Definitions Attending: The faculty member with primary responsibility for the care of a patient
and/or the education of a student or resident in a particular case.
Conflicts of Interest: Any situation in which an individual is in a position to exploit
his/her professional or official capacity in some way for personal benefit.
Faculty: Physicians/Professors who possess the requisite expertise, documented
educational and administrative abilities, and experience to teach residents and
students.
Meetings: Any gathering on FSU COM property involving FSU COM personnel. Such
gatherings would include but not be limited to faculty development meetings, resident
or student meetings, grand rounds, departmental, divisional or regional campus
meetings.
Personnel: Faculty, staff, residents, and medical students of the FSU COM.
Representative: Includes any individual who is employed by or who represents any
entity defined under ‘Vendor/Industry’.
Sponsorship: Vendor/Supplier funding
Unrestricted Educational Grants: It is recommended that industry representatives
provide financial support for FSU COM events directly to the COM in the form of an
unrestricted
educational
grant
to
then
be
spent
by
the
COM
departments/divisions/regional campuses/residency programs for educational activities
at their discretion. Appropriate recognition of the industry representative’s contribution
should be given by the department/division/regional campus/residency program.
Educational grants must not be made, conditioned, or related in any way to pre-existing
or future business relationships with Industry. Vendors should separate their grant
making functions from their sales and marketing functions. Accordingly, if vendor or
patient-service representatives or other corporate representatives wish to discuss a
corporate contribution of cash, equipment, supplies, or services, the employee should
immediately notify the Dean or the Sr. Associate Dean for Academic Affairs/DIO. This
individual, or a designee, should then become the principal point of contact with the
vendor.
47
Vendor/Industry: Includes those businesses, corporations, or entities that supply or
wish to supply equipment, goods, services, or other medical related products to
physicians, administrators, students, residents, staff or hospitals.
GENERAL DISASTER PLAN
Definition of Disaster
A disaster is defined herein as an event or set of events causing significant alteration to
the residency experience at one or more residency programs.
Declaration of Disaster
When warranted, the Accredited Council for Graduate Medical Education (ACGME)
Executive Director, with consultation of the ACGME Executive Committee and the Chair
of the Institutional Review Committee, will make a declaration of a disaster. A notice of
such will be posted (and periodically updated) on the ACGME website with information
relating to ACGME response to the disaster.
Resident Information
All programs will maintain a roster of all residents that includes at a minimum, the
following information: name, address, pager number, all available phone numbers
(home, cell, etc.), all available e-mail addresses, and emergency contact individual(s)
and their contact information. This information will be updated at least annually before
July 31, and as appropriate to maintain accuracy. The programs will maintain this
roster with internal backup, as well as external backup at the Florida State University
(FSU) College of Medicine.
As possible, residents may continue their roles and participate in disaster recovery
efforts. Resident reporting will continue during disaster recovery. Residents will
continue to receive their salary and benefits during the disaster event recovery period,
and/or accumulate salary and benefits until such time as utility restoration allows for
fund transfer.
Medical-Legal Aspects
There are multiple mechanisms that may afford liability protection to FSU residents who
are or will be working in the affected areas of disaster response in the State of Florida
from incurring personal liabilities. In the capacity of assignment by Florida National
Guard and/or Department of Homeland Security, residents may become temporary
employees of Health and Human Services (HHS) and therefore are subject to and
protected by the Federal Tort Claims Act. It is preferred, whenever possible, that
notwithstanding other capacities in which residents may serve, they also perform within
their FSU function when they participate in disaster recovery efforts. While acting
within their FSU function, residents will maintain their personal immunity to civil actions
via the state’s sovereign immunity and the University’s Self-Insurance Program.
Communication with ACGME
The Designated Institutional Official will call or email the Institutional Review Committee
Executive Director with information and/or requests for information.
Similarly, the Program Directors will contact the appropriate Review Committee
Executive Director with information and/or requests for information.
48
Residents should call or email the appropriate Residency Director (or Residency Review
Committee if unable to reach director) with information and/or requests for information.
In the ACGME Web Accreditation Data System, ACGME will provide instructions for
changing resident e-mail information as needed.
Resident Transfers / Program Reconfiguration
If, because of a disaster, at least an adequate educational experience cannot be
provided for each resident the sponsoring institution will:
(a) Arrange temporary transfers to other programs/institutions until such time
as the residency program can provide an adequate educational experience
for each of its residents;
(b) Cooperate
in
and
facilitate
permanent
transfers
to
other
programs/institutions. If more than one program/institution is available for
temporary or permanent transfer of a particular resident, the transferee
preferences of each resident will be considered. Programs/institutions will
make the keep/transfer decision expeditiously so as to maximize the
likelihood that each resident will timely complete the resident year; and
(c) Inform each transferred resident of the minimum duration of his/her
temporary transfer, and continue to keep each resident informed of the
minimum duration. If and when a program decides that a temporary transfer
will continue to and/or through the end of a residency year, it must so
inform each such transferred resident.
Within ten days after the declaration of a disaster, the Designated Institutional Official
(DIO) will contact ACGME to discuss due dates that ACGME will establish for the
programs, (a) to submit program reconfigurations to ACGME; and, (b) to inform each
program’s residents of resident transfer decisions. The due dates for submission shall
be no later than 30 days after the disaster unless other due dates are approved by
ACGME.
A form will be available on the ACGME website for institutions offering to accept
temporary or permanent transfers from disaster affected institutions that must be
completed. Upon request, ACGME will provide information from the form to the
affected programs and residents.
ACGME will expedite the process for reviewing (and approving or not approving)
submissions by programs relating to program changes to address disaster effects,
including the addition or deletion of a participating institution, change in the format of
the educational program, and/or change in the approved resident compliment.
Hurricane Preparedness
Please reference the Sacred Heart Hospital Emergency Policy at our Compliance 360
online at:
https://secure2.compliance360.com/DMZ/Policy/PolicySearch.aspx?PD=O8WBP3JV
W9br7RsJgeziB5OVmAaK7JLONj8bXJ7IjAfd9W60KJxmhBj2eKSsrF4qR2uD4MoCNrc7
OlU2cYUKTzR%2f2J0tCAx7MQzHXYXCnrHiquYl2hUx0N4FnFt9iyeV
BENEFITS & RESOURCES
49
Financial Support and Benefits
Stipend: Each resident is given a stipend to pursue the resident's graduate
medical education in an amount appropriate to the resident's level in the program.
Stipend levels are reviewed annually by the Graduate Medical Education Committee of
the College of Medicine and recommendations for changes are subject to approval by
the Dean of the College of Medicine. Stipend levels begin on the first (worked) day of
the new contract year and are paid biweekly.
Living quarters, meals, laundry, and other such expenses are the resident's
responsibilities. In some cases, meal tickets may be issued to the resident when the
resident is assigned in-house call on nights and weekends; similarly, living quarters
may be provided during some rotations outside of the primary location of the program.
Health, Dental, Vision, Life and Disability Insurance; Worker's Compensation
Insurance:
Health, Dental, Vision Live and Disability insurance are provided to the resident.
Disability insurance (DI) is offered to residents, and is provided for all who meet
the provider’s qualifications. DI coverage includes compensation for an occupational
injury that results in HIV infection. The approximate monthly compensation is up to
$2,000. Note: Prior to completion of this program, you will have the opportunity to
convert this group policy to an individual policy that provides compensation of up to
$2,000 per month (approximately $5000 per month for catastrophic illness or injury).
If a resident suffers a work-related injury, the resident is covered under the
workers' compensation program of the University provided the resident complies with
the requirements of the workers’ compensation program.
Confidential counseling and psychological support services, provided by
contracted personnel, are available on an on-going basis.
Professional Liability Coverage: As a participant in a graduate medical
education program of the University, a resident is an employee of Florida State
University, a public university of the State of Florida. The resident is personally immune
from civil liabilities which may arise from acts or omissions committed by the resident in
the course of employment. Section 768.28, Fla. Statutes, outlines the protection
against claims and/or judgments extended to employees of the University under
Sovereign Immunity. The Florida State University Board of Trustees is vicariously
responsible for any civil claims or actions arising from the acts of its employees and
agents. Pursuant to University Regulation, the University has created a program of
self-insurance covering claims and actions against the University which may arise from
the actions or omissions of University healthcare faculty members, residents, other
professional employees or students of the University. A resident must identify himself
or herself at all times as a Florida State University employee while participating in the
graduate medical education program in order to assure this coverage; a University
name tag will be provided.
FICA ALTERNATIVE PLAN - BENCOR
50
The FICA Alternative Plan is a defined contribution private retirement plan authorized
under Section 401 (a) of the Internal Revenue Code. Instead of paying 6.2% social
security taxes post-tax, eligible Residents/Fellows contribute 7.5% of pre-tax wages
into an investment account in the individual’s name. Medicare contributions at 1.45%
will continue to be withheld and matched by the university. The plan is mandatory for
all eligible Residents and Fellows.
There are a variety of investment options for this retirement plan that include a
Guaranteed Pooled Fund (an interest bearing account) and variable investment options.
As a participant in the plan, you may direct the investment of your funds at any time by
submitting a completed *Retirement Plan Enrollment Form to BENCOR Administrative
Services. If you do not submit this form to direct the investment of your funds, all of
your contributions are automatically deposited into the Guaranteed Pooled Fund, an
interest bearing account.
A statement of your account activity, including contributions and earnings will be mailed
after the end of each calendar year to your home mailing address.
Advantages of the FICA Alternative Plan include:
1) You are not subject to Social Security taxes while covered by this plan and you
permanently save the Social Security tax on these contributions.
2) Any benefits you have earned under another retirement plan (including Social
Security) will not be reduced by participation in this plan.
3) Contributions to this plan are pre-tax. Therefore, the amount of taxes you pay
will be reduced. No taxes are paid on the contributions until they are withdrawn.
4) The account balance is portable and there are no administrative fees.
BENCOR, Inc. is the plan administrator for the Florida State University. Additional
information about the plan may be found at the Florida State University’s Human
Resource Services web site, www.hr.fsu.edu
Under Faculty/Staff Benefits / Florida Retirement System / FICA Alternative Plan.
*First year residents receive this form during orientation
INSTITUTIONAL LEAVE POLICY
The leave policy incorporates sick leave, vacation, uncompensated leave, temporary
military duty, absences pertaining to education and training, and maternity/paternity
leave. Subject to the approval of the program director and consistent with the
guidelines of the appropriate specialty board, all residents receive fifteen (15) days of
annual leave each academic year (June–July). Unused annual leave cannot be carried
over from one year to the next and is non-transferrable and non-reimbursable; this
keeps you in compliance with the Accreditation Council for Graduate Medical Education
(ACGME).
A resident will accrue ten (10) days of sick leave for each full year of
employment. The resident will be entitled to utilize sick leave for death, or in special
cases, severe illness in the immediate family (spouse, parents, brothers, sisters,
51
children, grandparents, and grandchildren of both resident and spouse). The number
of days of sick leave allowed per illness will be determined by the program director.
Unused sick leave cannot be carried over from one year to the next and is nontransferable and non-reimbursable.
The total time allowed away from a graduate medical education program in any
given year or for the duration of the graduate medical education program will be
determined by the requirements of the specialty board involved. If leave time is taken
beyond what is allowed by the University or the applicable specialty board, the resident
is required to extend his or her period of activity in the graduate medical training
program accordingly in order to fulfill the appropriate specialty board requirements for
the particular discipline. The resident may be paid for makeup or extended time if
funds are available at that time.
LEAVE POLICIES (FURTHER DETAILED)
Annual Leave
1.
ALL VACATIONS MUST BE APPROVED AT LEAST 12 WEEKS IN ADVANCE OF THE
START OF A NEW ROTATION BY THE ADMINISTRATIVE CHIEF RESIDENT, AND
PROGRAM DIRECTOR.
2.
Only one resident from each service may be on vacation at a time.
3.
Only one week of leave is permitted during a given rotation. As a general rule,
vacations should not be taken during the same rotation when a scientific meeting
is scheduled. Exceptions to this policy must be approved by the program
director.
4.
Vacations should not be scheduled during the last two weeks of June or the first
two weeks of July.
Vacations may only be scheduled during electives, and Emergency Medicine
Except in unusual circumstances, vacations should not be scheduled during
rotations outside of the Pensacola location.
5.
6.
Annual leave may be advanced to a resident proportionate to their 2009-2010 expected
service, not to exceed the amount of his/her leave-earning rate for that year. Caution:
Annual leave which has been granted and which has not been earned by the
postgraduate trainee at the time of separation from the department will require an
appropriate reduction for the value thereof in the final stipend payment.
Sick Leave
1.
Sick leave may be used for illness or unanticipated family or personal
emergencies.
2.
Residents must notify the Chief Resident, supervising resident for Wards/Clinic
and the supervising attending for other rotations first thing in the morning for
sick leave, and must also arrange for coverage during absence, if necessary. If
it affects a CALL, you must obtain coverage.
3.
Under special circumstances consistent with a medically documented disability,
an approved leave of absence may be granted for a period not to exceed six
months. During this time, the house staff member will be required to remain in
the continuous care of a physician. Full compensation and all fringe benefits will
52
4.
continue during this approved leave of absence.
Florida State University administers the Family and Medical Leave procedures for
eligible employees in accordance with the Family and Medical Leave Act of 1993,
the Federal regulations and the State University System rules. All employees are
eligible for Family and Medical leave including Other Personnel Services (OPS)
employees so long as they have worked at least twelve (12) months (these need
not have been consecutive) and worked at least 1250 hours in the twelve (12)
months prior to the leave. OPS employees will be granted unpaid Family and
Medical Leave up to a total of twelve (12) work weeks/480 hours during the
twelve (12) month calendar year period.
Proper medical certification may be required to grant Family and Medical Leave
for one or more of the following reasons:
• For the birth and care of a newborn child (FMLA) of the employee or for
placement with the employee of a child for adoption or foster care;
• To care for an immediate family member (FMLA) with a serious health
condition; or
• To take medical leave when the employee is unable to work because of a
serious health condition.
COBRA
(Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985) In the event of
your termination, you have the option to continue your health insurance policy at the
current premium plus 2% for a maximum of 18 months under COBRA. Eighteen-month
continuation is also available in the event of reduction in hours or layoff. Thirty-sixmonth continuation is available to dependents in the event of divorce, death, Medicare
entitlement or a dependent losing that status because of age. It is your responsibility to
notify the Florida State University College of Medicine Graduate Medical Education
personnel within 30 days of any of the above events; failure to provide notification
could result in forfeiture of COBRA.
LEAVE FOR INTERVIEWING
It is expected that toward the end of the third year, residents will need to interview for
a Fellowship Program or for job placement. Interviews for Fellowships generally occur
during the week and residents may be allowed 1-2 days at a time without being
penalized for vacation. Job interviews can usually be arranged on weekends. The total
number of days allowed for interviewing is at the discretion of the Program Director.
CONTINUING MEDICAL EDUCATION ALLOWANCE
Residents are provided the opportunity to attend one CME conference per year (2nd
and 3rd years only). Currently Florida State University provides $600.00 per year for a
total of $1,800 over the three year period. Expenses must be validated with receipts. If
you spend more money than allotted it will come out of your pocket. The resident will
be given days off equivalent to the number of days of the conference plus travel time to
a maximum of 5 days. The conference must be related to pediatrics and within the
continental U.S. You will also need approval from the Program Director.
53
Only one funded meeting/program per year is permitted. The allowance may be used
for CME or educational expenses.
Requests for CME (Continuing Medical Education) must be submitted in writing to the
Chief Resident prior to the requested event and may only be taken during elective,
Emergency Medicine, Adolescent, and B&D Rotations.
HOLIDAYS
Florida State University holidays will be observed (New Years, Martin Luther King,
Memorial Day, Independence Day, Labor Day, Veteran’s Day, Thanksgiving and day
after, and Christmas). If the holiday falls on the weekend, the nearest Friday or
Monday will be designated. Clinic/Elective/Extended Hours residents have the day off.
Wards/PICU checkout to On Call Team early at 11:00 AM. NBN resident may leave
after rounds. ICN and Emergency Medicine residents may make arrangements with
their attendings. In the event a resident is unable to receive the time off while
accounting for patient care, a different day off will be afforded to the resident via block
scheduling.
MATERNITY/PATERNITY LEAVE
The duration of maternity leave before and/or after delivery will be determined by the
resident and her physician. All available sick and vacation leave must be used to cover
maternity leave. The Program Director must approve requests for leave in excess of six
weeks.
While on unpaid leave, the resident's insurance benefits will be maintained by the
department for up to two months. After two months, the resident will be responsible
for payment of insurance premiums.
Changes in the rotation schedule may be made for a resident who is pregnant if these
changes are approved by the Program Director.
Leave may be granted for a resident engaged in an adoption proceeding with advance
approval of the Program Director.
In special circumstances, paternity leave may be granted with the advance approval of
the Program Director.
FAMILY MEDICAL LEAVE ACT
Florida State University administers the Family and Medical Leave procedures for
eligible employees in accordance with the Family and Medical Leave Act of 1993, the
Federal regulations and the State University System rules. All employees are eligible
for Family and Medical Leave including Other Personnel Services (OPS) employees as
long as they have worked at least twelve (12) months (these need not have been
consecutive) and worked at least 1250 hours in the twelve (12) months prior to the
leave. OPS employees will be granted unpaid Family and Medical Leave up to a total of
twelve (12) work weeks/480 hours during the twelve (12) month calendar year period.
54
Proper medical certification may be required to grant Family and Medical leave for one
or more of the following reasons:
• For the birth and care of a newborn child (FMLA) of the employee or for
placement with the employee of a child for adoption or foster care;
• To care for an immediate family member (FMLA) with a serious health condition;
or
• To take medical leave when the employee is unable to work because of a serious
health condition.
CURRENT DEPARTMENTAL FRINGE BENEFITS
A brief summary of Program benefits includes:
a.
Pays dues for Junior Fellows membership with the American Academy
of Pediatrics
b.
Pays for USMLE, Step III, examination and expenses
c.
Pays annual fee for admission to the American Board of Pediatrics InTraining Examination.
d.
Pays the fee for State of Florida licensure when feasible and upon
completion of Step III of USMLE and PGY 1 year of residency
e.
f.
g.
h.
Provides professional coats, two the first year, one a year thereafter.
Provides pagers and business cards
Provides FSU COM Nametag
Large number of resources via the FSU COM and Sacred Heart on-line
libraries
COMMUNICATIONS
The major means of communications within the program will be via e-mail. Residents
are required to have an active e-mail address and should check their mailboxes
regularly. They may use either a personal account or the College of Medicine e-mail
account provided them. Computers are located on second floor lounge, third floor
rounding room and in the clinics. Resident and faculty physician e-mail addresses will
be distributed to members of the program
LIBRARIES
The Medical Library at SHH is available for use by the residents and includes such
programs as Up-to-Date and PEPID. The library is located on the first floor of the Main
Hospital and has recently undergone renovation. After-hours access can be obtained
by using the “88" key. Computers for literature searches are available in the library,
Pediatric Clinic, and the second floor lounge. The Librarian is available to assist you.
In
addition,
the
FSU
COM
has
an
extensive
on-line
library
(http://www.med.fsu.edu/library/) which is available for residents to use which also
55
includes a number of Pediatric journals and books. (See Attachment C). You will be
provided with a username and password. Training sessions will be held periodically
throughout the year.
MEAL TICKETS
Each resident will be given meal tickets for the Sacred Heart Hospital cafeteria to cover
the cost of meals while on call and for meals held during Morning Report and Noon
Lectures. Snacks are available in the 3rd Floor Rounding Room for times on call when
the cafeteria is not open.
RESPONSES TO INVITATIONS
From time to time residents may receive social invitations from faculty members. The
initials R.S.V.P. require a response, indicating whether or not you are going to attend.
Regrets means you need only respond if you are not going to attend. These various
functions allow us to interact socially with visiting professors and our colleagues. It is
considered common courtesy and professional behavior if these invitations receive a
response.
56
EDUCATIONAL INFORMATION
Regulatory & Service Organizations
The following is a list of organizations with a focus on residency education in Pediatrics.
•
American Academy of Pediatrics
141 NW Point Boulevard
Elk Grove, IL 60007
800 433 9016
www.aap.org
The American Academy of Pediatrics was founded in June 1930 by 35 pediatricians who
met in response to the need for an independent pediatric forum. Today, the Academy
unites more than 60,000 pediatricians through the Americas to ensure for all infants,
children, adolescents and young adults the attainment of their full potential for physical,
emotional and social health.
To this end, the Academy dedicates its resources to professional education,
advocacy for children, representation of pediatricians, public education, access to health
care and service to children. The American Academy of Pediatrics publishes Pediatrics
Review and Educational Program (PREP®).
•
American Board of Pediatrics
111 Silver Cedar Court
Chapel Hill, NC 27514
919 929 0461
www.abp.org
The American Board of Pediatrics is located in Chapel Hill, North Carolina. The ABP is
the organization that establishes criteria for certification of individuals in the specialty of
pediatrics. The ABP administers certifying exams in pediatrics and the annual InService Training Exam. The Board tracks the progress of each resident through the
course of their training.
•
Accreditation Council for Graduate Medical Education (ACGME)
515 North State Street, Suite 2000
Chicago, IL 60610 312 464 4920
www.acgme.org
ACGME is composed of representatives of the American Board of Medical Specialties,
the American Hospital Association, the American Medical Association (AMA), the
Association of American Medical Colleges, the Council of Medical Society Specialties, and
the federal government plus a resident and a public representative. The ACGME gives
delegated accreditation authority to the Residency Review Committee. To be
accredited, a residency program must meet the “General Requirements” and “Special
Requirements” listed in the ACGME Essentials of Accredited Residencies published by
AMA.
57
•
Residency Review Committee for Pediatrics
515 North State Street
Chicago, IL 60610 312 464 4920
www.acgme.org
The RRC operates under the auspices of the ACGME and is responsible for determining
whether a training program conforms to established educational standards. The RRC
requires certain elements to accredit a residency program. The Florida State University
residency program is accredited in meeting these requirements. The elements of your
training are designed to fulfill these requirements and you should be familiar with them.
EDUCATIONAL PROGRAMS, EXAMINATIONS, AND TRAINING
Required Training
Each resident is expected to become certified in Basic Life Support, Pediatric Advanced
Life Support, and Neonatal Resuscitation. Courses are offered by the hospital and time
will be designated to complete these skills. If the resident signs up for a course and
fails to attend or fails to cancel his or her registration within 48 hours of the course, the
resident will be assessed the full charge of the course. When the resident attends the
course, it is free of charge.
Residents are responsible for scheduling re-certification classes with the Education
Department. Cost of re-certification classes is paid by the Residency Program.
American Board of Pediatric In-Training Examination
Each year, all residents are required to take the ABP In-Training examination in July.
The examination feedback provides a method to determine individual strengths and
weaknesses in cognitive knowledge. Examination scores are one measure of the
resident’s clinical performance.
USMLE Step III
The USMLE Step III Examination is scheduled in the winter/spring of the PGY 1 year.
Residents are responsible for scheduling their two-day examinations (usually taken in
Mobile, Alabama) and coordinating with their individual schedules and the Chief
Resident. The Residency Program assumes the cost of this exam.
American Board of Pediatrics Board Certification Examinations
Third year residents should apply individually for their written American Board of
Pediatrics Examination prior to March of their graduation year. Materials are mailed
directly to residents from the AAP. The Residency Program assumes the cost of this
exam.
Continuing Education Conferences/Educational Programs
Formal learning does not end with medical school. Many aspects of pediatrics require
additional didactic instruction before they can be integrated into the resident’s fund of
working knowledge. A scholastic series of lectures for residents has been developed to
include the broad range of issues of importance to pediatricians.
58
Department Conferences
All residents are expected to attend scheduled conferences unless specifically excused a
minimum attendance rate of 50% is required. Attendance records are maintained.
Supervising residents are responsible for residents on their services and may be asked
to explain unexcused absences.
PEDIATRIC GRAND ROUNDS
Tuesday 8:00 - 9:00 AM weekly
PEDIATRIC MORNING REPORT
Monday-Friday 7:15 - 8:00 AM
CORE LECTURES
Monday-Friday 12:15 PM
FETAL BOARD MULTI-DISCIPLINARY CONFERENCE
Times to be announced
CONFIDENTIAL COUNSELING AND PSYCHOLOGICAL SUPPORT
Contracted personnel available on an on-going basis
ONCOLOGY CONFERENCE
1st Friday, 12:00 Noon
PEDIATRIC PATHOLOGY CONFERENCE
Time to be announced
JOURNAL CLUB/PREP REVIEW
2nd Friday of every month
59
Educational Objectives for Resident Rotations
Learning goals and objectives are located in New Innovations software. During
orientation, residents will be asked to sign a form indicating they received instructions
on how to access goals and objectives in New Innovations and that the resident is
expected to review the goals and objectives prior to the start of the rotation. Resident
rotations are scheduled in four-week blocks. Some rotations are mandatory (Ward, ED,
NICU, etc.) and others are elective. Please note the RRC Requirements state that a
minimum of four rotations be in the required sub-specialties. These rotations must be
of a minimum duration of four weeks (no vacation). As you complete each rotation,
you should make sure you have had the opportunity to have a face-to-face evaluation
with your preceptor.
Electives
A listing of electives available in Pensacola is below:
-Required electives (minimum of four 1-month block rotations)
Allergy/Immunology
Gastroenterology
Infectious Disease
Genetics
Cardiology
Hematology/Oncology
Nephrology
Pulmonology
Endocrine/Metabolism
Rheumatology
Neurology
-Additional electives
Child Psychiatry
Otolaryngology
Dermatology
Pediatric Radiology
Ophthalmology
Pediatric Surgery
Orthopedics and Sports Medicine
Resident Teaching Responsibilities
Lower level resident and student teaching is one of the most important resident
activities. Student responsibilities will vary with the service.
Because of the leadership qualities this residency is designed to foster, lower level
resident and student teaching will continue to be expected, and excellence in this area
will be noted. The opposite is also true. Those who fail to use common courtesy in
dealing with lower level residents and students, who neglect their role as leaders and
who deal with lower level residents and students in an antagonistic, counterproductive
manner will be similarly evaluated and open to faculty criticism. Chronic behavior of
this nature will not be tolerated.
60
Evaluations & Promotions
Criteria for Promotion, Probation & Termination (Further Detailed)
1.
March 1st is the cut off date by which time residents will be notified of promotion
or probation for the following academic year. Probation may be instituted earlier, at the
discretion of the faculty and program director.
2.
Promotion is dependent on fulfillment of the following criteria to the satisfaction
of the Faculty:
a.
Acquiring the specific cognitive, clinical, and operative skills for each level
of training, as stated by the various divisions and the RRC guidelines.
b.
Appropriate moral, ethical, and professional conduct.
c.
Attendance and participation in teaching functions.
d.
Acceptable performance on the Pediatric In-Service Training Examination.
“Acceptable” absolute (raw) scores and standardized scores will be
determined on an individual basis, taking into account level of training,
prior scores on standardized tests, and other aspects of clinical
performance.
3.
Any major departure from the Faculty’s standards of resident performance may
be judged grounds for TERMINATION without a preliminary PROBATIONAL PERIOD.
4.
Due process will be provided for any party potentially involved in dismissal
actions and for any Resident who has a grievance against the program.
5.
Due process will follow the procedure outlined in the Institutional GME policy.
Evaluation, Probation, Dismissal
At the end of each four-week rotation, residents are evaluated by the Attending Faculty
using New Innovations, Inc. software web-based system In addition, each resident
evaluates the senior or junior resident with whom he or she worked during that
rotation. Any problems noted in the evaluations are discussed with the resident by the
Chief Resident, Faculty Advisor, and/or Program Director.
Each resident has a Faculty Advisor who has access to all advisee evaluations. The
Faculty Advisor is expected to discuss evaluations with the resident. Twice a year, the
Program Director summarizes the residents’ progress in a written summary. The
evaluations of the residents by the faculty, their colleagues, the Chief Resident, and the
Program Director determine whether a resident will be advanced or whether any special
remedial measures would be instituted. Continuation in the training program is
dependent on satisfactory clinical performance.
Faculty Evaluations
Residents are required to complete an anonymous written evaluation of each faculty
member and an overall assessment of the residency education program at the end of
the academic year. The forms will be reviewed by the Program Director. These
evaluations will be used in making decisions about promotion and tenure for individual
faculty members. Faculty physicians are also evaluated by residents at the end of
61
each four-week rotation.
Suggested Reading List
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Standard Pediatric Textbooks (most recent versions)
(Rudolph, Nelson, Oski, etc.) - available on the FSU COM on-line library
Ask the sub-specialists for good references for their areas of interest
Guidelines for Health Supervision III
(Given to each PGY 1 - An AAP publication)
“The Trilogy” from AAP is a set of books for parents but practicing physicians and
residents in training would benefit from them:
A)
Caring for Your Baby and Your Child - birth to Age 5
B)
Caring for your School-Age Child - Ages 5 to 12
C)
Caring for your Adolescent - Ages 12 to 21
Pediatric and Adolescent Gynecology (Saunders) - available on the FSU COM online library
Clinical Pediatric Dermatology - Hurwitz (Saunders)
Pediatric Otolaryngology - Bluestone, Stool (Saunders)
Adolescent Medicine: Residency Training Resources (a handbook from AAP)
AMA Publication Guidelines for Adolescent Preventive Services
Assessment of Sexual States in Girls (Tanner) - AAP publication
Bright Futures (Guidelines for Health Supervision of Infants, Children and
Adolescents) published by National Center for education in maternal and child
health (Given to each PGY-1)
MEDICAL RECORDS AND DOCUMENTATION
Procedure Documentation
Throughout the three years of training, residents are expected to keep an accurate
record of their clinical experience. This is accomplished through the ACGME web site
under Resident Case Log System. (Please read section on residency procedure logs)
Medical Records
The medical record is an essential ingredient for good medical care. The record serves
many purposes and proper documentation; chart completion and respect for the
medical record are expected of all house staff. The medical record is, and always will
be, an important part of your medical career, so the time to develop good habits is
now!
It is the policy of the medical staff to ensure timely completion of medical records.
Incomplete records can compromise patient care and impede accurate and timely
billing. Incomplete records also violate JCAHO standards as well as state and federal
laws and regulations. (Please read above section on medical records.)
Documentation
•
Indicate patient’s full name and medical record number in the upper right corner
of all forms.
62
•
•
•
•
•
•
•
•
Write your note immediately after treating the patient. The longer you wait, the
less you will retain about the patient.
Be specific.
Sign, date and time all entries.
Do not use abbreviations unless they are listed in the approved abbreviation list
published by Health Information and Record Management.
Abbreviations are not acceptable for diagnoses and are not to be used on
informed consent forms. Choose your words carefully. The medical record is not
the place to vehemently disagree with a policy or a colleague.
Make alterations carefully; avoid obliterations or creating the appearance of
tampering. Cross off errors with a single line, ensuring the entry is still legible.
Date and initial the correction.
Write in black ink.
Write neatly so that another healthcare provider can read your entry in the
record.
Dictation
Tips For Would-Be Dictators
Do Not’s
•
•
•
•
•
•
•
•
•
DO NOT hold the microphone so close to your mouth that your voice is muffled.
DO NOT speak too loudly, too softly, or too hurriedly.
DO NOT speak too soon after pushing the pause button.
DO NOT dictate when chewing gum, eating food, or drinking.
DO NOT attempt to dictate in a crowded, noisy area.
DO NOT attempt to carry on other conversations when dictating.
DO NOT be resistant to constructive suggestions from secretaries or
transcriptionists.
DO NOT dictate over another letter.
DO NOT use unconventional abbreviations ( e.g., FOB, NKA ).
Do’s
•
•
•
•
•
•
•
•
•
Dictate discharge summaries at the time the patient is released from the
hospital.
When a discharge summary should be mailed to a referring physician, provide
the individual’s full name and address.
Enunciate words clearly.
Spell difficult words, such as the name of drugs and unusual medical disorders.
When appropriate, provide precise drug dosages and dosage intervals.
Indicate in your dictation when punctuation is necessary.
Indicate when a new paragraph should begin.
Use only conventional, widely accepted abbreviations.
Be brief, concise, and coherent. Avoid unnecessary verbiage. Try to limit letters
to one-page and discharge summaries to a maximum of two pages.
63
ADMIT H&P
Name
MR#
Date of Admission
Attending
CC:
HPI:
( Peds Staff or Intensivist )
Birth Hx:
weeks gestation
birth wt
delivery (SVD, C/Section, Forceps)
complications (STD, toxemia, illness, during delivery, etc.)
length of stay (ICN graduate, NBN)
chronological sequence of events
pertinent positives and negatives
detailed description of symptoms
(better, worse, duration, medication used, etc. )
PMH:
hospitalization, illness, accidents, exposures, surgeries
Current Medications
Allergies
(drugs/foods and their reactions)
Immunizations
Feeding/Dietary History (formula, etc.)
Developmental Hx: milestones for infants/children, school attending, current grade
and achievement
So Hx:
supply
live with and where (apartment, trailer, house), smokers, pets, water
F Hx:
CA, HTN, DM, sickle cell trait/dz, RAD, CVD, allergies
ROS:
pertinent, subjective positives and negatives (not in H&P)
PE:
General Appearance
VS & WT
Organ System
Lab Data:
( ABG )
X-Rays:
Assessment: (differential dx)
Plan:
(details)
64
Admit Orders
A = Admit to Peds Staff or ( Intensivist )
D = Dx ( in order of importance )
C = Condition
A = Allergies
V = VS ( q hour or shift )
A = Activity ( bed rest or ad lib, BR privileges )
N = Nursing ( strict I & O’s, daily wt., nasal suction, notify MD for fever, resp.
distress, etc. )
D = Diet ( NPO, clear liquids, soft, DFA (diet for age)
I = IVF (how much maintenance volume)
L = Labs ( CBC, BMP, METP, pH, Bld cult, x-ray, etc. )
M = Meds generic name with ( mg/kg/day or dose ) listed
O = Others (consults, labs to be followed from referring hospital )
Discharge Summaries/Notes
1.
Discharge Notes - All patients should have a discharge note on the chart on
the day of discharge
2.
Discharge Summaries - D/C summaries are required on all patients including
those admitted under Observation status (Program Policy)
3.
•
•
•
•
•
•
•
•
•
•
•
•
•
Discharge Summary Format:
Dictator’s name and service;
Attending physician’s name and address;
Referring physician’s name and address;
Patient’s name and medical record number;
Date of admission;
Date of discharge;
Chief complaint;
History of present illness/
Past medical history, brief admission history summary;
Family history;
Social history;
Review of systems if appropriate;
Physical examination;
65
•
•
•
•
•
•
•
Initial laboratory assessment;
Hospital course - include subsequent laboratory studies and diagnostic and
therapeutic procedures;
Final diagnoses;
Summary of procedures;
Condition on discharge;
Disposition and instructions to patient and family members; and,
Primary and secondary Dx.
Discharge Summaries should be dictated ON THE DAY OF DISCHARGE by the first,
second or third year resident directly responsible for the case. Timely dictation is an
essential part of training, since pediatric privileges at future hospitals will be suspended
in the event that medical records are not completed promptly.
All medical records must have a handwritten or dictated discharge summary (less than
48 hours stay a dictated summary is not required). A final progress note may be
substituted for a discharge summary in the case of patients with problems of a minor
nature who require less than a 48-hour period of hospitalization. A dictated discharge
summary is required on the Pediatric Service for any patient with hospital stays greater
than 48 hours.
The discharge summary concisely summarizes the reason for hospitalization,
significant findings, procedures performed, treatment rendered, condition of the patient
upon discharge, and any specific instructions given to the patient and family. For the
majority of patients, the discharge summary should be no more than 1-2 pages in
length. Be sure to include the full name and address of the referring physician so a
copy of the discharge summary can be sent to that individual.
66
Appendix I
FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
& SACRED HEART HOSPITAL
RESIDENT MOONLIGHTING POLICY
(ACGME references are to procedural documents available on-line)
1.1
The Purpose
The Florida State University College of Medicine (FSU COM), Sacred Heart Hospital (SHH),
Residency Training Program establishes this policy regarding resident moonlighting to ensure
program compliance with the Accreditation Council for Graduate Medical Education (ACGME).
The ACGME requires that the Sponsoring Institution have policies regarding professional
activities outside the educational program. (Institutional Requirement III.D.1.k.2)
2.1
General Policy
Individual residency programs are accredited by their Residency Review Committee (RRC) and
must adhere to RRC requirements regarding moonlighting. Although RRC’s vary, the general
scope is that any professional activities which are outside the established educational program
must not interfere with the resident’s established educational process or the quality care of
patients. Residents shall not be required to engage in professional activities outside the
educational program.
3.1
Common Definition
Moonlighting is defined as compensated clinical work performed by a resident during the time
that he/she is a member of a residency program. This policy addresses two categories of
moonlighting:
3.1.a Programmatic: The clinical work occurs within the specific residency program and
its participating institution(s), and is simply an extension of the same type and location of
clinical work performed as a requirement of the Graduate Medical Education (GME) program.
Programmatic moonlighting includes internal work only.
3.1.b Non-Programmatic: The clinical work is not an extension of the residency
program and its participating institution(s), and in no circumstance is the resident to hold
him/herself as an employee of the University while engaged in such activities. Nonprogrammatic moonlighting may include internal or external work.
4.1
Primary Responsibilities
4.1.1 Institution and Program
It is the responsibility of the program director to decide whether or not moonlighting will be
allowed. The program director must comply with the institution’s policies and procedures. The
conditions under which a resident may be allowed to participate in programmatic and/or nonprogrammatic moonlighting must meet ACGME requirements.
If a program director allows a resident to moonlight, a Programmatic Moonlighting Approval
Form is required if the moonlighting is programmatic, and a Non-Programmatic Moonlighting
Approval Form is required if the moonlighting is non-programmatic. The appropriate approval
form is then made a part of the resident’s file as required by the ACGME.
Because residency education is a full-time endeavor, the Program Director must approve and
monitor all moonlighting to ensure that moonlighting does not interfere with the ability of the
resident to achieve the goals and objectives of the educational program.
4.1.2 The Residents
The resident must be a current resident in the program, and must be in good standing.
67
Residents on J-1 visas may not moonlight, as mandated by the Educational Committee for
Foreign Medical Graduates (ECFMG).
A resident wishing to moonlight must obtain prior written approval from his/her program
director. (Ref. Section 4.1.1 above, para. 2)
Because residency education is a full time endeavor, residents must ensure that moonlighting
does not interfere with their ability to achieve the goals and objectives of their educational
program. Residents are responsible for ensuring that moonlighting and other outside activities
do not result in fatigue that might affect patient care or learning.
A resident’s failure to comply with the Moonlighting Policy is a breach of contract and grounds
for termination.
5.1
Programmatic Moonlighting
The Program Director must ensure, direct, and document supervision and faculty support
appropriate for the level of training of residents at all times. While performing these services,
residents are not to act as independent practitioners. Faculty schedules must be structured to
provide residents with continuous supervision and consultation.
Residents must be provided with efficient, reliable systems for communicating with supervising
faculty. Faculty are also responsible to recognize the signs of fatigue and adopt and apply
practices to prevent and counteract the potential negative effects.
6.1
Non-Programmatic Moonlighting
Residents must be licensed for unsupervised medical practice in the state where such activity
occurs, including DEA licensure as applicable and any other requirements for clinical privileging
at the employment site. There must be an exchange of permission letters between the Program
Director and appropriate staff at the institution where the moonlighting will occur if the
moonlighting is done externally.
Residents are not covered under the University’s professional liability insurance program as the
activity is outside the scope of University employment. The resident is responsible for his/her
own professional liability coverage (either independently or through the entity for which the
resident is moonlighting) and must provide documentation of such.
Non-programmatic moonlighting hours must be documented (including days, hours, location,
and brief description of type of service[s] provided).
7.1
Work Hours
All moonlighting hours must be documented, and they must comply with the written policies
regarding Duty Hours as per the training program, and the ACGME. The Program Director may
not approve residents for any internal moonlighting that requires residents to exceed the 80hour per week (on average per 4-week) rule or other provisions of the duty-hour requirements.
(Not applicable to non-programmatic external moonlighting).
8.1
Maintaining Approval
The Program Director will monitor resident performance in the Program to ensure that
moonlighting activities are not adversely affecting patient care, learning or resident fatigue.
The GME Committee will periodically review reports by the Program Director(s) regarding
moonlighting activity.
If at any time the Program Director determines that a resident’s moonlighting schedule is
adversely impacting the resident’s performance in the training program, the Program Director
68
may withdraw the permission to moonlight.
Approved By:
___________________________
Paul Baroco, M.D.
Chief Medical Officer
Sacred Heart Health System
Medicine
Pensacola, Florida
___________________________
Alma Littles, M.D.
Designated Institutional Official
Florida State University College of
Tallahassee, Florida
___________________________
Date
___________________________
Date
69
Appendix II
1115 West Call Street
Tallahassee, FL 32306-4300
Phone: 850.645.6867
Fax:
850.644.8924
PROGRAMMATIC MOONLIGHTING APPROVAL FORM
PARTS 1 & 2 TO BE COMPLETED BY THE RESIDENT:
Part 1: GENERAL INFORMATION:
Name __________________________________
Program
_______________________
Date
_________________________
Program Location ___________________ PGY ____
Part 2: I UNDERSTAND THE FOLLOWING:
All Moonlighting is voluntary, programmatic, and requires the approval of the Program Director;
Any resident who moonlights without permission will be subject to disciplinary action;
Moonlighting may not be done during duty hours and is not to interfere with my training, including my
learning and/or patient care;
My total work hours including residency and all moonlighting activities will not exceed 80 hours per
week, averaged over 4 weeks;
If my moonlighting activities contribute to undue fatigue, I will cease all moonlighting activities;
I am not to function as an independent practitioner during this activity. I will not function above my
level of training or without my usual faculty supervision; and
There will be periodic reviews of my residency training, and if it is less than expected, permission to
moonlight will be withdrawn;
I acknowledge that I have carefully read and fully understand the policies regarding programmatic
moonlighting as stated in this Approval Form as well as the Moonlighting Policy.
Resident Signature ___________________
Date ____________________
PART 3 TO BE COMPLETED BY THE PROGRAM DIRECTOR:
Part 3: DIRECTOR’S ATTESTATIONS:
The resident is not on academic probation;
The total hours in the resident’s educational program and the moonlighting activities will not
70
exceed the limits set forth by ACGME; and
This opportunity does not replace any part of the clinical experiences integral to the
resident’s training program, and the resident will be under faculty supervision while
engaging in moonlighting activities.
This approval form is valid for the current GME year only.
Rev. 3/1/07
Program Director Signature ___________________________________
Date ______________________
71
Appendix III
1115 West Call Street
Tallahassee, FL 32306-4300
Phone: 850.645.6867
Fax:
850.644.8924
NON-PROGRAMMATIC MOONLIGHTING APPROVAL
FORM
PARTS 1 & 2 TO BE COMPLETED BY THE RESIDENT:
Part 1: GENERAL INFORMATION:
Name ________________________
Program
Date
_______________________________
__________________ Program Location _____________________ PGY ___
Part 2: I UNDERSTAND THE FOLLOWING:
All Moonlighting is voluntary, non-programmatic, and requires the approval of the Program Director,
and any resident who moonlights without permission will be subject to disciplinary action;
Moonlighting may not be done during duty hours and is not to interfere with my training, including my
learning and/or patient care. My total work hours including residency and all moonlighting activities
will not exceed 80 hours per week, averaged over 4 weeks (not applicable to external nonprogrammatic moonlighting);
I am licensed for unsupervised medical practice in the state where such activity occurs, including any
other medical fees and/or requirements for clinical privileging at the employment site.
I understand I am not covered under the University’s professional liability insurance program and am
responsible for my own professional liability coverage (either independently or through the entity for
which I am moonlighting) and am attaching documentation of such;
If my moonlighting activities contribute to undue fatigue, I will cease all moonlighting activities; and
There will be periodic reviews of my residency training, and if it is less than expected, permission to
moonlight will be withdrawn;
I acknowledge that I have carefully read and fully understand the policies regarding non-programmatic moonlighting
as stated in this Approval Form as well as the Moonlighting Policy. Furthermore, I clearly understand and agree that
this non-programmatic activity is in no way related to my employment with the University and that the Florida State
University has no obligation, responsibility, or liability whatsoever for any injury or harm which I may incur or which
may befall me during my performance of or a result of this non-programmatic activity. Accordingly, I hereby release,
forever discharge, and waive any and all claims I may have now or in the future arising out of or connected with my
non-programmatic activities against the Florida State University, the State of Florida, the Department of Education for
the State of Florida, or the Board of Governors for the State of Florida, and any and all officers, agents, employees,
underwriters, and insurers, all individually and in their respective official capacities.
Resident Signature ___________________________________
Date ____________________________
PART 3 TO BE COMPLETED BY THE PROGRAM DIRECTOR:
Part 3: DIRECTOR’S ATTESTATIONS:
The resident is not on academic probation, and the total hours in the resident’s educational
program and the moonlighting activities will not exceed the limits set forth by ACGME; and
72
This opportunity does not replace any part of the clinical experiences integral to the
resident’s training program.
This approval form is valid for the current GME year only.
Rev. 3/1/07
Program Director Signature ___________________________________
Date ______________________
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Appendix IV
ORGANIZATIONWIDE POLICY - ONLINE DOCUMENT (9/9/09)
Policy Number HR
Title INTERNET
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SOCIAL NETWORKING AND BLOGGING
POLICY:
Sacred Heart Health System recognizes that technology of Internet Social Networking and/or the act of
“blogging” have become an increasingly popular activity. Sacred Heart takes no position on an associate’s
decision to start or maintain a personal website and/or blog, or to publish comments on online bulletin
boards or online forums. In general, what associates do on their own time is their own business. However,
activities in or outside of the workplace that affect an associate’s job performance, the performance of
others, or the Health System’s business
interests are a proper focus for Health System policy. The Health System has established Values and
Performance Standards that associates must adhere to when identified as Sacred Heart Health System
staff.
PROCEDURE:
1. If it Is deemed that an associate’s personal blog, or online bulletin board/online forum comments have a
negative impact on Sacred Heart, the nature and content of any website and/or blog posting will be a
factor in determining what (or whether) discipline action will be imposed. Violation of any of the following
may be grounds for discipline, up to and including termination, as outlined in the Progressive Discipline
Policy HR44:
A. Associates are not permitted to write online postings while on duty. Such action may be viewed
as an abuse of Health System time and inappropriate use of Health System computers.
Associates may also refer to the Electronic Communication (IM 2) policy.
B. Associates must be respectful in all communications and online postings related to or referencing the
Health System and/or its associates.
C. Associates must not use blogs or other online posting sites to defame the Health System and/or its
associates.
D. Associates must not use blogs or other online posting sites to harass, bully, or intimidate other
associates. Behaviors that constitute harassment and bullying include, but are not limited to,
comments that are derogatory with respect to race, religion, gender, sexual orientation, color, or
disability; sexually suggestive, humiliating, or demeaning comments; and threats to stalk, haze, or
physically injure another associate.
E. Associates must not post pictures of associates without obtaining permission from the associate.
No pictures, photographs or any identifying information pertaining to Health System patients,
patients’ families, or visitors may be posted without written consent of the family or patient, and
approval from the Marketing/Public Relations Department.
F. Associates are not authorized to speak on behalf of the Health System and, therefore must not do so
without written permission from the Health System’s Public Relations Director. Any postings
which in any way pertain to the Health System should clearly state that they represent personal
views and opinions of the associate and do not represent Health System positions or opinions.
G. Associates are prohibited from posting or referring to confidential information concerning patients or
Health System business on any internet site. Associates may not identify patients or discuss any
confidential information about patients. Associates may not comment on confidential financial information
of the Health System, including but not limited to business performance, strategic plans, budgets, and the
like.
2. Laws against defamation, libel, slander and privacy apply to blogging. Associates could be subject to
legal action for spreading disparaging and untrue information related to the Health System or for defaming
another person.
A. Defamation is generally defined as a false accusation or malicious misrepresentation that causes
someone to be shamed, ridiculed, held in contempt, lowered in the estimation of the community, or to lose
employment status or earnings or otherwise suffer a damaged reputation. Libel and slander are
defamation.
B. Associates who publish information regarding a person’s medical, financial or personal life could be
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subject to a claim for violation of privacy and/or violation of HIPAA privacy regulations.
C. Blogging under an alias provides no protection against legal action, because administrators of
blogging websites may be forced by court order to reveal the blogger’s identity.
Originated:
Reviewed Date
Karen Emmanuel, General Counsel 12/2007
Karen Emmanuel, General Counsel 03/2008
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Updated 12/3/2010
Appendix V
POLICY: SUPPORT FOR RESIDENT PHYSICIANS WITH IMPAIRMENT
DEFINITION
For the purpose of this policy and procedure, impairment is defined as a condition which is, or
may be, adversely affecting patient care, including, but not limited to: alcoholism/alcohol abuse,
other drug addiction, sexual misconduct and/or harassment, physical or medical conditions,
psychiatric disorders, emotional disorders or behavioral disorders.
PURPOSE
The purpose of this policy is:
1. To establish a process to identify and manage matters of individual resident physician
impairment, separate from the medical staff disciplinary function.
2. To establish a mechanism of reporting for any individual with a reasonable suspicion that a
resident physician is impaired.
3. To provide a process that offers support and compassion to the affected resident physician.
POLICY
1. This policy places the highest priority on protection of the patient, while promoting prompt
referral for evaluation, treatment and support for resident physicians.
2. The sponsoring institution and each program are responsible for monitoring residents for
signs of psychological, medical or substance abuse problems that may be causing impairment,
and for initiating appropriate interventions. The FSU COM has contracted (via the Employee
Assistance Program of Florida State University) with LifeWorks, an organization that provides
24/7 access to free confidential help with personal and work-related problems, and which can
assist residents with almost any issue, including: Life; Family; Money; Work; and Health.
Residents may phone toll-free to speak with a LifeWorks consultant, or they may visit the
website www.lifeworks.com to find the help and resources needed. (See Attachment 1 for further
details).
3. The FSU COM conforms to the Florida Medical Practice Act (F.S. 458), which provides for the
Impaired Practitioners Program, which is administered through the Professionals Resource
Network (PRN). PRN works closely with the State Board of Medicine and is recognized as the
primary mechanism for providing assistance to impaired physicians in the state. Information on
the PRN and its program can be obtained by calling 1-800-888-8776 or by writing to the PRN at
P. O. Box 1020, Fernandina Beach, FL 32035-1020.
4. It is the intent of the FSU COM that all appropriate rules that govern the practice of medicine
and all FSU COM related polices be strictly enforced.
a. Each program will provide an educational program to its residents regarding substance abuse
and other impairment and available assistance.
b. A resident physician whose behavior is consistent with substance abuse or other impairment
may be required by his/her Program Director to submit to a drug screen. Drug screens will be
performed by Sacred Heart Hospital Human Resource Office Personnel.
i. Behavior indicating substance abuse may include:
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1. Observed impairment of job performance.
2. Abnormal conduct or erratic behavior.
3. A serious workplace accident or number of minor workplace accidents.
4. Evidence of drug tampering in the employee’s workplace.
5. Arrest or conviction on an alcohol- or drug-related offense.
c. All referrals to the PRN are confidential and are evaluated by the professionals of the PRN.
Decisions about intervention, treatment and after care are determined by the PRN.
d. As long as the resident physician satisfactorily participates in the PRN program, no regulatory
action would normally be anticipated by the Board of Medicine.
e. Resumption of clinical activity and residency program training will be contingent upon the
continued successful participation in the PRN and continuation of the resident in the program will
be determined in consultation between the program director, DIO and the professionals at the
PRN.
PROCEDURE
1. Resident physicians with a past or current history of drug or alcohol addiction, or mental or
physical health condition that may impact patient care should report such condition to PRN.
2. Faculty, staff, peers, family members or other individuals who suspect that a member of the
housestaff is suffering from a psychological, medical or substance abuse problem impacting
patient care are obligated to report such problems. Individuals suspecting such impairment can
discuss their concerns with the Program Director, Chief of Medical Staff at SHH and/or the DIO,
or may report it directly to the Professionals Resource Network (PRN).
3. Residents meeting any of the above criteria in 4b, or other reasonable criteria utilized by the
Program Director, may be required by the Program Director to submit to a drug test. Refusal or
failure to submit to a timely drug test is sufficient cause for termination of employment.
4. The resident will be relieved of his/her duties and will be given a specific time (generally less
than two hours) that he/she is to report to the testing facility. Failure to report at the specified
time, without pre-approval of the Program Director, is sufficient cause for immediate termination.
In the event that the resident is obviously impaired, consulting staff members will make
arrangements to provide transportation to the testing facility.
5. The Designated Institutional Official should be promptly notified. Suspicious behavior should
be documented on the form appended to this policy (Attachment 2). This form is to be retained in
the resident’s confidential personnel file.
6. The submitted sample (blood, hair and/or urine, as appropriate) will be screened. If an initial
screen returns a positive result, a confirmatory test on the same sample will be conducted. If the
confirmatory test is also positive, the result will be turned over to the Program Director. All
sample collections for drug tests conducted for cause will be performed under observation.
7. Test results will be granted confidentiality in accordance with all federal and state laws and
residency policy. Tests will be performed at the Sacred Heart Hospital Human Resource Office
and will be paid for by SHH. Notification of any other agency or licensing board will be
accomplished by the Residency Director in accordance with this policy.
8. Applicants may be asked to provide information as necessary to interpret drug screen results.
Such information will be considered confidential.
9. Attempts to alter or substitute a specimen will be cause for immediate termination, even if the
attempt is discovered at a later date.
10. The Program Director will schedule an appointment with the resident to discuss with him/her
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the results and will inform the DIO and other hospital administration as appropriate.
11. Along with the DIO and hospital administration as appropriate, the Program Director will
determine the appropriate action necessary which will include prompt referral to with the
Employee Assistance Program (EAP) / Lifeworks and PRN, and depending upon the
circumstances may include immediate termination, while adhering to the ADA.
12. The Program Director will determine the resident’s ability to continue in the program and/or
remain in patient care activities after consultation with the professionals at EAP and the PRN.
Any resident terminated for cause will be ineligible for rehire for a minimum of six months, may
be more if situation indicates longer term.
Florida State University College of Medicine
Graduate Medical Education
Policies and Procedure
Rev. 6/18,2010
78
ATTACHMENT A
A
79
ATTACHMENT A cont.
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ATTACHMENT B
Program Director Documentation Form
Organization:
Time of Call:___________________
Program:
Supervisor:
Telephone:
Title:
Beeper/Other:
Other Faculty:
Telephone#:
Title:
Beeper/Other:
Employee:
Job Title:
Length of Service:
Behavior
Observed
Date
Yes
No
CONSENT TO RELEASE OF DRUG TEST RESULTS
I, the undersigned resident physician at the Florida State University College of Medicine/Sacred
Heart Hospital Residency Program(s) hereby acknowledge and agree as follows:
As a resident employee, I am bound by the Graduate Medical Education “Support for Resident
Physicians with Impairment” Policy;
This policy may require me to submit to periodic drug testing;
I hereby consent to and expressly authorize the release by Hospital of any of my drug test
results to the FSU COM; and,
I hereby forever release Hospital from any and all liability, claims or causes of action which might
otherwise accrue against Hospital and which arise from or are related in any way to Hospital’s
release of my drug test results to the FSU COM.
IN WITNESS WHEREOF, I have executed this Consent to Release of Drug Test Results
effective as of the date set forth below.
__________________________________
Signature
__________________________________
Print Physician Name
__________________
Date
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