please type (handwritten applicaton will not be accepted). · copy of current cv/resume copy of...

ROTATING RESIDENT/FELLOW CHECK LIST

Name of Resident/Fellow __________________________________________________________

Dates of Rotation _______________________until_________________________________________

Home Institution _________________________________________________________________

The following information must be attached when submitting your application to Laura Daly, House Staff Affairs Coordinator, in the Medical Education Office for processing:

Affiliation Agreement and/or Program Letter of Agreement (PLA)

Rotating Resident & Fellow Allegra Request application must include all the following documents:

Copy of Current CV/ResumeCopy of Medical License (Controlled Substance License required with Permanent Medical License) Copy of DEA License or letter indicating that DEA is privided by home institution (include number) Copy of ECFMG certificate (Foreign Graduates Only)Signed CareConnection/Confidentiality Statement National Provider Identifier Number (NPI) Current TB/Immunization History (proof of immunization must be attached) Proof of Malpractice coverage - certificate required with AIMMC listed for rotation dates Letter of Good Standing Copy of Current ACLS/BLS Card AIMMC Program Director’s Signature

”Universal Protocol Video” must be viewed by all residents/fellows. Documentation of review should be forwarded to the Office of Medical Education at AIMMC within 24 hours or the resident/fellow will not be able to stay on the rotation. (Click here to view the Universal Protocol Video)

Clearance Form - must be completed on last day of rotation.

To obtain NPI #: https://nppes.cms.hhs.gov/NPPES/Welcome.do

Updated 04/2016

Please type (handwritten applicaton will NOT be accepted).

AIMMC Program Name: ______________________________________________________________

First Name Middle Name Last Name

mm/dd/yy mm/dd/yy

https://nppes.cms.hhs.gov/NPPES/Welcome.do

https://adobeformscentral.com/?f=5adjljsKme90lIsDNOrgUA

http://www.screencast.com/t/SfsqJX1LkD9v

ROTATING RESIDENT & FELLOW ALLEGRA REQUEST

For Use ONLY at Advocate Illinois Masonic Hospital H o m e I n s t i t u t i o n : R e q u e s t e d R o t a t i o n :S t a r t D a t e : E n d D a t e :

RESIDENT & FELLOW BIOGRAPHICAL INFORMATION Last Name First Name Middle MD DPM DO Other_______

Ethnic Origin/Race Visa Status Birth Date & Place Gender M F US PR J-1 Other _________

Current Street Address City State ZIP Code Social Security Number Home Phone No. ( )

Pager No. Cellular No. E-mail ( ) ( ) MEDICAL SCHOOL INFORMATION City/State/Country Name of School Start Date End Date

RESIDENCY/FELLOWSHIP TRAINING From-To(mm/dd/yy) Name of Institution Type of Training/Program PGY Level

Current PG Level PGY- IN CASE OF EMERGENCY Name of Friend or Relative Relationship to

Resident/Fellow Home Phone No. Work Phone No. Cellular No.

( ) ( ) ( )

OPERATING ROOM ACCESS REQUEST Operating Room Access

Yes No OR Locker Room Access

Yes No OR Orientation Request

Yes No The following information MUST be attached to this form prior to you starting ANY rotation.

Copy of Current CV/Resume Letter of Good Standing Copy of Licenses: Medical/Controlled Substance /DEA Signed CareConnection/Confidentiality Statement Copy of ECFMG certificate (Foreign Graduates Only) NPI Number Proof of Malpractice coverage Copy of Current ACLS/BLS Card Current TB/Immunization History (attach proof of immunization – Flu Vaccine and TB done within the last 12 months)

X

AIMMC Program Director Approval signature for rotating resident/fellow Date X

Director of Medical Education Approval signature Medical Education Office Use Only

Date Updated 04/2016

Allegra Number __________ Universal Protocol Video Date _________ P&P Date ________ Clearance Date ________

ADVOCATE HEALTH CARE System Access Request/Change/Termination Form

CC

ms

CC

ms

CC ms Care Connection - Resident/Fellow CC ms (Please print and write legibly. The Bold and * items are required)

*Hospital, Choose one only: Condell (CND) Christ (CMC) Shepherd (GSH) Good Sam (GSA) Lutheran (LGH) Masonic (IMC) South Sub (SSH) Trinity (TRI)

*Name: ______________________________________ _________________________ _____________________________________(First) (Middle)

Credentials (circle one): MD DO DDS DPM PsyD PhD

(Last)

IL license number: ____________________________

Allegra number: ______________________________________

Request type: Addition Change Deletion

Effective date: ___ ___ / ___ ___ / ___ ___ ___ ___ Expiration date: ___ ___ ___ ___ ___ ___ ___

Confidentiality Agreement: As a non-employee of Advocate Health Care, you or your representatives may have access to patient, medical record, employee or other confidential information. As a condition to being granted such access, you are required to agree to the following:

I understand that in the course of my working relationship with Advocate Health Care, I share the responsibility of maintaining the confidentiality of any patient, medical record or employee information that I may have available to me. I understand that it is my responsibility to follow Advocate Health Care policies and procedures as they relate to the assurance of patient rights and the confidentiality of information both written and verbal.

Computer Systems: I understand that I may receive a unique User-Id and a personal password necessary for me to gain access to an Advocate Health Care computerized system. I understand and agree that both the User-id and my Password are for my own personal use and are not to be disclosed to or used by third parties. If at any time I feel that the confidentiality of my User-id or password has been compromised, I will contact appropriate management (Advocate employee that approved your access) for direction within 24 hours.

Conduct and Confidentiality: I understand that I must maintain the confidentiality of any written or oral patient, medical record or employee information that I have access to or view as a result of my working relationship with Advocate Health Care. I understand that the release of patient, medical record or employee information of any kind is only allowed by Advocate Health Care policy guidelines. If I am uncertain or do not understand the Advocate Health Care policy guidelines, I will contact the appropriate Advocate manager (Advocate employee that approved your access) for assistance and direction within 24 hours. I agree to only release patient, medical record or employee information under the Advocate Health Care policy guidelines or as required by law.

Patient, Medical Records and Employee Information: I acknowledge that all information involving patients, medical records and employee information is private and confidential. I agree that I shall access only that data necessary for the proper performance of my job responsibilities under my business relationship with Advocate Health Care. I further agree to keep confidential any and all information that I access, receive or transcribe, and not to disclose any such information to third parties. I am aware, that, unless specifically identified as part of my job by “Advocate Health Care”, I am not authorized to discuss any information concerning a patient’s or employee’s personal data or medical condition. I am responsible for ensuring that discussions regarding patient, medical record and employee information are held in appropriate locations with only authorized individuals.

Any unauthorized disclosure on my part or my representatives will be a very serious offense to Advocate Health Care. Such unauthorized disclosure may result in Advocate’s repossession of all of my or my representative’s access to patient, medical record and employee information, Advocate may also act up to and including termination of my business relationship with Advocate and asserting its full rights under the law.

*Resident/Fellow Signature _______________________________________________ Date ______________________________

Access Required:

Emergency Medicine Resident = ED Resident/Inter w/Order Entry

OB, Anesthesia and All Other Specialties Resident or Fellow = Profile: PN Res/Intern w/Order Entry

*Does this Resident/Fellow require access to psychiatric (confidential) units? X YES *Reason: Needed for Patient Care

Authorized by: (Please make sure all of the above are correct) (Upon receipt please allow 3 to 4 business days to complete this request)

Print Name: ___Laura Daly_____________________________________________________________________________________

Title/Dept: ___Medical Education______________________________ Phone #: __773-296-5944_______________________

_______________________________________________________ Date: _____________________________________ (**Authorizing Signature**)

Scan completed form and send by email ([email protected]) or fax (630-575-5395 c/o IS Security)

( For Information Systems Security Administration Use Only )

Completed by: ______________________________________________________ Date: __________________________

November 11, 2013 Version 2 ~ Confidential ~ CareConnection

mailto:[email protected]

IMPLEMENTING THE Universal Protocol Policy/Time out Video

Residents rotating at AIMMC

IMMC’s Hospital policy mandates the video MUST be viewed within 24hrs of starting the rotation. Residents not complying with this request will not be able to rotate.

DATE VIDEO VIEWED:_____________________________________________

Name of Rotation:_______________________________________________________

Resident Name (Please Print):_____________________________________________

Resident Signature:______________________________________________________

E-mail:________________________________________________________________

Phone or Cell Phone #:___________________________________________________

Resident must receive from coordinator the following: • Culture of Safety ID Card ______ (Resident’s initials) • Dangerous Abbreviations Do Not Use ID Card ______ (Resident’s initials)

Coordinator Initials: ______________

Previously Viewed on_________________ If a resident is returning to AIMMC for a rotation and the Universal Protocol Video was viewed during the previous rotation please list the viewing date above. Residents are only required to view the video once.

http://immconline.advocatehealth.com/homepage.cfm Under Culture of Safety - click on <more>: Universal Protocol Video

Fax copy to Medical Education at 61-5051 Original for Coordinator

http://immconline.advocatehealth.com/homepage.cfm

Effective 7/2015

ADVOCATE HEALTH CARE MEDICAL EDUCATION STUDENT/RESIDENT MEDICAL & IMMUNIZATION CLEARANCE FORM

This form must be completed in its ENTIRETY and on file 4 weeks before the rotation start date.

Name: SSN:(last 5 digits)

Address: Street City, State Zip Code

Phone: DOB ___/___/___ College/Univ./Sponsor Hosp.:

AHC Hospital/Rotation: Rotation Dates:

REQUIRMENTS

TB Surveillance:

a.) Skin Testing: Last TB skin test OR Quantiferon (QFT) test must be done WITHIN ONE CALENDAR YEAR OF THE ROTATION END DATE. Skin test result MUST be read in mm of induration.

b.) If TB skin test OR QFT is/was POSITIVE, the student MUST attach a copy of a negative CXR report. In addition, if a student/resident has had a positive TB screening in the past he/she MUST attach a copy of the Advocate annual screening questionnaire completed within one year of the rotation start date.

DATE of last TB skin test: RESULT in mm:

DATE of last QFT: RESULT:

TB Mask Fit Testing: Required prior to rotation start date; must be specific for the mask listed Required Brand: Kimberly Clark Tecnol Fluid Shield PFR95 N95 Particulate Filter Respirator TB Mask Fit Test Date: ____/____/____ Size (circle one): Regular/Model #46767 or Small/Model #46867

Immunization Record: Circle Results

Rubella Immunity Status Rubella Titer: Date____/____/____ Result: Immune / Non Immune - or Proof of Vaccination: Date # 1 ____/____/____ # 2 ____/____/____

Rubeola Immunity Status Rubeola Titer : Date ____/____/____ Result: Immune / Non Immune - or Proof of Vaccination: Date # 1 ____/____/____ # 2 ____/____/____

Mumps Immunity Status Mumps Titer: Date ____/____/____ Result: Immune / Non Immune - or Proof of Vaccination: Date # 1 ____/____/____ # 2 ____/____/____

Varicella Immunity Status Varicella Titer: Date ____/____/____ Result: Immune / Non Immune - or Proof of Vaccination: Date # 1 ____/____/____ # 2 ____/____/____

Hepatitis B Immunity Status Hepatitis B AB Titer: Date ____/____/____ Result: Positive / Negative Hepatitis B Vaccination: Date #1____/____/____ # 2 ____/____/____ # 3 ____/____/____

Tetanus/Diphtheria/Pertussis (Tdap): Date vaccinated ____/____/____

Flu Vaccine: Current flu season vaccine required prior to rotations occurring between 10/1 and 4/30. Date vaccinated ____/____/____

The information provided on this questionnaire is accurate to the best of my knowledge. I understand and agree that any misrepresentation or omissions may be justification for denial of student/resident privileges. I authorize Advocate Heath Care to verify any information contained in this health history.

Signature Date

Please return this form to the appropriate personnel of the Hospital Department/Program where you will be rotating.

ROTATING RESIDENT/FELLOW CLEARANCE FORM

In order to be released officially from Advocate Illinois Masonic Medical Center the following areas must be cleared/signed by all the respective departments.

Residents Name: __________________________________________ Rotation: ____________________

Dates of Rotation: _______________________________________________________________________

1. Medical Library:(Room 7501) (Ext. 61-5084)

___________________________________________Date:_________________________ OFFICE HOURS: (M-TH 8:00am to 6:00pm, F 8:00am to 5:00pm

Closed Weekends and Holidays)

2. PagersCommunications: Room (G-240) (Ext. 61-5211)

___________________________________________Date:_________________________ OFFICE HOURS: (24 Hours)

3. HIM-Medical Records:(Room G-130) (Ext. 61-5191) (Alternate ext.’s

___________________________________________Date:_________________________ OFFICE HOURS: (M-F 8:00am-4:30pm – Closed Weekends and Holidays)

61-5178 & 61-5438)

4. IMMC I.D. Badge:($10.00 Fee if Lost) Support Center (Room G-706)

___________________________________________Date:_________________________ OFFICE HOURS: (M-F 7:00am to 4:00pm – Closed Weekends and Holidays)

5. DEPARTMENT- Residency Coordinator: ___________________________________________Date:________________________

Fax copy to Medical Education at 61-5051 Original for Coordinator

Please read the following policies prior to starting your rotation:

1. Graduate Medical Education Policy on Supervision

2. Transitions of Care – Patient Handoff

3. Resident Employment Outside the Residency Program, i.e., ResidentMoonlighting

4. Integrated Quality and Patient Safety Plan

5. Duty Hours and Call Schedules for Residents

6. Implementation of Universal Protocol

7. House Staff Compliance with Timely Completion of Medical Record

8. Advocate Health Care Handwashing Expectations

I ,______________________, reviewed all seven policies on ____________

(full name and signature) (date)

Template Date: 05/15/2014

Advocate Health Care

Title: Graduate Medical Education Policy on Supervision

Policy Procedure Guideline Other:

Scope: System Site: Department: Graduate Medical Education

I. PURPOSE

To provide guidelines for the supervision of residents and fellows who are training in Advocate Health Care System.

II. POLICY

Advocate Health Care (Advocate) will provide a clinical learning environment thatpromotes appropriate supervision and progressive responsibility for residents.This clinical learning environment will include:

An identifiable, appropriately credentialed and privileged attending physician who is ultimately responsible for each patient assigned to a resident.

Patient attending physician information is available to residents, faculty and patients.

Residents and faculty will inform patients of their respective roles in each patient’s care

A mechanism by which residents and/or ancillary staff can report inadequate supervision in a protected manner.

Each residency program must have a written supervision policy that is available to residents in the Program Handbook and that is on file in the Graduate Medical Education Office.

Any Advocate sponsored program that does not have specific accreditation requirements related to supervision will comply with the ACGME Common Program Requirements.


III. DEFINITIONS/ABBREVIATIONS

Resident: a physician in an accredited graduate medical education program,including interns, resident sand fellows

IV. PROCEDURE

Program Supervision PolicyThe Program Director shall provide explicit written descriptions of lines of responsibilityfor the care of patients, which shall be made clear to all members of the teaching teams.Residents shall be given a clear means of identifying supervising physicians who shareresponsibility for patient care on each rotation. In outlining the lines of responsibility, theProgram Director will use the following classifications of supervision:

Direct Supervision: the supervising physician is physically present with the residentand patient.

Indirect Supervision, with Direct Supervision immediately available: the supervisingphysician is physically within the hospital or other site of patient care and is immediatelyavailable to provide Direct Supervision.

Indirect Supervision with Direct Supervision available: the supervising physician isnot physically present within the hospital or other site of patient care but is immediatelyavailable to provide Direct Supervision.

Oversight: the supervising physician is available to provide review ofprocedures/encounters with feedback provided after care is delivered.

Supervision shall be structured to provide residents with progressively increasingresponsibility commensurate with their level of education, ability, and attainment ofspecialty specific competencies and/or milestones. The Program Director, in conjunctionwith the program’s faculty members, shall make determinations on advancement ofhouse officers to positions of higher responsibility and readiness for a supervisory role inpatient care and conditional independence through assessment of competencies basedon specific criteria (guided by national standards-based criteria when available).

Faculty members functioning as supervising physicians should assign portions of care toresidents based on the needs of the patient and the skills of the resident. Based onthese same criteria and in recognition of their progress toward independence, seniorresidents or fellows should serve in a supervisory role of junior residents.

Each program must set guidelines for circumstances and events in which residents mustcommunicate with appropriate supervising faculty members, such as after-hours cliniccall, the transfer of a patient to an intensive care unit, taking a patient to surgery, or end-of-life decisions. Each resident must know the limits of his/her scope of authority and thecircumstances under which he/she is permitted to act with conditional independence.

Each Advocate program will use E*Value as the means for residents, faculty, nurses andother clinical staff to identify which procedures a resident is privileged to perform andunder what level of supervision. E*value is accessed from the Advocate home page.


Residents will be assigned a faculty supervisor for each rotation or clinical experience (inpatient or outpatient). The faculty supervisor shall provide to the Program Director a written evaluation of each resident’s performance during the period that the resident was under his or her direct supervision. The Program Director will structure faculty supervision assignments of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility.

GMEC Monitoring of Supervision The Advocate GMEC will monitor supervision by:

Maintaining an updated supervision policy for each residency program in the central GME Office,

Monitoring of the annual ACGME Survey Results (for ACGME programs), Monitoring and reviewing any Safety reports that involve resident workload or

supervision issues, Monitoring and reviewing resident reporting of concerns through the Advocate hotline or Confidential Resident reporting Form.

V. CROSS REFERENCE

VI. REFERENCES

ACGME Institutional Requirements www.acgme.org (Section IV.I) ACGME Common Program Requirements www.acgme.org (Section VI. D) AOA Basic Documents for Postdoctoral Training www.osteopathic.org (Section VII, I Trainee Supervision Policy) CODA Commission on Dental Accreditation www.ada.org/coda (Section 3.) CPME Council on Podiatric Medical Education www.cpme.org Section 6.9)

VII. RELATED DOCUMENTS/RECORDS


Title: Transitions of Care—Patient Handoff

[x] Policy Procedure Guideline Other ______________ Scope: System [x] Site IMMC Department: Medical Education

I. PURPOSE

To establish a protocol and standards within Advocate Illinois Masonic Medical Center Training programs (residency and fellowship) to ensure the quality and safety of patient care when transfer of responsibility occurs during duty hour shift changes, during transfer of the patient from one level of acuity to another, and during other scheduled or unexpected circumstances.

II. POLICY

Individual programs must have a policy addressing transitions of care. Faculty and trainees must be aware of their Department policy. Individual programs should provide instruction to and review Departmental processes with trainees regarding handoff of care. Individual programs must design schedules and clinical assignments to maximize the learning experience for residents as well as to ensure quality care and patient safety, and adhere to general institutional policies concerning patient safety and quality of healthcare delivery. Individual programs should evaluate trainees in their capacity to perform a safe, effective, and accurate handoff of care. Recommendations for implementation of this policy can be found in the Protocol for Implementation of the Transitions of Care Policy. PROTOCOL FOR IMPLEMENTATION OF TRANSITIONS OF CARE-PATIENT HANDOFF POLICY The transition/hand-off process should involve face-to-face interaction with both verbal and written/computerized communication, with opportunity for the receiver of the information to ask questions or clarify specific issues. The hand-off process may be conducted by telephone conversation. Voicemail, text message, and/or any other unacknowledged message are not an acceptable form of patient hand-off. A telephonic hand-off must follow the same procedures outlined in this Section, and both parties to the hand-off must have access to the electronic medical record and an electronic or hard copy version of the sign-out evaluation.

Patient confidentiality and privacy must be guarded in accordance with HIPAA guidelines.

1. The transition process should include, at a minimum, the followinginformation in a standardized format that is universal across allservices.

SBAR format (Situation, Background, Assessment, Recommendations) is one such format, or providing the following information:

Essential Elements for Successful Handoffs

Each physician team should be assigned a distinctive name and color (as appropriate).

List all staff names and other team members with pager numbers, including covering attending physicians if applicable.

Include complete patient identification (full name, age, sex, race, location, Social Security number or hospital number), date of admission, and location. At least two forms of identification should be listed to avoid mistakes of patient identity in case a procedure needs to be performed while on-call.

Add a one-or-two-sentence assessment of the patient’s presentation.

Include an active problem list plus a pertinent past medical history. List all active medications. List allergies. Supply information on venous instrumentation and access, status of

access, and any actions to be taken if access changes. Include the patient’s code status. Include pertinent laboratory data. List your concerns for the next 18-24 hours and a recommended

course of action. For the intensive care unit, use a system-based approach. For the general medical wards, use a problem-based approach.

Consider listing the long-term plans, as family may visit in the evening during off-hours to discuss this issue with covering house staff.

Discuss any psychosocial concerns that may influence therapeutic choices.

ANTICIpate

Administrative data New information (clinical update) Tasks (what needs to be done)

Illness Contingency planning/code status

HANDOFF

Hospital location: wing, room number Allergies/adverse rx/medications Name (age, gender)/number (MR) DNR/diet/DVT prophylaxis Ongoing medical/surgical problems Facts about the hospitalization Follow-up on Scenarios

SIGNOUT

Sick or DNR (code status) Identifying data (name, age, gender, dx) General hospital course New events of the day Overall health status/clinical condition Upcoming possibilities with plan, rationale Tasks to complete overnight with plan

2. Each residency program must develop components ancillary to the

institutional transition of care policy that integrate specifics from their specialty field. Programs are required to develop scheduling and transition/hand-off procedures to ensure that:

Residents comply with specialty specific/institutional duty hour

requirements . Faculty are scheduled and available for appropriate supervision

levels according to the requirements for the scheduled residents. All parties (including nursing) involved in a particular program

and/or transition process have access to one another’s schedules and contact information. All call schedules should be available on department-specific password-protected websites and also with the hospital operators.

Patients are not inconvenienced or endangered in any way by frequent transitions in their care.

All parties directly involved in the patient’s care before, during, and after the transition have opportunity for communication, consultation, and clarification of information.

Safeguards exist for coverage when unexpected changes in patient care may occur due to circumstances such as resident illness, fatigue, or emergency.

Programs should provide an opportunity for residents to both give and receive feedback from each other or faculty physicians about their handoff skills.

3. Each program must include the transition of care process in its curriculum.

4. Residents must demonstrate competency in performance of this task.

There are numerous mechanisms through which a program might elect to determine the competency of trainees in handoff skills and communication. These include:

Direct observation of a handoff session by a licensed independent

practitioner (LIP)-level clinician familiar with the patient(s). Direct observation of a handoff session by an LIP-level clinician

unfamiliar with the patient(s). Either of the previous, by a peer or by a more senior trainee. Evaluation of written handoff materials by an LIP-level clinician

familiar with the patient(s). Evaluation of written handoff materials by an LIP-level clinician

unfamiliar with the patient(s). Either of the previous, by a peer or by a more senior trainee. Didactic sessions on communication skills including in-person

lectures, web-based training, review of curricular materials and/or knowledge assessment.

Assessment of handoff quality in terms of ability to predict overnight events.

Assessment of adverse events and relationship to sign-out quality through:

Survey Reporting hotline Trigger tool Chart review

5. Programs must develop and utilize a method of monitoring the transition of

care process and update as necessary. Monitoring of handoffs by the program to ensure:

There is a standardized process in place that is routinely followed. There is consistent opportunity for questions. The necessary materials are available to support the handoff

(including, for instance, written sign-out materials, access to electronic clinical information).

A quiet setting free of interruptions is consistently available, for handoff processes that include face-to-face communication.

Patient confidentiality and privacy are ensured in accordance with HIPAA guidelines; this includes the appropriate disposal of any written material in HIPAA-compliant receptacles, and encryption of any electronic devices used during the handoff process.

6. Programs should evaluate trainees in their ability to communicate patientinformation clearly, accurately, and responsibly to support the safetransfer of care from one provider to another.


A transition of care (“handoff”) is defined as the communication of information tosupport the transfer of care and responsibility for a patient/group of patients fromone service and/or team to another. The transition/hand-off process is aninteractive communication process of passing specific, essential patientinformation from one caregiver to another. If utilizing email for writtencommunication, only Advocate email is approved. Transition of care occursregularly under the following conditions:

Change in level of patient care, including inpatient admission from the ambulatory setting, outpatient procedure, or diagnostic area.

Inpatient admission from the Emergency Department. Transfer of a patient to or from a critical care unit. Transfer of a patient from the Post Anesthesia Care Unit (PACU) to

an inpatient unit when a different physician will be caring for that patient.

Transfer of care to other healthcare professionals within procedure or diagnostic areas.

Discharge, including discharge to home or another facility such as skilled nursing care.

Change in provider or service change, including resident sign-out, inpatient consultation sign-out, and rotation changes for residents.

IV. PROCEDUREN/A

V. CROSS REFERENCE N/A

VI. REFERENCESN/A


Systematic Review of Handoff Mnemonics Literature.

Lost in Translation: Challenges and opportunities in Physician-to-Physician Communication During Patient Handoffs.


Title: Resident Employment Outside the Residency Program, i.e., Resident Moonlighting (Dept)

[x] Policy Procedure Guideline Other ______________

Scope: System [x] Site IMMC Department: Medical Education

I. PURPOSE

This policy establishes a uniform policy and procedure regarding the conditions under which House Officers may perform moonlighting activities. This Policy is applicable to all House Officers enrolled in any of the Hospital’s GME Programs. The term “House Officer” shall include interns, residents or fellows (hereinafter “Trainees”). It is the aim of this policy to ensure that all GME programs adhere to the GMEC approved policy and ACGME requirements for Resident Employment outside the Residency Program.

“Moonlighting,” includes the performance of clinical activity, which is beyond the duties usually performed by a Trainee in the Hospital GME Program, regardless to where the practice occurs or the source of compensation.

II. POLICY

Applies To: This policy applies to the all Graduate Medical Education (GME)programs.

Moonlighting activities are not included as part of the educational program in theresidency/fellowship programs. Moonlighting activities must not interfere with theability of the resident to achieve the goals and objectives of the educationalprogram. Time spent by residents in Internal and External Moonlighting (asdefined in the ACGME Glossary of Terms) must be counted towards the 80-hourMaximum Weekly Hour limit. PGY-1 residents are not permitted to moonlight.


See ACGME Glossary of Terms on Moonlighting.

IV. PROCEDURE

A. All moonlighting, regardless of where it occurs, must be reported and counted towards the trainees’ weekly 80 hour duty limit in accordance with the revised ACGME Duty Hour Requirements.

B. Trainees who wish to moonlight are required to obtain prospective permission from their program directors. Failure to provide this

information is grounds for discipline under the Residency/Fellowship Agreement.

C. The Program Director determines the moonlighting policy for all trainees within their program. Each Program Director is responsible to review the Hospital/Program moonlighting policy with the resident.

D. Program directors will acknowledge in writing their awareness that a trainee is moonlighting and will include this information in their training file.

E. Program directors may withdraw permission to moonlight for any given trainee or group of trainees if those activities have been shown to interfere with their performance or violate duty hours.

F. Residents on probation or on an academic remediation plan may have their moonlighting privileges curtailed or revoked.

G. Residents may not concurrently moonlight at the same time as they are conducting scheduled residency activities or they may face disciplinary action up to and including immediate dismissal from their programs.

H. Trainees on J-1 visas are not permitted to be employed outside the residency/fellowship program. Therefore they are not allowed to moonlight.

I. Residents are not required to engage in moonlighting.

J. The resident’s performance will be monitored. If any adverse effects are discovered as a result of moonlighting activities, permission to moonlight may be withdrawn.

K. Internal moonlighting and Home Call will be counted towards the 80 hour work week

V. CROSS REFERENCE

Professional Liability: Moonlighting activities and any activities that are not part of the formal education Program, are not covered under professional liability policy provided through the Resident Agreement.

VI. REFERENCESN/A

VII. RELATED DOCUMENTS/RECORDSN/A

2016 Quality & Patient Safety Plan

1 | P a g e 10/20/15

Integrated Quality and Patient Safety Plan 2016

I. Philosophy and Framework

In support of Advocate’s vision to be a faith-based system providing the safest environment and best health outcomes while building lifelong relationships with the people we serve, the core value of excellence is fundamental. Excellence at Advocate Health Care is defined as empowering people to continually improve the outcomes of our service, to advance quality, and to increase innovation and openness to new ideas. In support of a systematic approach to achieve and sustain excellence, Advocate Health Care utilizes a balanced scorecard involving six Key Result Areas (KRA’s):

Safety Quality Service Growth Funding Our Future Coordinated Care

Advocate lives our MVP through the Advocate Experience, with our commitment to create the safest and best place for our patients, associates and physicians – always. The Advocate Experience is: An experience without harm – Safety An experience of excellence – Quality An experience of engagement and trust – Service Always

II. Quality Management System

Quality Policy: The Advocate Health Care quality policy is: Safety, Quality and Service Always through Continual Improvement. The leadership and associates of Advocate Health Care execute our quality policy through our quality management system and a commitment to continual improvement to enhance patient safety, health outcomes, operational excellence, and patient satisfaction. Quality and Patient Safety Plans are maintained by the sites to provide operational framework. Advocate Health Care is committed to evidence-based performance improvement using a holistic approach to problem solving. The organization is steeped in a culture of continual improvement to enhance patient safety, health outcomes, service and operational excellence from the patient’s perspective. Accountability for performance is addressed through an objective leadership evaluation system in which management performance objectives directly align to KRA performance. Performance improvement initiatives are driven by performance gaps as measured by KRA’s and opportunities identified by leadership. Advocate’s measurement philosophy is supported by a robust business intelligence environment:

Responsible leadership demands familiarity with and rigorous use of data


2 | P a g e 10/20/15

Processes are in place to accurately and consistently obtain a balanced set of measures that monitor health outcomes, customer satisfaction, functional status, and resource utilization that ultimately supports a culture of accountability

Data driven decisions are made that assist in identifying opportunities and corresponding improvement strategies

ISO 9001 is the foundation for performance improvement for Advocate. The ISO foundation includes a wholistic approach to performance improvement methods that includes PDSA as the core performance improvement approach and includes the Change Acceleration Process (CAP), Lean and Six Sigma tools and methodologies. The Change Acceleration Process is a change model designed to increase the success and accelerate the implementation of organizational change efforts. It addresses how to create a shared need for the change; understand and deal with resistance from key stakeholders; and build an effective strategy and communication plan for the change. Lean Six Sigma is a business process philosophy that focuses on the customer and increasing value and improving quality, safety and productivity. Recognizing the complementary nature of the two methodologies, Advocate uses a blended approach of Lean and Six Sigma concurrently, utilizing different tools to address specific improvement problems along a value stream and/or project. The 2016 KRAs are listed in the 2016 Balanced Scorecard posted on the intranet. A. Quality Management System Oversight and Structure

The Advocate Health Care Board of Directors oversees the business management functions of the Advocate System. There is two way communication and interaction between the Board and Advocate system senior leadership and the site Governing Councils. The system ISO 9001 Quality Management Review Committee interacts and is accountable to these two groups. The Medical Executive Committees at each hospital report to the site Governing Councils. The site Quality Management Oversight Committees report to the site Governing Councils and to the system Quality Management Oversight Committee. The system and site Quality Management Oversight Committees provide leadership and resources to support the quality management system objectives. For the purposes of quality review, improved patient outcomes and reduction in morbidity and mortality, the Health Outcomes Council and Advocate's Quality Management Oversight Committee will designate specific site committees to provide professional and peer self-evaluation of the adequacy of patient care. These may include but are not limited to:

Patient Safety Committees Health Outcomes Committees Morbidity and Mortality Committees Peer Review Committees Cause Analysis Committees

The system and each hospital have a Quality Management Representative. The site Quality Management Representatives report site information to the system Quality Management Representative.


3 | P a g e 10/20/15

The Advocate Health Care Quality Manual provides an overview of the Quality Management System. Results from the quality management system audits, corrective and preventive actions will be reviewed and acted upon by the Quality Management Review Committees at the site and system level. B. Quality Management System Metrics The following are required to be reported to the Quality Management Oversight Committee:

Results of Quality Management System (QMS) audits Patient feedback Process performance and product conformity Status of preventive and corrective actions Follow-up actions from previous management reviews Changes that could affect the QMS, and Recommendations for improvement.

Additional data may also be submitted.

III. Patient Safety Program The goal of Advocate’s patient safety program is to eliminate all events of serious harm within the system by December 31, 2020, with a target of achieving an 80% reduction in the rate of serious events between 2013 and 2017. In 2012, a strategic plan for patient safety was completed and implementation initiated. This plan maps out a multi-year plan for achieving high reliability in care delivery across Advocate. The development of the plan involved the collective efforts of key executive leaders from across the system, site and system patient safety leaders as content experts together with input from front line associates and physicians. The strategic plan outlines four key strategies, including:

1. Establish patient safety as the foundation of care 2. Teach leaders how to lead to safety 3. Empower the front line to address safety issues 4. Engage patients and families in patient safety

The strategic plan will serve as the primary roadmap for operational work in patient safety for the system in the near future. In 2015, the focus of the patient safety program included: 1. Transition from a primary focus on leadership to a focus on safety at the front line through

the creation of High Reliability Units (HRUs). HRUs will be clinical departments in which there is a focused training effort in high reliability healthcare, training on error prevention techniques, coaching to integrate the techniques into front line clinical work, and front-line problem solving with issues that impact the safety of care delivered.

2. Engagement of the front line in safety efforts through implementation of a Safety Coach and Physician Champion program

3. Launch of the system simulation program focused on in-situ simulated learning, along with establishing the first hospital-based simulation lab.

1. Completion of the high reliability leader training series.


4 | P a g e 10/20/15

2. Greater focus on the integration of the Advocate Experience through the development of a Leader tool box for safety, quality and service.

3. Initiation of actions to address items on the Safety Top Ten list. 4. Improved reporting of patient safety events. 5. Establishing a baseline for Advocate’s hospital Serious Safety Event Rate. 6. Full standardization of the RCA process throughout the system. 7. Realignment of the patient safety reporting structure across the system to enable safety

standard work. 8. Implementation of the updated version of the Cause Analysis Database (CAD 2.0) for the

collection and utilization of system causal data. 9. Improved focus and utilization of Advocate’s Just Culture Decision Matrix.

In 2016, the focus of the patient safety program as outlined in the strategic plan strategies and tactics will include: 1. Launch the front line High Reliability Units (HRU) with all clinical departments at Advocate

hospitals across the system. The HRU initiative will appoint and train a team of safety coaches in each clinical department, training in high reliability principles, coaching techniques and the PDSA model for front line problem solving.

2. Expand the front line approach to include the medical staff, through launch of the Physician Safety Champion program. Physician safety champions, as partners to the safety coaches, will serve to influence the culture of the medical staff in Advocate towards high reliability.

3. Continued development of the system simulation program through in-situ simulations focused on high risk areas as identified by the Serious Safety Event Rate, opening of the first hospital-based simulation center at Illinois Masonic Medical Center, and acquisition of funds and planning for three additional hospital-based simulation labs.

4. Pilot of the Cognitive Bias and Diagnostic Error program throughout all Emergency Departments across the system

5. Refreshing the Patient Safety Strategic Plan to identify strategies and tactics to guide safety efforts between 2016 and 2020.

Classifying and Measuring Patient Harm

Advocate utilizes the Serious Safety Event Rate (SSER), through Healthcare Performance Improvement (HPI) as the foundational measure of patient harm within the system. The SSER classifies patient harm according to severity (severe, moderate or minimal) and duration (temporary or permanent), using standardized definitions. The methodology used also classifies near miss events based on the type of barrier that prevented the event from reaching the patient. The SSER will serve as a key metric for the advancement of Advocate toward a culture of high reliability.


5 | P a g e 10/20/15

In 2013 Advocate revised the medical staff peer review process in order to align peer review cases classified as a patient safety event with key reporting metrics. As such, the SSER will include cases identified as a patient safety event by the peer review process and determined to be a serious safety event through application of harm classification.

AHRQ Culture of Safety Survey

Advocate Health Care participates annually in the AHRQ Culture of Safety Survey for associates. This survey serves as a key metric for the movement towards high reliability facilitated by the strategic plan. It is the expectation that Advocate sites will implement unit/department based action planning to facilitate advancement of the culture.

A. Patient Safety Program Oversight and Structure

Advocate’s patient safety program is endorsed by the Advocate Board of Directors. The Health Outcomes Committee of the Board is the safety and clinical oversight committee of the Board. Advocate’s Health Outcomes Council oversees the system-wide safety and clinical performance improvement projects and initiatives. The Health Outcomes Council reports to Advocate's Quality Management Oversight Committee. For the purposes of quality review, improved patient outcomes and reduction in morbidity and mortality, the Health Outcomes Council and Advocate's Quality Management Oversight Committee will designate specific site committees to provide professional and peer self-evaluation of the adequacy of patient care. These may include but are not limited to:

Patient Safety Committees Health Outcomes Committees Morbidity and Mortality Committees Peer Review Committees Cause Analysis Committees

Patient Safety Team A corporate patient safety department supports system-wide safety initiatives, reports, data, education and consultation. Strategic collaboration occurs to enhance this work, including but not limited to:

The risk management department collaborates with patient safety to reduce and eliminate actual and potential risk factors that may impact the safety of care provided to our patients. The center for health information services (CHIS) oversees system-wide clinical data measurement, reporting, analytics and provides public data expertise. The department of quality management and regulatory collaborates to integrate safety with Advocate’s ISO 9001 Quality Management System, and into the Advocate Experience. The patient experience department collaborates to integrate safety into the Advocate Experience.


6 | P a g e 10/20/15

All sites of care within Advocate Health Care have identified safety leaders that report directly to the system safety department. Additionally, each site has a committee that guides clinical safety and quality initiatives. Together, leaders at the system and site collaborate on key strategies, programs and tactics that enhance the safety of the system.

B. Patient Safety System Metrics

A variety of metrics are used in the patient safety program. The majority are included in either the 2016 Balanced Scorecard or the Safety & Quality Close. Both dashboards are distributed to sites monthly.

The following are key patient safety metrics for 2016 reported on the Safety & Quality Close and reported to the Quality Management Oversight Committee:

Safety Event Reporting Rate AHRQ Culture of Safety Survey Results Serious Safety Event Rate Change RCA Aging OSHA Employee Injury Rate Unassisted Falls Percentile


Title: Duty Hours and Call Schedules for Residents (Dept)

[x] Policy Procedure Guideline Other ______________ Scope: System [x] Site IMMC Department: Medical Education

I. PURPOSE

The purpose of this policy is to ensure training programs at Advocate Illinois Masonic Medical Center meet the Accreditation Council for Graduate Medical Education (ACGME), and the American Osteopathic Association (AOA) requirements for resident duty hours. Each residency program is required to develop and communicate to residents and faculty, a program specific policy on Resident/Fellow Duty Hours and call Schedules to ensure training programs meet the requirements of the ACGME Resident Review Committee (RRC). In addition, the purpose of this policy is to support the physical and emotional well-being of the resident while promoting an educational environment. Duty hour assignments recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. These procedures have been developed to regularly monitor resident/fellow duty hours for compliance with this Policy and the ACGME Institutional and Program Requirements. Applies To: This policy applies to all ACGME, and AOA, approved residency and fellowship programs at Advocate Illinois Masonic Medical Center. It sets forth minimum criteria for resident duty hours. More detailed written duty hour policies shall be established by each residency program director. Residency program policies must be approved by the Graduate Medical Education & Research Committee (GMERC).

II. POLICY All Graduate Medical Education (GME) programs will use standard criteria to coordinate resident duty hours and on-call schedules as mandated by the program and institutional requirements of the ACGME and AOA.

III. DEFINITIONS/ABBREVIATIONS A. Duty Hours are defined as all clinical and academic activities related to

the residency program, i.e., patient care (inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled

academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

A. In-house Call is defined as those duty hours beyond the normal workday

when residents are required to be immediately available in the assigned institution.

B. At-home (pager) Call is defined as call taken from outside the assigned

institution.

IV. PROCEDURE

A. Oversight

1. The Graduate Medical Education and Research Committee (GMERC) is responsible for establishing and implementing formal written policies and procedures governing resident duty hours in compliance with the ACGME and AOA Institutional and Program Requirements. Requirements for resident’s on-call or duty hours should reflect an educational rational and patient need (including continuity of care).

a. Each program must establish written policies and

procedures with regard to resident duty hours and working environment consistent with the Institutional, Common and Specialty Program Requirements. The GMERC will work with the individual programs to ensure compliance with the duty hour regulations specific to those programs’ accreditation bodies. As necessary, program directors are encouraged to agree on duty hour specifics for a given rotation between departments through a written agreement. Program policies must be approved by the GMERC and distributed to all residents and the faculty.

b. Resident duty hours and on-call periods must be in

compliance with the Institutional and Program Requirements. The structuring of duty hours and on-call schedules must focus on the needs of the patient, continuity of care, and the educational needs of the resident.

c. Programs must assure that residents are provided with

appropriate backup support when patient care responsibilities are especially difficult or prolonged.

d. Programs are to monitor the duty hours and call schedules and adjustments made as necessary to address excessive service demands and/or resident fatigue.

e. Program Directors are responsible for educating residents

and faculty on duty hour requirements. B. Monitoring

1. The Program Directors are responsible for monitoring Trainee working hours with oversight from the GMERC. Each Program must employ an acceptable electronic methodology for logging of duty hours on a continuous basis. Monitoring must be done for all work hours Trainees spend at all training sites, including all moonlighting activities, if permitted by the Program. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service. Each Program Director shall report duty hour compliance to the GMERC. The GMERC shall review and monitor duty hours and ensure compliance with the Common Program Requirements. Program Directors are responsible for obtaining data on compliance with Resident Duty Hours Policy for their programs. Each resident will be responsible for providing accurate and timely data on compliance with the Resident Duty Hours to the Program Director, the ACGME and AOA, when this information is requested.

Programs which demonstrate regular non-compliance will be required to develop an action plan and report more frequently at the discretion of the GMERC.

In order to provide appropriate responses to non-compliance with duty hours requirements, complaints from Trainees shall be brought to the Program Director, Chairpersons, Designated Institutional Official, Director of Medical Education or Vice President Medical Management. Upon receipt of a complaint, a thorough investigation shall be conducted and corrective measures implemented, as appropriate.

C. Duty Hour Requirements

1. Must be limited to 80 hours per week, averaged over a four-week

period inclusive of all in-house call activities and all moonlighting. Time spent in the hospital by residents on at home call must count towards the 80 hour maximum weekly hour limit.

2. Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). At- home call cannot be assigned on these free days.

3. Duty periods of PGY-1 residents must not exceed 16 hours in

duration. PGY-1 residents should have 10 hours off duty and must have eight hours, free of duty between scheduled duty periods.

Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 pm and 8:00 a.m. is strongly suggested.

Intermediate-level residents (as defined by the Residency Review Committee (RRC) should have 10 hours free of duty and must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty.

Residents in the final years of education (as defined by the RRC must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods. This preparation must occur within the context of the 80 hour, maximum duty period length, and one-day-off in seven standards.

While it is desirable that residents in their final years of education have eight hours free of duty between scheduled duty periods, there may be circumstances (as defined by the RRC) when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty. Circumstances of return-to hospital activities with fewer than eight hours away from the hospital by residents in their final years of education must be monitored by the program director.

Programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 pm and 8:00 am, is strongly suggested.

The program must: Educate all faculty members and residents to recognize the signs of fatigue and sleep deprivation; educate all faculty members and residents in alertness management and fatigue mitigation processes, and adopt fatigue mitigation processes to manage the

potential negative effects of fatigue on patient care and learning such as naps or back-up call schedules.

4. Residents may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct out-patient clinics, and maintain continuity of medical and surgical care as defined in Specialty and Subspecialty Program Requirements.

D. Call Activity

1. In-house call must occur no more than every 3rd night, averaged

over a four-week period. 2. The frequency of at-home call is not subject to every 3rd night

limitations. However, at-home call must not be so frequent as to preclude rest and reasonable personal time.

3. 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.

4. When residents are called into the hospital form home, the hours

spent in-house are counted toward the 80-hour limit.

5. The program director and faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.

E. Moonlighting

1. Moonlighting must not interfere with the ability of the resident to

achieve the goals and objectives of the educational program.

2. Time spent by residents in Internal and External Moonlighting (as defined in the ACGME and AOA Glossary of Terms) must be counted towards the 80 hour Maximum Weekly Hour Limit.

3. Resident moonlighting must be approved in advance and monitored

by the Program Director.

4. PGY-1 and OGME-1 Residents are not permitted to moonlight.

F. Duty Hour Exception

1. If a program requests an exception in the weekly limit on duty hours up to 10 percent or up to a maximum of 88 hours, the Program Director must submit such request to the GMERC which must review and endorse such request prior to submission of such request to RRC. Request for duty hour exception shall be made in writing by the Department Chairperson and residency training Program Director and submitted to the GMERC. The GMERC shall review each request and provide a documented written statement of approval or denial of the request.

G. Transitions of Care

1. t is essential for patient safety and resident education that effective

transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours.

2. Residents must not be assigned additional clinical responsibilities

after 24 hours of continuous in-house duty.

3. Programs must design clinical assignments to minimize the number of transitions in patient care.

4. Sponsoring institutions and programs must ensure and monitor

effective, structured hand-over processes to facilitate both continuity of care and patient safety.

5. Programs must ensure that residents are compliant in

communicating with team members in the hand-over process.

6. The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient’s care.

H. Institutional Communication

1. The GMERC is to report on compliance with the duty hour requirements to the organized Medical Staff and the governing body annually.

V. CROSS REFERENCE

N/A

VI. REFERENCES N/A


N/A



Title: Implementation of Universal Protocol


Scope: System Site: Department:

I. PURPOSE

A. The purpose of this policy and procedure is to define the expectations for compliance with the Universal Protocol (UP) within all Advocate facilities, and corrective actions that will occur should a failure of the Time Out process occur.

B. The UP requirements are applicable to all high-risk medical and surgical

procedures for which a written informed consent is obtained. For a list of those procedures, please refer to Attachment A.

C. The UP applies to these procedures regardless of the Advocate site in which

they are performed. The UP applies to procedures performed in operating rooms, emergency departments, at the patient’s bedside, in hospital ambulatory settings or in special procedures units including but not limited to the cardiac catheterization lab, GI lab, and interventional radiology.

II. POLICY

A. Compliance with the Universal Protocol is mandatory for all associates and physicians at Advocate sites of care who perform or participate in high-risk medical procedures for which a written informed consent is obtained. It is the responsibility of every Advocate associate and medical staff member to actively participate in the safety procedures of the Universal Protocol.


A. Team: All individuals assigned to a particular medical or surgical procedure.

B. Informed Consent: Agreement or permission accompanied by full notice of what is being consented to. A patient must be apprised of the purpose, nature, risks and benefits of the procedure, alternatives to the procedure, the risks and benefits of the alternatives, the risk of no intervention and the probability of success of the procedure, before the physician or other health care professional begins any such course. After receiving this information, the patient then either consents to or refuses such a procedure or treatment.

C. Emergency Procedure: A case in which there is an immediate threat to life or

limb, and the patient is unable to give informed consent.


D. Governing Council: The term Governing Council, as used in this policy and procedure shall refer to the leadership body that has the authority to approve privileges recommended by the hospital or surgicenter medical staff, or the authority to hire and terminate physicians in the medical groups. That body may be called Governing Council or Board of Directors or other similar names conveying this concept regarding its role in governance.

IV. PROCEDURE

A. COMPONENTS OF THE UNIVERSAL PROTOCOL 1. The components of the Universal Protocol include:

a) Pre-procedure brief including site marking b) Time out c) Closing debrief

2. Performance of ALL elements of the UP are required for all non-emergency procedures. For EMERGENCY PROCEDURES:

a) The Time Out will be performed with the exception of the informed consent (refer to definition of emergent procedures in section III)

b) The closing debrief 3. All procedures requiring written informed consent will not be started

unless there is a trained clinical associate, resident or physician present to assist the individual performing the procedure (see exception below). The responsibilities of the second individual include:

a) Assist in the procedure set-up b) Participate in the completion of the Universal Protocol c) Monitor the status of the patient during the procedure

4. The Surgical Safeguards Checklist (Attachment B) will be used to guide the completion of the Universal Protocol in the Operating Rooms.

B. PRE-PROCEDURE BRIEF, INCLUDING SITE MARKING

1. Verification of the correct person, correct site and correct procedure should occur at the following times:

a) When the procedure is scheduled b) At the time of pre-admission testing and assessment c) Upon admission or entry into the facility for a procedure. At this

time, include the patient in the verification when able. d) When the responsibility for the patient is transferred from one

team member to another. 2. Prior to the procedure, a checklist is used to verify the following:

a) An ID band is in place and patient’s identity has been verified b) An accurate and complete informed consent c) The site is confirmed with the patient or duly appointed

guardian. d) Relevant documentation is available e) Relevant diagnostic reports are available


f) Any required blood or blood products are available g) Any required implants, devices or equipment are available h) All documents match the patient i) All documents list the correct site or side

3. Site marking is required regardless of the location in which the procedure is performed. Marking is required for procedures that include:

a) Laterality (regardless of approach) b) Level (spine) c) Digit (fingers and toes) d) Sites involving multiple lesions (i.e. skin)

4. For spinal procedures, in addition to pre-operative skin marking of the general spinal region, intra-operative radiographic techniques will be used to mark the exact vertebral level.

5. For procedures in which a regional block will be used, the intended site of injection must be marked in addition to the intended site of incision.

6. The site is to be marked before the procedure is performed. 7. The site will be marked with the initials of the individual performing the

procedure, by the individual performing the procedure. 8. The site marking should occur prior to sedation with the patient, or their

duly appointed guardian, awake and involved, if possible. 9. The mark is positioned so that it will remain visible after skin prep and

drape, and with the patient in their final position. C. TIME OUT

1. The Time Out involves all immediate members of the surgical or procedural team who will be participating in the procedure from the beginning.

2. During the Time Out, all other activities are suspended, to the extent possible without compromising patient safety.

3. Interactive, challenge-response communication will be used. 4. The Time Out is initiated by the physician or licensed clinical associate

performing the procedure. 5. If the physician or licensed clinical associate fails to initiate the Time

Out, every member of the team is individually responsible for calling attention to this omission. Team members will then work together to ensure that the Time Out occurs prior to the start of the procedure.

6. Any and all team members are authorized and required to express any concerns or discrepancies that exist.

7. No procedure will be initiated until all identified differences and/or concerns are reconciled to the satisfaction of all team members.

8. The Time Out will verify: a) Correct patient identity b) Agreement on the procedure to be done c) Confirmation of an accurate and complete informed consent d) Confirmation that the correct site, including side, is marked


e) Immediate availability of relevant diagnostic reports and images that match the patient

f) Images are appropriately displayed g) Antibiotics have been administered h) Immediate availability of the correct equipment, devices or

implants. 9. Multiple Time Outs are required when:

a) Multiple procedures are performed on a single patient that requires completion of multiple informed consents.

b) Multiple procedures are being performed on the same patient by different surgical or procedural teams. This includes administration of a regional anesthetic block prior to or following the procedure.

c) Multiple procedures are being performed on the same patient by the same team, and the procedures involve laterality, spinal level, digit or lesion OR the procedures are not usually performed together.

10. Documentation of the Time Out a) The Time Out is documented in the patient’s medical record. b) If multiple Time Outs were performed, each will be documented. c) If the procedure was halted during the Time Out due to any

concerns or discrepancies, the details will be noted in the medical record.

D. CLOSING DEBRIEF

1. Performing a Sign Out at the conclusion of surgeries or procedures performed in the OR or procedural areas, is recommended to enhance patient safety.

2. The Sign Out should include the following, as applicable a) The procedure(s) performed b) Verification of correct counts, when applicable c) Verification of specimen labeling, when applicable d) Identification of the estimated blood loss e) Key concerns for recovery or management of the patient

3. During the Closing Debrief, all other activities are suspended, to the extent possible without compromising patient safety, so that all members of the team are focused on the process.

E. RED RULE: COMPLETION OF THE TIME OUT

1. Educational requirements for physicians, residents and associates related to completion of the Time Out are detailed in Attachment C (The Universal Protocol: Education and Red Rule Implementation).

2. Information on dealing with failures of the Time Out are also detailed in Attachment C (The Universal Protocol: Education and Red Rule Implementation)


V. CROSS REFERENCE A. N/A

VI. REFERENCES

A. Joint Commission Comprehensive Accreditation Manual, 2013 VII. RELATED DOCUMENTS AND RECORDS

A. Hospital Procedures Requiring Completion of the Informed Consent Form B. Surgical and Procedural Site Marking Alternative Body Diagram C. The Universal Protocol Education and Red Rule Implementation


Title: House Staff Compliance with Timely Completion of Medical Records


Scope: System Site: AIMMC Department: Medical Education

I. PURPOSE

To outline a process for timely completion of medical records (MR) by the House Staff at Advocate Illinois Masonic Medical Center (AIMMC); define terms and outline responsibilities and procedures involved to ensure compliance with this policy; and provide a process that holds residents accountable for their role in the timely completion of patient records to facilitate appropriate continuity of patient care and ensure AIMMC’s ability to meet regulatory expectations on MR completion.

II. POLICY

House Staff will be required to complete all elements of the Medical Record for which they are responsible within fifteen (15) business days of patient discharge.

III. DEFINITIONS/ABBREVIATIONS Resident: A physician in in an accredited graduate medical education program, including interns, residents and fellows. Residents have a contractual relationship with Advocate for graduate medical education training.

IV. PROCEDURE Residents must complete all elements of the Medical Record as directed by AIMMC’s Medical Staff Rules and Regulations. Such items of completion include signing of the history, physical, operative notes, and verbal orders. These items also include dictating the discharge summary and operative report. Failure to do so may result in negative evaluations citing failure to meet proficiency in the core competency of professionalism. In addition, requests for verification of affiliation or education during search for employment will include a reference regarding timely MR completion. Department-specific methods may be used to ensure compliance with this policy. Programs choosing to develop a different process from that prescribed within this policy, should obtain approval from the Graduate Medical Education and Research Committee before implementation. RESIDENT: All residents should adhere to the following guidelines: 1. All residents will have immediate notification of, and access to, all MR items requiring

dictation via their electronic MR Inbox. 2. Residents/fellows will be encouraged to dictate discharge summaries from the

patient care area. 3. Discharge summaries can also be dictated from any phone (in or out of hospital)

using the dictation system and accessing the patient record via portal access to CareConnection.

4. It is expected that operative reports will be dictated the day of the procedure.

5. A list of “To Be Dictated” reports is easily available to the resident/fellow on line via CareConnection/Profile/Provision.

HEALTH INFORMATION MANAGEMENT (HIM): 1. The HIM will assure multiple notifications of items requiring completion of patient

documentation by using the following steps: All incomplete patient documentation will remain visible in a user’s MR Inbox until

dictated. Every Wednesday, HIM staff distributes a list of all deficiencies including

delinquent records to the Residency Program Directors (PDs) for final notification to the responsible residents. At this point, following notification by the PDs, the resident must complete the records within five (5) business days.

Program Directors will receive a weekly list from the HIM Department detailing their resident delinquent charts – greater than 15 days up to and including greater than 120 days.

PROGRAM DIRECTOR (PD): 1. Each PD is expected to have their own program medical records completion policy,

consistent with institutional policy, which will include measures to monitor and ensure resident/fellow compliance.

2. The PDs are encouraged to use the following steps with residents who have delinquent items reported: a. Verbal Counseling – For the first occurrence, the PD will meet with the resident

to detail the concern, including the date of the event, and review the Medical Records policy and expectations for record completion. The resident’s explanation will be heard and documented.

b. Letter of Formal Counseling – For the second occurrence, the PD will inform the resident of the delinquency incident, document the details of the concern in a formal letter of counseling and then meet with the resident to discuss the event and expectations for resolution.

c. If the resident shows persistent deficiency in ability to meet this professional proficiency or other core competencies, the PD may determine the need to engage disciplinary steps as determined by the program and this may result in actions such as program-level remediation and subsequent formal probation.

V. CROSS REFERENCE

N/A VI. REFERENCES

N/A VII. RELATED DOCUMENTS/RECORDS

N/A

Created 2/16

Created: April 19, 2016

Created by: Donna Willeumier, Quality/Regulatory Revised: April 25, 2016

Reviewed by: Donna Currie, Laurel Mode & Linda Stein Post until:

The following are the Advocate expectations of either hand washing with soap and water or with hand sanitizer.

QMS audits will be following these expectations to ensure appropriate hand hygiene to reduce hospital acquired

infections. Hand hygiene is expected both when entering and exiting any area occupied by a patient.

Clean hands prevent the spread of infection!

SITUATION EXPECTATION COMMENTS

If an associate or physician leaves one room or patient bed area and cleans their hands and goes directly into the next room without touching anything, this is considered compliant with hand hygiene. If the person touches a phone, computer, paper or supplies, he/she must clean his/her hands before entering the next patient area.

This applies between beds in the NICU, ED and other areas where patients do not have their own room and in diagnostic testing areas.

When using alcohol sanitizer, hands must air dry. Do not use paper towels to dry.

Hands shall be washed with soap and water when hands or gloves are visibly soiled and during outbreaks of C.difficile and norovirus infections.

Water in the absence of soap is not considered effective hand hygiene.

Hand hygiene is expected prior to putting on gloves and after removing gloves.

When entering the patient’s area and carrying clean items, the person may place the clean item down and is then expected to proceed to the hand sanitizer dispenser and clean hands.

Food trays or clean supplies are applicable.

When exiting a patient area with soiled items, the person may carry the items directly into the soiled utility room. Upon exiting the room, the person is expected to perform hand hygiene.

Hand hygiene is expected upon exiting a soiled storage/utility room.

Use Soap and Water

Entering and

Exiting Consecutive

Rooms

Use of Gloves

Carrying

Clean

Items

Dirty Store/Utility

Room/Carrying

Contaminated

Items

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