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OSMC MEDICAL EDUCATION
POLICYMANUAL
2014
1
Graduate Medical EducationResident Policies
Index Page
ADA Accommodation (Human Resources)
ACLS/BLS Certification
Allocation of Book Funds, Conference, Professional & License Dues Allowance
Anonymous Contact Flyer
Benefits
Boards and In-Training Exam Assistance
Chief Intern Job Description
Chief Resident Job Description
Completion of Medical Records by House Officers
Counseling and Support
Credentials, File Retention and Request for Information Policy
Disruptive Behavior and Sexual Harassment
Dress Code Policy (Medical Education)
Dress Code Policy (Human Resources)
Due Process Policy and Procedure and Corrective Action Plan
Eligibility and Selection
Employment Procedures, Credentialing, Criminal Background Check
GME In/Out Rotation Policy
Grievance Procedures
Housestaff Evaluation and Promotion
Housestaff Supervision, Duty Hours and Work Environment
Incident Reporting
Infection Prevention & Control
Post Exposure Prophylaxis (PEP)
HIV/HBV/HCV Infected Healthcare Workers
Exposure Control Plan- Blood Borne Pathogens
Employee Health Services Exposure Procedure
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5
6-9
10
11-13
14
15
16
17-18
19-22
23
24
25
25
26-30
31
32-38
39-45
46-48
49
50-52
53-55
56
2
Internship/Residency Certification Policy
Intern & Resident Licenses
Leave Policies (Human Resources)
Maternity, Paternity, Adoption Leave (Medical Education)
57
58-59
60-61
60-61
Medical Education Communication Modes
Moonlighting Policy
Order Writing & Co-Signing
Personal Data Assistant Policy (PDA)
Vendor Interaction Policy
62
63
64
65-66
67
Physician Impairment Policy
Professionalism
68
69
Policy on Use of Paid Time Off For Interns & Residents 70
Sentinel Events
Visiting Residents and Interns
71
72
3
ADA AccommodationAmericans with Disabilities Act.http://oaknet/documents/PolsNProcs/HR/412.pdf
4
ACLS/BLS (Cardiac Life Support) Certification Policy
Oakwood Healthcare System (OHS) requires that all interns and residents have a valid, current certification in ACLS and BLS. This is required to provide excellence in patient care and to meet the standards set by the Joint Commission on Hospital Organizations and the American Osteopathic Association (AOA). To facilitate these requirements, OHS provides housestaff with ACLS/BLS courses in June. These courses are offered at no charge to all housestaff under contract to OHS.
If an individual cannot attend one of these courses, the individual must schedule their own ACLS/BLS class and may have to use their conference funds for payment.
If the intern or resident is more than sixty days past their certification date, they will be suspended without pay until they receive their certification.
5
Policies on Allocation of Book Funds
Prior approval by Program Director of Medical Education is required.
Book allotment may be spent on books, journals, audio tapes, video tapes, board exams and/or CME oriented medical software.
Book allotment may not be spent for conferences.
Book allotment may not be carried over from year to year.
Residents should not purchase books without prior approval and expect to be reimbursed.
6
Policies on Conference Allowance
Prior approval by Program Director of Medical Education is required at least 45 days prior to the start of conference. A copy of program is required.
An average of 4 hours of CME per day of conference is required for approval.
Conferences must take place in the continental United States or Canada.
Conference allowance may be carried over from year to year.
Conference allowance in whole or part may be spent as a book allowance.
Conference days may not be carried over from year to year.
Conference funds may be utilized for specialty Board certification fees with prior approval.
Conference days may still be used for approved conferences even if the resident has expended all of their conference allowance for books or Board certification fees.
7
Policies on Professional Dues
Dues must be spent on the primary organization of the resident's training program (i.e., ACP, AAFP, ACOBGYN, etc.)
Prior approval is required by the Program Director of Medical Education.
Dues allotment may not be carried over from year to year.
Dues allotment may not be spent for any other purpose.
8
Policies on Medical License Fee Allowance
Prior approval of Program Director of Medical Education is required.
Medical license allowance may not be carried over from year to year.
Medical license allowance may not be spent for any other purpose.
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MEDICAL EDUATIONRESIDENT ASSISTANCE
If you have a sensitive issue, grievance or need counseling, assistance is available to you.
Contact:
Larry Fischetti, PhD Office: 734.727.1067, Pager: 1241
Ulliance – EAP Office: 800.448.8326(Employee Assistance Program) www.ulliance.com
www.lifeadvisoreap.com Emp: Oakwood Healthcare System, Inc.City: Dearborn
Anonymous Contacts:
Diana Balint Office: 734.362.6745(Librarian)
Jodie Petrie Office: 734.671.3647, 734.671.3779, Pager: 6125Bev Beltramo Office: 313.982.5698, Pager: 3675(Spiritual Support)
Lyle Victor, MD Cell: 313.515.4303
All discussions are confidential.For further information, see
OakNet \ Physicians \ Resident Policies \ Counseling & Support10
SALARY AND BENEFITS2014-2015
EXHIBIT A
Pay Scale
Intern Year 1 $50,128Resident Year 1 $50,128Resident Year 2 $51,688Resident Year 3 $53,664Resident Year 4 $55,744Resident Year 5 $57,678Includes meal allowance
Paid Time Off
Twenty days paid time off per year including vacation time, personal days, holidays, and sick days. Holidays are not guaranteed days off. Interns/Residents are allowed five additional conference days.
Conference Allowance
Conference allowance is available as follows:$400 for Intern/Resident Year 1,$1,000 for Resident Year 2,$1,200 for Resident Years 3-5.Funds can be accumulated from year to year and may be expended in whole or part on medical literature. Conference funds may be used to pay for board exam fees.
Book Allowance
Book allowance is available as follows: $200 for Intern/Resident Year 1 and$500 for Residents Year 2-5.Funds may be used for a variety of medical literature and/or CME oriented medical software.
* Note: Book and Conference Money may be used for Board Exams.
Medical Licenses
A $170 license fee is available.
Health Care
Medical, dental, optical, life insurance and prescription coverage provided under Oakwood's employee benefits program, taking effect on the first day of employment.
Long & Short Term Disability Insurance
Long and short-term disability is provided at no charge to all interns/residents.
Malpractice Insurance
Paid for by the Hospital but limited to activities within the training program.
Meal Allowance
A yearly stipend of $1934 for Intern/Resident Year 1 and$1664 for Resident Years 2-5 is added to your base salary and included in your payroll checks.
Uniforms
Three lab coats per year are provided for by the Hospital.
Miscellaneous
Interest free salary advance available up to $2,000.
Professional Dues
A $105 allowance is available to all interns/residents for memberships to various medical associations.
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HOUSE OFFICER BENEFITS
MEDICAL PLAN Medical Plan Choices program includes medical insurance and Flexible Spending Accounts. Medical election is available the date of hire. Employee contribution is required.
DENTAL INSURANCE: MetLife. Depending on election employee contribution may be required. Effective on date of hire.
VISION INSURANCE: Eye exam and glasses or contact lens. Once every 24 months for adults and once every 12 months for children under 19 years of age. May choose enhancement plan which offers these services once every 12 months. Depending on election contribution may be required. Effective date of hire.
LIFE INSURANCE: Coverage of 1 times annual base pay. Effective the first of the month following 90 days of employment. No employee contribution required. In addition employees automatically receive Accidental Death & Dismemberment insurance equal to 1 times annual base pay.
PAID TIME OFF: Twenty days off per year includes vacation, personal, Holiday and sick time.
SHORT TERM Basic plan: No employee contribution required. Benefits are paid on the 15th day of continuous disability resulting from any non-occupational surgery, hospitalization or accident. Amount paid is up to 60% of base weekly wage (40 hours per week), up to $2,000 for a maximum of 24 weeks (must use sick/vacation time for first 2 weeks). Enhanced: Employee contribution required. Benefits are paid on the 1st day of continuous disability resulting from any non-occupational surgery, hospitalization or accident. Amount paid is up to 60% of base weekly wage, up to $2,000 for a maximum of 26 weeks (all paid).
LONG TERM Employees are automatically enrolled in this benefit after completing a minimum of 6 months of employment. Employer pays 100% of this benefit. Benefits are provided after 6 consecutive months of disability and pays 60% of pre-disability earnings.
RETIREMENT: Cash Balance plan with no employee contribution required. 100% vested in 5 years. Employer contribution based on years of service and employee’s base earnings.
TAX DEFERRED 403(b) savings program through payroll deductions - ANNUITY:defers Federal and State taxes.
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DIRECT DEPOSIT: No cost service to deposit paycheck directly into bank account.
Medical EducationResident Salaries
Effective 7/1/2013
PGY Level
Job Code Title
Annual Salary
Hourly Rate
Meal Allow.
Per Pay Meal Allow
Total Salary with meals
I 1405 Resident I $48,193.60 $23.17 $1,934.40 $74.40 $50,128.00 II 1406 Resident II $50,024.00 $24.05 $1,664.00 $64.00 $51,688.00 III 1407 Resident III $52,000.00 $25.00 $1,664.00 $64.00 $53,664.00 IV 1408 Resident IV $54,080.00 $26.00 $1,664.00 $64.00 $55,744.00 V 1409 Resident V $56,014.40 $26.93 $1,664.00 $64.00 $57,678.40
Chief I 1010 Chief Resident I $50,024.00 $24.05 $1,934.40 $74.40 $51,958.40 Chief II 1011 Chief Resident II $52,000.00 $25.00 $1,664.00 $64.00 $53,664.00 Chief III 1012 Chief Resident III $54,080.00 $26.00 $1,664.00 $64.00 $55,744.00 Chief IV 1013 Chief Resident IV $56,014.40 $26.93 $1,664.00 $64.00 $57,678.40 Chief V 1014 Chief Resident V $57,803.20 $27.79 $1,664.00 $64.00 $59,467.20
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Policy for Boards and In-Training Exam Assistance
Medical Education will provide financial assistance to interns/residents that have failed all or part of a board exam. The maximum that interns/residents can be reimbursed is $750. This assistance is provided only one time per individual.
The Program Directors must first determine that a resident or intern would benefit from coaching, as opposed to studying more. The Director of Medical Education must also agree to this assessment. If a resident or intern wants to be reimbursed for the coaching, only trainers approved by the Medical Education Department are allowed.
In the event that a Program Director does not feel an intern or resident would benefit by receiving training for test taking, the intern or resident may appeal to the Director of Medical Education.
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Chief Intern Job Description
Title: Chief Intern
Duration: 12 Months
Appointment: Selected by Intern class
Qualifications: Intern (OGME 1), evidence of leadership, organizational and communication abilities and skills. Professional attitude.
Duties and Responsibilities:
Representation: Represents the Intern class on the Medical Education Committee, and in other internship related activities.
A Liaison between the interns for information and problem solving.
Orientation: Participate in planning and presenting orientation for the next intern class during the end of June and the first week of July.
Recruitment and Selection: Assist in interviewing candidates for OGME 1 positions and with other recruitment at the request of the Program Director and/or DME.
Scheduling: Weekend and Holiday Call. Verify monthly rotations and sign-off on monthly attestation forms.
Problem Solving: Deal with problems involving interns in the program. These problems may involve other interns, residents, attending physicians, medical students, auxiliary staff or administration, etc.
Assist in Planning and Organization of Teaching Activities: e.g., Journal Club on a monthly basis, conferences, interesting case presentations, or any other meetings/educational activities that require the presence of interns, e.g. the annual research presentation by residents.
Educational Activities: Coordinate teaching and conference participation of the interns and medical students with residents.
Regular Meetings with the Program Director, Medical Education Committee, others as assigned by the Program Director and/or DME.
Other Functions and Duties: As assigned by the Program Director and/or DME.
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Chief Resident Description of Duties
Title: Chief Resident
Duration : 12 Months
Appointment: Nominated by the Department; approved by the Medical Education Committee
Qualifications: Final year (or senior level) of residency, evidence of leadership, organizational, communication abilities and skills. Professional attitude.
Duties and Responsibilities:
Representation: Represents to their Department, Medical Education Committee, and in other residency related activities.
A Liaison between the residents for information and problem solving.
Orientation: Participate in planning and presenting orientation for interns and OGME 2 residents during the end of June and the first week of July.
Recruitment and Selection: Assist in interviewing candidates for OGME 1 and 2 positions and with other recruitment at the request of the Program Director and/or DME.
Scheduling: Annual and monthly rotation schedules; night, weekend and holiday call scheduling to provide appropriate coverage, as well as vacation scheduling. Verify monthly rotation assignments and sign-off on attestation form.
Problem Solving: Deal with problems involving residents in the program. These problems may involve other residents, interns, attending physicians, medical students, auxiliary staff or administration, etc.
Annual Evaluation of the Program by Residents: See that the residents complete these evaluations in a timely fashion and provide information feedback.
Assist in Planning and Organization of Teaching Activities: e.g., Journal Club on a monthly basis, conferences, interesting case presentations, or any other meetings/educational activities that require the presence of residents, e.g. the annual research presentation by residents.
Educational Activities: Coordinate teaching and conference participation of the residents with interns and medical students.
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Housestaff Medical Records Completion
Introduction
This policy is written to insure that the responsibility to complete medical records, including discharge summaries, is accomplished in a timely manner by all residents and interns, who are part of Medical Education at Oakwood Healthcare System in compliance with the Center for Medicare Services (CMS) and Joint commission requirements.
Policy
1. The resident physician responsible for completion of the medical record is the resident indicated on the discharge sheet. In addition, the patient’s record must indicate the resident physician who is responsible for dictating the discharge summary, their pager number and the name of the attending physician responsible for co-signing the summary. For example, Discharge summary to be dictated by Dr. J. Jones, pager #1234 and co-signed by Dr. S. Smith. This can be indicated on the discharge sheet or in the progress notes.
2. All dictations must include the attending co-signer in order for Health Information Management (HIM, formally known as Medical Records) to assign the report to the appropriate physician. If an incorrect co-signer is listed, the resident should change the name of the attending co-signer at the time they electronically sign the record.
3. Questions concerning the resident physician responsible for chart completion from HIM personnel will be addressed by the responsible Chief Resident of each program respectively. The Director of the HIM Department will be apprised of the Chief Resident of each residency. It is the Chief Resident’s responsibility to identify who is responsible for record completion if the information is not clearly listed in the patient’s record. Medical Education will notify the HIM Department if a resident will be informed to re-assign these records to the appropriate resident.
4. Resident must have been involved in the care of the patient for a significant portion of the hospitalization to be reasonably expected to complete the discharge summary. Dictations on patients removed from a teaching service within 48 hours of discharge will be the responsibility of the resident. However, summaries on those patients whose stay on the teaching service was short (less than 48 hours) prior to being removed are the attending physician’s responsibility.
5. Residents rotating from institutions other than another OHS site will not be eligible to dictate. Dictation of patient records will be the responsibility of the OHS resident directly involved in the care of the patient. If no other OHS resident is assigned to the patient then it is the responsibility of the attending physician to complete the record.
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Procedures for Suspension of Resident’s Privileges
H.I.M. will notify Medical Education weekly via e-mail of the residents who have at least one delinquent medical record. A delinquent record is a record that has not been completed 7 days after discharge of the patient. Resident will receive a text page from Medical Education Department informing them of delinquent records that need to be completed as soon as possible. A copy of the delinquent records notice will be given to the appropriate program director. This is considered the first notice of delinquent records.
NOTE: When completing delinquent records outside of HIM department, residents should call 734.671.3270 to notify HIM of completion.
1. The resident should electronically sign patient records daily. Post-operative reports must be completed immediately following surgery. History and physicals must be dictated within 16 hours of admission. Inpatients require a full History and Physical (a short form is not appropriate for an Inpatient stay). Discharge summaries must be completed no more than 48 hours after the patient is discharged.
2. Residents with incomplete records 15 days or older will be notified by the program director via text page that they have 48 hours to complete these records. This is considered the second notice of delinquent records. A copy of the delinquent records notice will be given to the appropriate program director.
3. If records are not completed within this 48-hour period, the program director will pull the resident from service until all records are completed. A formal corrective action plan will be placed in the resident’s permanent record. In addition, any subsequent deficiencies in the next 12 months will result in progressive corrective action.
4. Resident physicians who are on vacation, at a conference, on a sick leave or ill for more than two days, must inform the program director’s office. If a resident needs to request exemption from these procedures for these reasons, the program must notify HIM.
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Medical Education Policy for Counseling & Support Services
Personal issues that sometimes emerge during residency include stress due to work problems, conflict between personal demands, family life, and professional workload, and psychological/psychiatric problems. In these and other situations, Medical Education recognizes the benefit of mental treatment and counseling in supporting residents’ personal and professional growth. Medical Education has identified a number of internal resources and will assist residents desiring confidential treatment outside of the Oakwood Healthcare System .
I N -N ETWORK R ESOURCES F OR R ESIDENTS
Oakwood Employee Assistance Program (EAP)
Oakwood’s EAP provides brief, confidential assessment and treatment services for employees/residents experiencing work or family related stress or substance use concerns at no charge. For individuals requiring longer-term treatment, EAP staff will help facilitate referral to a qualified community provider. Medical Education may initiate a Supervisor Formal Referral for evaluation and treatment of possible emotional, substance-related, and learning problems. EAP staff can be reached at phone number 800.448.8326 or for information at www.ulliance.com. Information can also be reach at OakNet \ Programs \ Employee Assistance – Ulliance.
APEX Behavioral Health
APEX is OSHCare’s contracted mental health and substance use provider. APEX has approximately 20 psychiatrists and 70 psychologists, social workers, couples and family therapists on staff at seven locations. Jenny Ballard, ACSW, is the Project Manager for APEX. To schedule an appointment at the Westland office, call 734.729.3133. The Dearborn office number is 313.271.8170. Web-address is: www.APEXBehavioralHealth.com. HAP subscribers should call 800.422.4641 or check the website: www.hap.org.
Medical Education Ombudsperson
Residents with a sensitive concern or grievance may contact the Medical Education Ombudsperson for confidential guidance and support. Residents may also elect to communicate their concerns anonymously. Mrs. Diana Balint (734.362.6745) and Dr. Lyle Victor (313.515.4303) serve in the role.
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Medical Education Counseling & Support Team (C&ST)
The Medical Education C&ST serves as an advisor to the Director of Medical Education, residency program directors and faculty, and to residents on issues of work and family stress, mental health and substance use concerns, spiritual and ethical issues, and residency performance problems. Residents may elect to contact members of the C&ST for confidential guidance, short-term counseling, and referral. The C&ST will not enter into open-ended treatment relationships with residents. Contact persons are as follows:
Larry Fischetti, PhD (734.727.1067; P: 1241)Ulliance – EAP (800.448.8326)Spiritual Support Services (734.671.3779: P 6125)Diana Balint (734.362.6745)
Spiritual Support Services
Chaplin Jodie Petrie is the Manager of Spiritual Support Services for Oakwood Southshore. A number of full-time chaplains and many active volunteers representing a variety of religious traditions provide spiritual support and counseling in Oakwood’s various venues. Chaplin Jodie Petrie can direct you to a chaplain or lay minister to address your concerns in a manner consistent with your spiritual beliefs and/or religious affiliation. She can be reached at 734.671.3647, 734.671.3779, Pager: 6125.
Oakwood Staff Development
Oakwood Healthcare System offers a variety of online and scheduled group courses to help employees and residents develop their effectiveness as members of healthcare teams and organizations. These courses can help residents meet expectations in a number of the ACGME/AOA General Competencies including Systems-Based Practice. To review offerings, go to the OakNet website and click on Training. For online courses, click on the link to HealthStream; for scheduled group courses, click on Oakwood Leadership Development.
OUT-OF-NETWORK RESOURCES FOR RESIDENTS
For some residents, the added assurance of confidentiality may outweigh the costs of seeking out-of-network assessment, mental health treatment, or substance abuse services. Should Medical Education require an evaluation by an out-of-network provider, Dr. Glines has arranged for Medical Education to help offset the costs of services. In these situations, Medical Education may request consent for some communication with out-of-network providers; these plans should be made explicit and an agreement reached before entering into treatment. Residents who choose to seek out-of-network
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assistance on their own accord will be liable for the cost of treatment unless prior agreement for Medical Education support is obtained through their program director or the Director of Medical Education.
Private Mental Health Assessment and Consultation
Roger Lauer, PhD, is a licensed psychologist and clinical neuropsychologist. His clinic provides neuropsychological assessments, cognitive and learning assessments, and therapy/coaching for residents experiencing attentional, learning, and other performance problems. Contact information is as follows:
Center for Neuropsychology, Learning & DevelopmentRoger E. Lauer, Ph.D., Clinic Director1955 Pauline Boulevard, Suite 100AAnn Arbor, Michigan 48103phone: 734.994.9466 / fax: 734.994.9465email: [email protected] website: www.CNLD.orgwww.facebook.com/CNLDa2
Joel Young, MD, is a psychiatrist with a special interest in the assessment and treatment of adult attentional and learning problems. His clinic provides psychopharmacologic treatment and cognitive training. Debra Luria, PhD, RN, a psychologist working with Dr. Young, provides intellectual and neuropsychological assessment services and related counseling. Contact information is as follows:
441 S. Livernois, Suite 205Rochester Hills, Michigan 48307248.608.8800www.rcbm.net
Speech and Language
Ms. Judy Raven of the Accent Reduction Institute is a speech and language therapist. Ms. Raven has extensive experience tutoring physicians to improve their English pronunciation and grammar in support of doctor-patient communication. Ms. Raven can meet residents in their work settings. Her organization has also developed procedures for distance learning. Ms. Raven can be contacted at 734.665.2915. The web-address is: www.lessaccent.com.
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Substance Use Assessment and Treatment1
Michigan’s Health Professional Recovery Program (HPRP; 800.453.3784; www.hprp.org) provides confidential assessment and treatment services. For professionals found to be impaired by substance use, confidentiality is maintained while the individual faithfully pursues treatment to discharge. Also include mental health concerns that could interfere with a health care professional’s ability to practice effectively. By law, impaired professionals who fail to comply with treatment will be reported to the Michigan Department of Consumer and Industry Services (HPRP: 800.453.3784). Sue Bushong is the State of Michigan’s HPRP Contract Administrator & Outreach Coordinator Outreach Coordinator and Contract Administrator
Susan M. BushongLARA/BHCS/HPD611 W. Ottawa, 1st FloorLansing, MI 48909Office: 517.335.1760Cell: 517.243.3525Fax: 517.241.1212
Note that under the Michigan Public Health Code, licensed health professionals are required to file a report with the Department of Community Health—Bureau of Health Professions if there is reason to believe another licensed health professional has a mental health- or substance use-related impairment that limits his or her ability to practice in a manner consistent with the minimal standards of acceptable and prevailing practice. A referral or self-referral to HPRP satisfies the reporting requirement. If, as a result of an assessment, a health professional is found to suffer impairment, a treatment plan will be proposed. The results of the assessment and all treatment records will be expunged five years after the successful completion of treatment. A report is forwarded to the Department of Community Health—Bureau of Health Professions only if the referred health professional refuses to comply with an assessment or treatment plan or is deemed to be a threat to public health, safety, or welfare.
Credentials, File Retention and Request for Information Policy1
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File Retention:Intern and resident files are maintained in the Medical Education Office. Once an intern/resident has graduated or left the program, their file is kept in the department for three years. After three years, their file is sent to storage.
Once a verification of internship/residency form has been received, the intern’s/resident’s file is sent for (if over 3 years), or pulled from the filing cabinet. It is then given to the individual intern/residency program director for signature on the form provided or on a letter, if required.
A copy of the form/letter, along with the request and authorized release form signed by the intern/resident, and any other information sent, is placed in the intern’s/resident’s file and put back in the filing cabinet or sent back to storage.
Requests for Residency/Internship Certification:
1. Upon successful completion of training, every intern/resident will receive a certificate verifying successful completion signed by the CEO, Chairman, Board of Trustees, Chief of Staff, Director of Medical Education, Chief of Service, and Program Director of the internship/residency.
2. A copy of this certificate will be marked “copy” and placed in the intern’s/resident’s permanent file (record).
3. If the intern/resident subsequently requests certification of training, Oakwood Healthcare System (OHS) will provide either a) a copy of the file copy of the certificate, b) a letter that certifies that the intern/resident successfully completed the program, signed by the current Program Director and current Director of Medical Education, or c) a diploma signed by the current CEO, Chairman, Board of Trustees, Chief of Staff, Director of Medical Education, Chief of Service, and Program Director of internship/residency with the duplicate reissue date noted on the certificate.
4. A period of 30 days is required from the time the request is received to mailing of documentation to allow for location and review of file to determine that the physician making the request successfully completed training at OHS. A fee of $100 will be required for duplicate diplomas to be created. Copies of unsigned diplomas and letters are free of charge.
Disruptive Behavior and Sexual Harassment23
Dress Code PolicyMedical Education
1. Preferred attire shall be shirt, tie, and slacks for males. Skirt or slacks for women.
2. Scrubs (tops and bottoms) may be worn in situations where appropriate and for “on call”.
3. Clean white lab coats to be worn over scrubs at all times.
4. All hospital owned and laundered scrubs will remain on the hospital premises. Scrubs should not be worn into the hospital and you should not leave the hospital in your scrubs. Please change into and out of scrubs at the hospital.
5. Scrub clothes are not considered appropriate in non-invasive situations.
6. Hospital ID must be worn at all times on campus.
7. T-shirts and blue jeans are considered inappropriate at all times.
8. Body Sculpting/Tattoos/Piercing (except pierced ears) are not acceptable to have showing during work hours.
Public Health policy dictates the following:
9. Women to wear hose or socks. Men to wear socks.
10. Footwear should be clean and appropriate. No opened toe shoes.
11. Foot covers are not be worn out of appropriate clinical areas.
(See Human Resources Policy)Dress Code http://oaknet/documents/PolsNProcs/HR/407.pdf
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Corrective ActionDue Process Policy and Procedure
Medical Education will be notified of any corrective action plans for residents in its GME programs. The attached corrective action plan form (CAP), must be completed and forwarded to the Director of Medical Education (DME) within 72 hours of the time/date it is implemented by the program director. The program director will also forward a copy of the detailed written remediation plan given to the resident with the form. If there are any changes in the action taken with the resident, the DME must be notified within 24 hours. After the CAP is completed there must be a review decision indicated by checking one of the four boxes at the bottom of form and re-submitting to the DME’s office within one week of completion so the action plan can be monitored.
Only probation, suspension and terminations, contract non-renewals will be reported and limited to 5 years after graduation for external references.
If the Director of Medical Education and/or Program Director believes corrective action is necessary to address any difficulties or deficient areas in the Intern or Resident’s performance noted during the evaluation process or during the course of the Intern or Resident’s performance of his/her obligations, the Director of Medical Education and/or Program Director may take any one or more of the following corrective actions designed to address the difficulty or deficiency:
Informal counseling and opportunities for residents to correct deficiencies should be documented by the program director prior to considering a major corrective action, unless a major work infraction or a violation of GMEC policy is the concern.
Place the Resident on probation, during which time the Resident will be expected to increase his/her effort to improve performance.
Require the Resident to seek counseling and/or psychological support services. Require the Resident to seek the assistance of an impaired physician committee, or other
similar committee or organization within or outside Oakwood, designed to address the needs of impaired professionals.
Require the Resident to spend additional time at the Resident's present level in the Oakwood Residency Program.
Require the Resident to take a leave of absence with or without pay. Restrict the Resident's activities outside the Oakwood Residency Program for which the
Resident receives compensation.
The Director of Medical Education shall notify the Intern or Resident both verbally and in writing of any corrective action taken and shall specify in the notice the period of time during which the corrective action shall remain in effect and how and when such action will be reviewed and/or lifted. This document will be signed by the Director of Medical Education, the program director and the intern/resident identified.
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Summary Suspension
Right to Suspend – Other provisions the Oakwood Southshore Medical Center Board of Directors, the Intern and Resident’s Program Director, or the Director of Medical Education may summarily suspend the Intern or Resident from the Oakwood Southshore Program, if in the opinion of the person or entity initiating the summary suspension, such suspension is or may be necessary in order to avoid an adverse effect on patient care. The person or body initiating a summary suspension shall provide the Intern or Resident with immediate written notice of the summary suspension, and, if initiated by the Board of Directors, shall also provide the Program Director and the Director of Medical Education with notice of the suspension.
Effect of Suspension – Immediately upon receipt of a notice of summary suspension, the Intern or Resident shall be relieved of all patient care obligations. The Intern or Resident Agreement shall terminate immediately if the Intern or Resident fails to request reconsideration of the summary suspension or the summary suspension is upheld after reconsideration.
Termination
Termination by Oakwood Southshore Medical Center – Oakwood Southshore Medical Center may terminate the Intern/Resident’s Agreement if Oakwood determines in its sole discretion that the Intern/Resident has failed or is unable to perform his/her duties under this Agreement in accordance with applicable standards of medical practice, has failed to comply with Oakwood Southshore policies, procedures, rules or regulations, or has breached this Agreement. Oakwood Southshore shall not be required to take any corrective action prior to terminating the Agreement. Through the Director of Medical Education, Oakwood shall provide the Intern/Resident with written notice of the termination, which notice shall specify the date of termination and the reasons for the termination. Termination of this Agreement shall constitute dismissal from the Oakwood Southshore Medical Center Training Program.
Residency Closure Reduction – Oakwood Healthcare, from time to time, may reevaluate the types and sizes of its residency programs. An advisory group including stakeholders from residency programs, medical staff and administration, will review pertinent information and make recommendations regarding such closures or size reductions to the Medical Education Committee and Oakwood administration. Final decisions are the responsibility of Oakwood’s Governing Board and its Executive Council.
If Oakwood determines that it is necessary to reduce the size of a residency program or to close a residency program, Oakwood shall inform the DIO, GMEC, program director and residents within 60 days of the final decision. In the event of such a reduction or closure, Oakwood will make every effort to allow residents already in the program to complete their education. If any residents are displaced by the closure of a program or reduction in the number of residents, Oakwood shall make every effort to assist the residents in identifying a program in which they can continue their education.
Revised 03/17/11
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Reconsideration
Right to Reconsideration – The Intern/Resident may request reconsideration of a summary suspension, termination of their Agreement, or any corrective action taken by Oakwood Southshore. Requests for reconsideration must be made in writing to the Director of Medical Education within 10 calendar days of the date of notification of the intern/resident of the action. The request for reconsideration must specify the action, which is to be reconsidered. A proper request for reconsideration shall stay any action being reconsidered, except summary suspension. If the Intern/Resident fails to request reconsideration of an action, the action shall become immediately final.
Reconsideration Committee – Upon receipt of a proper and timely request for reconsideration, the Director of Medical Education shall appoint a committee to undertake the reconsideration. The Director of Medical Education will act as chairman of the Reconsideration Committee unless the Intern/Resident requests that the Director of Medical Education disqualify himself from appointing and serving as chairman of the Reconsideration Committee. The request for disqualification must be made in writing at the time the request for reconsideration is made. If the Director of Medical Education disqualifies himself, the Chief of Staff will appoint the Reconsideration Committee and act as its chairman. In addition to the chairman, the Reconsideration Committee will consist of two individuals selected from the Medical Education Committee, two individuals selected from the Medical Staff, two intern/residents, and one individual selected from Oakwood Southshore Administration. A majority of the physicians serving on the Reconsideration Committee shall be from other than the department in which the Intern/Resident is in training. The individual serving as chairman of the Reconsideration Committee shall be responsible for appointing members to the committee in accordance with this Section.
Notice of Meeting – The chairman of the Reconsideration Committee shall set a date for the committee to meet that is within fourteen (14) calendar days of the date upon which the Intern/Resident submitted the written request for reconsideration. At least seven (7) calendar days prior to the scheduled Reconsideration Committee meeting, the chairman shall provide the Intern/Resident and all members of the Reconsideration Committee with written notice of the date, time, and place of the meeting, delivered personally or by certified mail, return receipt requested.
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Conduct of the Meeting – The Intern/Resident may appear at the Reconsideration Committee meeting and may ask one medical staff or faculty member to appear at the meeting with him/her to provide counsel and/or to speak on the Intern or Resident’s behalf. Legal counsel shall not be permitted to attend the meeting with or on behalf of any party or the Reconsideration Committee. The chairman shall conduct the meeting and shall request the Intern/Resident to present any information he/she feels is relevant to the committee’s reconsideration of the matter. The Reconsideration Committee meeting shall in no manner constitute a hearing. After the Intern/Resident has presented his/her information, the chairman shall excuse the Intern/Resident and the Intern/Resident’s medical staff representative, and the committee shall deliberate the matter in private.
Committee Decision – The Reconsideration Committee shall make a decision either to uphold or to overturn the action being reconsidered. The decision of the Reconsideration Committee need not be unanimous; the majority decision of the committee rules. Within seven (7) days of the committee’s meeting, the Reconsideration Committee chairman shall provide the Intern/Resident and the Director of Medical Education with the written decision of the committee, which shall include the Committee’s rationale for its decision. Delivery of notice of the decision to the Intern/Resident shall be by personal delivery or by certified mail, return receipt requested. The decision of the Reconsideration Committee shall be final. The Intern/Resident shall be entitled to only one reconsideration of any summary suspension action, termination action, or any corrective action.
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OAKWOODOSMC Intern/Resident Corrective Action Plan (CAP) *
Print Housestaff’s Name: Date:
Residency Dermatology Ob/Gynecology Diagnostic Radiology Ophthalmology Preliminary Emergency Medicine Ophthalmology General Surgery Podiatry Internal Medicine Traditional Rotating
PGY 1 2 3 4 5 Reason
Academic Disciplinary Impairment Knowledge deficit Violation of departmental policies Chemical dependence Skills deficit Violation of GMEC policies Mental impairment Attitude problem Loss of limited or permanent license Psychological impairment Unsatisfactory clinical performance
Failure to meet licensure standards Medical impairment
Unsatisfactory progress toward educational objectives
Failure to meet expectations of personal and/or professional growth
Other
Non-participation in mandatory conf/seminar
Acting in an unethical manner
Failure to meet research/ scholarly activity time line
Illegal conduct
Other Contract violation
Other
Type of Action Date/Duration Significant Oral warning/Reprimand Written warning Non-progression to next PGY level Probation Suspension Non-renewal of contract Termination
Review Decision Complete/Successful Action Reviewed/Discontinued Action Review/Continued New Corrective Action plan formulated* Must attach detailed, written remediation plan.
Date:_____________ Date:______ Program Director Housestaff
Date:_____________ Director Medical Education
Housestaff Eligibility and Selection30
Oakwood Southshore Medical Center believes strongly that the selection of high quality interns/residents for its graduate training programs is critical to our mission of providing the highest quality education programs. To this end, in compliance with AOA institutional requirements, applicants must meet one of the following qualifications to be considered eligible for matriculation into our internship/residency programs:
1. graduate of an AOA Osteopathic accredited medical school in the U.S.
2. member in good standing of the AOA.
Oakwood Southshore Medical Center participates in the AOA Intern Registration Program to select candidates for its internship/residency programs. Candidates are invited for personal interviews based on their eligibility above and consideration of the selection criteria below. Candidates for our internship/residency programs will be ranked and selected according to a composite evaluation of the following and other criteria:*
1. passing score on National Board of Osteopathic Medical Examiners (NBOME) Part I. Must have taken and passed Part II prior to Rank Order List being submitted to National Matching Service (occurs on the fourth Friday of January) . Residents must have successfully completed COMLEX III prior to entry into the OGME-3 year. See Policy on Housestaff Evaluation and Promotion.
2. interview ratings of personal attitudes – personality, communication skills, motivation, integrity,
3. visa status,
4. special attributes – medical school honors, research experience, community service.
At the conclusion of the recruitment process, a rank order list of candidates is compiled by the internship/residency program director with input from their program’s selection committee. The rank list is then submitted to the Intern Registration Program. Each program has established criteria for selection as described in their program policies. If positions are not filled with the matching process through Intern Registration Program, candidates are interviewed and selected to fill open positions using the same criteria as those used for the matching process.
*Applicants who completed medical school training prior to 2002, at a minimum (i.e. if boards were not taken during medical school), must show evidence of criteria 2, 3, and 4.
Oakwood does not discriminate when considering candidates with regard to gender, race, age, religion, national origin, disability, veteran status, marital status, weight, or height.
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Housestaff Employment Procedures
1. Interns and residents will sign the employment agreement and return to the Medical Education Office. Once signed, one original will be mailed to the intern/resident and one original will be kept for the intern’s/resident’s file.
2. All employees of the corporation are required to have a physical. This is done during their orientation. A physical consists of a urine drug screen, urine dip, TB test (x2)*, respiratory fit test, eye exam, blood draw, injection of hepatitis series*.*If you have had a TB test or hepatitis B vaccine done within the last year, please bring documentation with you or send it with your H & P packet.
3. Orientation is usually the last two weeks of June. Orientation is mandatory for all incoming interns and residents. If an incoming intern or resident is unable to attend orientation, they must see the education program coordinator to receive pertinent information and schedule for necessary information, i.e., physical, beepers, DEA#, etc.
4. All housestaff must be licensed by the State of Michigan before they are able to begin their training. If they are an intern or first year resident, they will receive a limited educational license. An application is mailed to all incoming interns/residents in March. The individual fills out the application, returns it to Medical Education, who then sends it with payment to the State of Michigan. Once the paper copy is received, a copy is given to the education program coordinator. If a resident is a second year or has had 2 years previous training as a resident, they may apply for a permanent license. These applications may be obtained on the www.michigan.gov/elicense web site. Once the paper copy has been received, they need to provide a copy to the education program coordinator. If you don’t have your license by July 1st, you cannot begin your training program. If you haven’t renewed your license by the end of the 60-day grace period, you will be suspended without pay until you are licensed.
5. New housestaff will sign up and choose their benefits during orientation.
6. All housestaff must be ACLS and BLS certified and maintain certification throughout their internship/residency.
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Requirements for the Credentialing of Housestaff
PURPOSE: Oakwood Healthcare is committed to provide the public with well-trained physicians who possess the traits of high moral character and standards. The purpose of this policy is to help ensure a safe environment for patients, employees, and the general public by establishing required credentials for all residents training at our institutions.
SCOPE: This policy applies to all residents receiving offers of employment from any facility or entity associated with Oakwood Healthcare on or after the effective date shown above. It also applies to residents rotating at Oakwood facilities from other institutions. This policy does not apply to residents who are moonlighting at Oakwood. Moonlighting is a special privilege granted through the appropriate hospital Medical Staff Credentials Committee process.
AUTHORIZATION: Applicants for training experiences at Oakwood institutions must provide a signed release-of-information request establishing Oakwood’s right to secure the information necessary to fulfill this policy.
GENERAL INFORMATION
All residents must be credentialed in accordance with the following requirements prior to assuming patient care responsibilities.
All required materials must be submitted to the Medical Education Office no less than 60 days prior to the effective date of the resident's appointment/reappointment.
The Coordinator will review the materials and: o Submit them to the Medical Education Committee for approval OR o Notify the appropriate program director of deficiencies that prevent approval (i.e.,
missing documents, copies vs. originals, etc.). The application will be submitted to the Medical Education Committee as soon as the deficiency is corrected.
Upon approval by the Medical Executive Committee, the Chairman of the Medical Education Committee will send an appointment letter to the resident and program director.
It is the responsibility of the program director to notify the Medical Education Committee of any changes in a resident's clinical privileges (additions, reductions, restrictions, termination, etc…). Notification must be submitted, in writing, when the change becomes effective as an amendment to the current appointment.
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REQUIREMENTS FOR INITIAL RESIDENT APPOINTMENTS Educational Program Responsibilities:
1. Letter from the program director requesting appointment of new resident member, including: Specific residents staff title (resident, fellow, etc.), For fellows, division/subspecialty designation, Dates of appointment -- limited to one year only, and Statement regarding the applicant's physical and mental health.
2. Resident supplemental application form, completed by the applicant: Responses to all sections must be complete. MUST include picture.
3. Curriculum Vitae: All periods from graduation to present must be specified. For any periods not accounted for on the CV, the applicant is responsible for providing
details. If, during any of this time, the applicant was not in training or employed, he/she must document his/her activities in writing.
4. Documentation of medical education: Original Dean's letter (now titled Medical Student Performance Evaluation - MSPE). Note
that 'Dean's letters' often are written prior to graduation and, therefore, do not contain the date of graduation.
Original Transcript . Document a. or b. above must specify date of graduation (exception - see #10 below).
5. Documentation of all periods of graduate medical education residencies: Notarized copy of training certificate, or Letter of recommendation from program director specifying inclusive dates of training and
level successfully completed.
6. Verification of all non-training clinical activities: Original documentation from locations of non-training employment/practices (hospitals,
practices, etc.). See General Reference Form. Statement from applicant for any period since medical school graduation not covered under
#5 or #6a.
7. Three letters of recommendation: Must be originals, At least one must be provided by person with/for whom applicant has worked during past
year. One may include the Program Director’s reference (See #1 above). Must be from the prior program director if applicant is coming from another training program.
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8. Proof of Michigan licensure, temporary or permanent, if applicable: Must be official transcript or original valid license with expiration date. License Verification Form must be completed. (see OHI policy on licensure/certification)
9. Original documentation from all residency training programs of liability coverage and claims history for applicants beyond the PGY 1 level:
Statement from all past carriers on past claims/actions occurring during the past ten years must include inclusive dates of coverage.
'Certificate of insurance' for current liability insurance coverage, including inclusive dates of coverage.
'Certificate of insurance' for future liability coverage if applicant will be covered by non-Oakwood carrier during appointment.
Residency Office Responsibilities: 10. For June/July intern (PGY 1) appointments:
Applications should be submitted by September 1st. Non-compliant residents will face suspension after November 1st.
Proof of graduation directly from the medical school. Original documentation of liability insurance coverage and claims history.
11. Secure Supplemental Application (confidential questions) and Release Statement from applicants. 12. Secure Recommendation letters (sent with employment packet), one signed by program director/another from a supervisor of the applicant. 13. Secure temporary Michigan medical training licenses. 14. Query the AMA database, and the National Practitioner Data Bank (NPDB) if currently a resident. 15. Secure statement of applicant’s physical and mental health from Occupational Medicine including drug screen results.
Prior to authorizing that applicant may begin working: 16. Secure results of pre-employment drug screening from Occupational Health. 17. Secure results of Criminal Background Check from Human Resources.
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Criminal Background Check Required for Housestaff
POLICY1. Oakwood Healthcare requires a criminal background check as part of the credentialing process
for all residents.2. Background checks will be performed only after the applicant has received an offer of
employment.3. All employment offers are contingent upon satisfactory results of a criminal background check.4. Criminal background information released to Oakwood will be used only for purposes of assisting
in making hiring or other employment decisions.5. If a background check identifies issues which may preclude employment, the case will be referred
to the Graduate Medical Education Committee for review and action or the Chair of the Graduate Medical Education Committee.
PROCEDURE1. Application: The Application for Appointment includes an inquiry about criminal convictions.
Applicants who refuse to complete this section or do not answer truthfully and completely, will not receive offers of employment, or employees will have their employment terminated. Any Resident Agreement already signed will be cancelled.
2. Waiver/Consent: The Application for Appointment will include a Consent Form for a Criminal Background Investigation. Refusal to provide adequate/correct information or to provide consent for investigation will result in withdrawal of offer of employment.
3. Inquiry:a) The background check will be initiated by Human Resources as part of the routine
credentialing of residents prior to appointment.b) A copy of the informed consent form will be faxed to the company authorized to perform
the background check.c) A confidentiality agreement must be signed by the receiving company. The authorized
company will be instructed to provide results to authorized individuals only.4. Convictions:
a) If an applicant truthfully discloses conviction(s) on the application, an evaluation of each conviction will be made before making a conditional offer of employment.
b) The existence of a conviction does not automatically disqualify an individual from eligibility for employment. Relevant considerations may include, but are not limited to the date, nature and number of convictions; the relationship the conviction bares to the duties and responsibilities of the job; and successful efforts toward rehabilitation. Any decision to reject or accept an applicant with a conviction is solely at the discretion of Oakwood.
c) If the background check identifies a criminal conviction not disclosed on the employment application, the applicant will be notified and the offer of employment withdrawn.
d) If Oakwood becomes aware that a current employee has not completed the application truthfully, he/she will be subject to disciplinary action up to and including termination.
5. Results:a) Confidentiality: Reasonable efforts will be made to ensure that results of criminal
background checks are kept as confidential as possible with a limited number of persons authorized to review results. (Refer to #3 (d) above).
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b) Access to Results: The Director of Medical Education will review all criminal background checks concerns. If adverse information deemed to be relevant to the applicant’s suitability for employment is contained in the background check, the Director of Medical Education will notify the applicant in writing and will refer the report the Medical Education Committee. The Graduate Medical Education Committee or the Chair of the Graduate Medical Education Committee will make all decisions relative to employment.
c) Information Available through Background Checks: The criminal background check will include a record of all arrests and convictions. In almost every case, only conviction information will be considered. If the check reveals information that could be relevant to the suitability for the job, the Medical Education Committee may request additional information from the applicant.
d) Ability of Applicant to Review Information: The applicant may review the criminal background check received by Oakwood by contacting the Director of Medical Education in writing.
e) Right to Respond to Adverse Report: The applicant will be asked to review any adverse information and to provide a written response to the Medical Education Committee. When appropriate, the resident may be asked to meet with the committee in person to answer questions.
f) Right to Change and/or Terminate Policy: Reasonable efforts will be made to keep employees informed of any changes in the policy. However, Oakwood reserves the right, in its sole discretion, to amend, replace, and/or terminate this policy at any time.
Approved by:Medical Education CommitteeJune 2003
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Informed Consent / Release for Criminal Background Investigation
I hereby authorize the Oakwood Healthcare System Office of Medical Education, or any qualified agent of Oakwood Healthcare, to obtain the following in connection with my appointment as house officer: criminal background information including copies of my past and present law enforcement records. This criminal background investigation is being conducted for the purpose of assisting the Oakwood Healthcare Resident Credentials and GME Committees in evaluating my suitability for appointment to the residency. The release of information pertaining to this criminal background investigation is expressly authorized.
I understand that information contained in the criminal background report may result in the withdrawal of my offer of training. I also understand that any such withdrawal may be appealed to the Graduate Medical Education Committee.
I understand that I have a right to review the information that the Oakwood Healthcare System Medical Education Committees receive in this criminal background investigation by putting a request in writing, and that I may respond to the information.
I understand that all reasonable efforts will be made by Oakwood Healthcare to protect the confidentiality of this information.
I further understand that the results of the criminal background check will be reviewed by the Oakwood Healthcare System Medical Education Committees. If negative information is contained in my report, I understand that I will be notified by the respective Director of Graduate Medical Education and will be asked to provide information in writing to the Medical Education Committee. In the case of a negative decision by the Graduate Medical Education Committee, I understand that I may appeal any decision subject to the “Due Process Policy” as outlined in the Resident Handbook.
I hereby release those individuals or companies from any liability or damage in providing such information. I agree that a photocopy of this authorization may be accepted with the same authority as the original. I hereby further release Oakwood Healthcare and its agents and employees from any and all claims, including but not limited to, claims of defamation, invasion of privacy, wrongful termination, negligence, or any other damages of or resulting from or pertaining to the collection of this information.
Signature of Applicant Date
Print Name
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Graduate Medical EducationIn/Out Rotation
Policies and ProceduresIntroduction
When the Balanced Budget Act (BBA), became law in 1997, it vastly changed the regulations governing the federal Medicare program’s reimbursement of medical education expenses incurred by teaching hospital resident training programs. The BBA regulations have simultaneously reduced those payments and increased the level of documentation required to receive them. Changes in policy, procedures, and monitoring of compliance with these regulations will ensure Oakwood receives the financial support for its medical education programs it is due.
Primary Policy
All rotations by residents in Oakwood training programs will be allowable for medical education reimbursement, as defined by HCFA regulations, unless specifically approved (as a non-allowable rotation) by the Director Medical Education.
Procedures:
1. Rotation Approval
Oakwood residency programs must obtain approval from the Director Medical Education for all rotations of residents from Oakwood to other non-Oakwood institutions or sites. Programs and/or medical staff must also obtain approval from the Director Medical Education for rotations of residents from other institutions to Oakwood clinical sites. A Rotation Request Form (RRF) must be completed and submitted to Medical Education administration by May 1 preceding the beginning of the academic year (July-June), in which the rotations will occur. Special cases can be considered for approval if the RRF is submitted 60 days in advance of the proposed rotation. RRF’s will be processed and action taken within 2 weeks of receipt by Medical Education administration.
2. Resident Information Form (RIF)
A RIF must be completed for every Oakwood resident. A RIF must also be completed for every resident rotating into or out of an Oakwood site or residency training program. This form provides the specific information on each resident (name, social security number, etc.), and the rotation that they are participating in (Oakwood site, non-Oakwood site, etc) for entry into the GME Track system. All RIF’s will be completed and entered by the program coordinator into the GME track system by July 1 of the appropriate academic year. RIF’s for schedule changes that occur after July 1 must be entered 60 days prior to the resident beginning the rotation. A copy of each RIF will be forwarded to Medical Education administration and the original retained in the resident’s program file.
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3. Resident In-rotation Orientation
Residents rotating into Oakwood sites and training programs from other institutions must check-in and receive orientation in Medical Education administration prior to beginning their rotation. Resident information will be verified in the GME Track system, general information will be provided, as well as issuing beepers and ID’s.
4. Resident Information Files
Programs will maintain a reimbursement sub-file in each resident’s program file with a checklist that documents that the following information is present:
Copy of current license Copy of ECFMG certificate (if applicable) Resident Information Form All rotation schedules applicable to that resident Information on clinical activity occurring during research months Summary of all elective rotations including name and address of site and supervising
physician
A similar file will be maintained in Medical Education administration for residents rotating into Oakwood sites and training programs from other institutions.
Failure to Comply
Failure to comply with the above referenced policies may result in termination of the rotation by the Director Medical Education. Compliance with the above policy and procedures will be included in staff and program director annual evaluations.
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MEDICAL EDUCATIONPROGRAM LETTER OF AGREEMENT &
ROTATION SCHEDULE APPROVAL FORM
MUST BE SUBMITTED FOR ALL ROTATIONS OF OAKWOOD RESIDENTS TO NON-OAKWOOD FACILITIES AND BETWEEN OAKWOOD SITES NO LATER THAN 60 DAYS PRIOR TO ANY ANTICIPATED ROTATION. FAILURE TO COMPLY MAY RESULT IN DENIAL OF ROTATION.
A RESIDENT INFORMATION FORM FOR EACH ROTATING RESIDENT MUST ACCOMPANY THIS REQUEST.
SECTION I: TO BE COMPLETED BY PROGRAM DIRECTOR
Name of Rotation: _______________________________________________________________
Requesting Residency Program: ____________________________________________________
Home Institution of Rotating Resident: _________________________________________
Institution/Site where majority of rotation will occur: ____________________________________
Signed active agreements for rotation is available: Yes (attached) No
Number of Residents Length of Rotation:for rotation: (i.e. number of months/academic year)
PGY I ______ PGY I Length ______PGY II ______ PGY II Length ______PGY III ______ PGY III Length ______PGY IV ______ PGY IV Length ______PGY V ______ PGY V Length ______ Goals & Objectives of rotation: ______________________________________________________ _________________________________________________________________________________
_________________________________________________________________________________
Official responsible for rotation on-site: ________________________________________________
Title: ________________________________________________
Address: ________________________________________________ ________________________________________________
Phone: ____________________ Fax: _____________________
Supervising Teaching Physician(s): ______________________________ Date: _________
Signature
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Evaluations to be completed by supervising physicians: Yes No Evaluations due no later than 30 days after rotation completed: Due date: _______________
Policies & Procedures of host institution apply: Yes No
Requesting Program Director: __________________________ Date: ____________ Signature
Requesting Director of: _______________________________________ Date: ______________Medical Education Signature
SECTION II: TO BE COMPLETED BY DIRECTOR OF MEDICAL EDUCATION
Agreement on file: Yes No
Meets Requirements: Yes No
Cap Review Complete: Yes No
Approved: Denied:
Director of Medical Education: ________________________________ Date: ______________Signature
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MEDICAL EDUCATIONRESIDENT ROTATION INFORMATION FORM
LICENSES AND CERTIFICATIONS: The following information must accompany this form: (NOTE: This information need only be submitted once per academic year for rotations occurring between Oakwood sites)
Michigan Educational Limited License OR Michigan Permanent Physicians License and DEA license Michigan Controlled Substance License Proof of current ACLS certification Copy of ECFMG Certificate (if applicable) Proof of current TB skin test Proof of Liability Coverage
Rotation Requested: _________________________Preceptor: ____________________________
Resident Name: ____________________________Program: ___________________________
PGY Level: ___ I ___ II ___ III ___ IV ___ V
Pager Number: ___________________ Alternate Number: ____________________
Dates of rotation: ______________________ to __________________________ Month/Day/Year Month/Day/Year
Please estimate the percentage of time the resident will spend during the requested rotation at the
following:
Oakwood Hospital and Medical Center ______ %
Oakwood Annapolis Hospital ______ %
Oakwood Southshore Hospital ______ %
Oakwood Heritage Hospital ______ %
Other Hospitals (please indicate): __________________________________ _____%Location Name
__________________________________ _____%Location Name
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PROGRAM DIRECTOR ATTESTATIONI verify that:
(a ) The above named Resident/Fellow/Intern is a trainee in good standing in a program, which I direct, and that there has been no licensing, liability, disciplinary or other problems with this applicant.
(b ) The above named Resident/Fellow/Intern has received all hazardous material training and universal body fluidprecautions training and exposure to blood borne pathogens training as required by the State of Michigan and Federal Law.
(c ) The above named Resident/Fellow/Intern will complete all medical records, for which they are responsible, in a timely manner and in full compliance with all policies and/or requirements established by the hospital and/or Medical Staff and/or attending physician.
(d ) The above named Resident/Fellow/Intern is able to perform the duties and responsibilities determined by the preceptor of the defined rotation as listed in the goals/objectives section of the Rotation Schedule Approval Form.
(e ) The above named Resident/Fellow/Intern’s activities at OHS sites and outside institutions will be adequately covered by Professional Liability Insurance under a policy issued to the home institution by the program.
Program Director: _______________________________________ Date: ______________ Signature
Action by OHS Director of Medical Education: _____ Approved _____ Denied
If denied, reason for denial: ___________________________________________________________________
___________________________________________________________________
Director of Medical Education: ______________________________________ Date: ______________ Signature
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MEDICAL EDUCATIONOAKWOOD SOUTHSHORE INTERN/RESIDENT
OUT ROTATION APPROVAL FORM (for Non-Oakwood sites)
Oakwood Resident Name:
PGY Level: I II III IV V VI Program:
Name of Rotation:
Institution/Site where majority of rotation will occur:
Signed active agreements for rotation is available: Yes (attached) No Rotation Supervising Physician Signature:
Signature
Rotation Supervising Physician Name: Print Name
Title:
Address:
Phone: Fax:
Email:
Goals & Objectives of rotation:
Length of Rotation: _____________________________ Date: _______________________________
Evaluations to be completed by supervising physicians: Yes No (Due two weeks after rotation completed)
Policies & Procedures of host institution will apply. PROGRAM DIRECTOR SIGNATURE: __________________________________________________________
Signature
SOUTHSHORE DIRECTOR OF MEDICAL EDUCATION __________________________________________Craig Glines, DO
TO BE COMPLETED BY DIRECTOR OF MEDICAL EDUCATION
Agreement on file: Yes NoMeets Requirements: Yes NoCap Review Complete: Yes No
Approved: Denied: ____________________________________________________________ Hosting Site Director of Medical Education Signature
Date: ____________________
PLEASE RETURN COMPLETED FORM TO:Oakwood Southshore Medical Center
Department of Medical Education5450 Fort Street
Trenton, MI 48183(Ph) 734.671.3297 (Fx) 734.362.6715
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Intern/Resident Grievance Procedure
The purpose of this policy is to define the usual process at Oakwood Southshore for housestaff to communicate substantive issues and concerns to the program’s and institution’s administration. It also defines the mechanisms for an official, impartial hearing of concerns that are not resolved through usual, initial communications with administration. The intent is to provide the due process and an appeal mechanism in instances where it is needed.
1. Housestaff who have concerns or issues related to the interpretation, application, or breach of any policy, practice, or procedure in their educational program, or Medical Education in general should:
a) first discuss them with their program director,b) if reasonable discussion with the program director does not lead to resolution of
the concern, the intern(s)/resident(s) should bring the issue to the attention of the Medical Education office,
c) if reasonable discussion with the Medical Education office does not resolve the issue, a formal grievance may be sent in written form to the Medical Education Committee.
2. Housestaff wishing to resolve a specific grievance will forward their complaint in writing (addressed to the Medical Education Committee), to the Medical Education office. The intern(s)/resident(s) concerned, or their colleagues representing them – such as the chief resident(s), will then be scheduled to present a summary of the complaint to the Medical Education Committee at its next meeting. Legal representatives will not participate in or be present during Medical Education Committee of subcommittee deliberations.
3. If interns/residents desire confidentiality in forwarding the grievance to the Medical Education office or in its presentation to the Medical Education Committee/subcommittees, they should contact Diana Balint (library manager).
4. Upon hearing the summary of the complaint, the Medical Education Committee will nominate a subcommittee to review that specific complaint. The subcommittee must be made up of Medical Education Committee members and include:
a resident two faculty (one from the program from which complaint emanated and one
not) a medical staff physician a chairperson who cannot also simultaneously fill one of the above positions a non-voting administrative resource person
The chairperson will be nominated and elected by the Medical Education Committee.
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5. The Grievance Subcommittee will meet within two weeks to consider resolution for the complaint. Residents, program directors, and the Medical Education office will submit documentation they feel is important to the committee secretary prior to the first meeting. The subcommittee chairperson may request additional documentation, as they or the subcommittee feels necessary.
6. The subcommittee will, at the designated time and place, hear the intern(s)/resident(s) concerned present the details of their complaint and their proposed solutions in full. Other concerned parties may also present their views on the issues to the subcommittees at that time. Having heard the intern(s)/resident(s) and other parties concerned, they will then be excused from the meeting.
7. The subcommittee will then immediately deliberate behind closed doors, without interference or participation by anyone other than subcommittee members.
8. The subcommittee will have the fiduciary responsibility to make a final recommendation regarding resolution of the complaint. This will be expected at the time of the first meeting. In rare circumstances, at the chairperson’s discretion, the subcommittee may elect to obtain additional information and meet again in one week to finalize their recommendation(s) for resolution of the complaint.
9. The final recommendation(s) of the Grievance Subcommittee will be distributed by the chairperson to the Medical Education Committee, the intern(s)/resident(s) concerned, and the Medical Education office within 3 work days.
10. The subcommittee’s final recommendation(s) for resolution of the complaint are not necessarily final and binding:
Those recommendations requiring financial remuneration are subject to review and approval by Oakwood Healthcare System.
Intern(s)/ Resident(s) concerned with the complaint may choose to appeal the subcommittee’s recommendation(s). The appeals process is outlined below.
In all other cases, the subcommittee’s recommendations are final and binding, and the Medical Education Committee will affect the recommendations of the subcommittee or direct the Medical Education office to do so.
11. If the intern(s)/resident(s) appeal the subcommittee’s recommendations, they will submit in writing their appeal to the Medical Education Committee, including specific reasons why they feel an appeal is necessary despite the Grievance Subcommittee’s deliberations. The Medical Education Committee will consider this request for appeal and vote to:
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a) retain the subcommittee’s recommendations,b) or nominate a Grievance Appeals Committee.
If the Medical Education Committee votes to retain the recommendations, they are final and binding.
12. In case of appeal, if the Medical Education Committee elects to nominate an Appeals Subcommittee, the constituents will be from the same groups as outlined for the Grievance Subcommittee, but new persons will be nominated first from the Medical Education Committee. If an appropriate member is not available from the Medical Education Committee, nonmembers will be nominated. In addition to the constituents outlined for the Grievance Subcommittee, an administrator from Oakwood Southshore Medical Center will be nominated to the Appeals Subcommittee, as will a program director or leader from an outside institution.
13. The Appeals subcommittee will follow the same process as outlined above for the Grievance Subcommittee. The Grievance Appeals Subcommittee recommendations for resolution of the complaint are final and binding on all parties.
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Policy on Housestaff Evaluation and Promotion
1. All housestaff must be evaluated in writing and their performance reviewed with them verbally upon completion of each rotation.
2. Residents must receive a written summary of the residency program’s evaluation of their clinical competence at least twice a year.
Written summate evaluations will be generated by the residency program on or before November 15th and June 15th each year. Residents will be notified in writing if they are not eligible for promotion in the next academic year on or before the Oakwood uniform contract renewal date (March 1st).Interns will meet with the Director of Medical Education quarterly to discuss their progress through the internship.
3. Housestaff evaluations must include an assessment of their: a) interpersonal skillsb) clinical examination skillsc) procedural skillsd) decision-making and judgmente) medical recordsf) professional conduct
A resident must have passed COMLEX III by December of their OGME-2 year to be granted entry into the OGME-3 year. The resident must notify Medical Education of test results from the December test immediately upon receipt.
4. Residents must maintain logs as specified by their residency program. Residents should familiarize themselves with the specialty college specifications for the log recording.
5. A permanent record of all semiannual evaluation summaries, procedures logged, and a summary of counseling provided for residents must be maintained by the Medical Education Office. Such records must be available in the resident’s file and accessible to the resident and other authorized personnel.
6. The program director must prepare a written overall evaluation of the resident’s clinical competence at the conclusion of the resident’s period of training in the program (either termination or successful completion).
7. In the event of an adverse annual evaluation, the resident must be offered an opportunity to address the stated deficiencies or misconduct with a clinical competence committee constituted by the residency program. Academic due process must be followed as described in sections four (4) through seven (7) of the resident contract.
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Housestaff Supervision, Duty Hours, and Work Environment
Medical Education will ensure that our GME programs are provided appropriate supervision for all housestaff, as well as a duty hour schedule and work environment that is consistent with proper patient care, the educational needs of interns/residents, and the applicable program requirements.
Supervision:
There will be sufficient institutional oversight to assure that housestaff are appropriately supervised. Interns/residents will be supervised by teaching staff in such a way that the interns/residents assume progressively increasing responsibility according to their level of education, ability, and experience. On-call schedules for teaching staff will be structured to ensure that supervision is readily available to interns/residents on duty. The level of responsibility accorded to each intern/resident must be determined by the teaching staff.
To ensure oversight of resident supervision and graded authority and responsibility, the program must use the following classification of supervision:
a) Direct Supervision – the supervising physician is physically present with the resident and patient.
b) Indirect Supervision with direct supervision immediately available - the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.
c) Indirect Supervision with direct supervision available - the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision.
d) Oversight – The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
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Duty Hours: AOA Work Hours Policy
All residents will log all duty hours using the New Innovations on-line application. Residents will enter data on their duty hours at least twice monthly.
Program directors will take immediate action to respond to any reported violations and provide a monthly summary of duty hour violation and action taken to the Medical Education Committee meeting.
1. Housestaff are not assigned to work physically on duty in excess of 80 hours per week averaged over a 4-week period, inclusive of in-house night call and any allowed moonlighting. If moonlighting is permitted, all moonlighting will be inclusive of the 80-hour per week maximum work limit and must be reported (see Moonlighting Policy below).
2. Housestaff shall not work in excess of 24 consecutive hours.
a. Allowances for already initiated clinical care, transfer of care, educational debriefing and formal didactic activities may occur, but shall not exceed 4 additional hours and must be reported in New Innovations Duty Hours by the Housestaff in writing with rationale to the DME/program director and reviewed by the MEC for monitoring individual residents and program. These allowances are not permitted for OGME-1 trainees.
b. Housestaff shall not assume responsibility for a new patient or any new clinical activity after working 24 hours.
3. Housestaff shall have 48-hour periods off on alternate weeks, or at least one 24-hour period off each week and shall have no call responsibility during that time.
4. Upon conclusion of a 20-24 hour duty shift, Housestaff shall have a minimum of 12 hours off before being required to be on duty or on call again. Upon completing a lesser hour duty period, adequate time for rest and personal activity must be provided.
a. Upon completing a duty period of at least 12 but less than 20 hours, a minimum period of 10 hours off must be provided.
5. All off-duty time are totally free from clinical, on call and educational activity.
6. Rotations in which Housestaff are assigned to Emergency Department duty shall ensure that Housestaff work no longer than 12 hour shifts with no more than 30 additional minutes allowed for transfer of care and shall be required to report in writing to the DME/program director for review by the MEC, only any time exceeding the 30 additional minutes, for monitoring individual trainees and program.
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7. In cases where Housestaff is engaged in patient responsibility which cannot be interrupted at the duty hour limits, additional coverage shall be assigned as soon as possible by the attending staff to relieve the Housestaff involved. Patient care responsibility is not precluded by the duty hour’s policy.
8. The Housestaff shall not be assigned to in-hospital call more often than every third night averaged over any consecutive four-week period. Home call is not subject to this policy; however it must satisfy the requirement for time off. Any time spent returning to the hospital must be included in the 80 hour maximum limit.
Medical Education will ensure that each internship/residency program establishes formal policies governing housestaff duty hours that foster intern/resident education and facilitate the care of patients.
Work Environment:
Medical Education will provide services and develop systems to minimize the work of interns/residents that is extraneous to their educational programs, ensuring that the following conditions are met:
1. The training institution shall provide an on-call room for residents, which is clean, quiet, safe and comfortable, so to permit rest during call. A telephone shall be present in the on-call room. Toilet and shower facilities should be present in or convenient to the room. Nourishment shall be available during the on-call hours of the night.
2. Patient support services, such as intravenous services, phlebotomy services, and laboratory services, as well as messenger and transporter services will be provided in a manner appropriate to and consistent with educational objectives and patient care.
3. An effective laboratory, medical records, and radiologic information retrieval system will be in place to provide for appropriate to and consistent with educational objectives and patient care.
4. Appropriate security and personal safety measures will be provided to housestaff in all locations including but not limited to parking facilities, on-call quarters, hospital and institutional grounds and related clinical facilities, (i.e., medical office building).
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Incident Reporting
PROTOCOL: INCIDENT REPORTING
PATIENTS: All patients to whom intern/resident physicians are assigned.
DEFINITIONS:
Incident: Any occurrence that happens to a patient that generates either a medication incident report or a quality control report.
Minor Incident: Any occurrence to a patient which results in the filing of a medication incident report or a quality control report, where the patient is not adversely affected and no treatment is required.
Major Incident: Any occurrence to a patient, which results in the filing of a medication incident report or a quality control report where the patient has been adversely affected or required follow-up treatment.
PROTOCOL:
1. An intern/resident physician must be notified of all incidents involving a patient.
2. An intern/resident physician shall determine whether the incident is minor or major.
3. The attending physician shall not be notified by the intern/resident physician if the incident is minor.
4. Nursing staff will flag the patient’s chart to alert the attending physician that a minor incident occurred.
5. The attending physician shall be notified by the intern/resident physician if the incident is major.
6. Notification of the attending physician must be documented in the patient record.
7. Nursing staff will flag the patient’s chart to alert the attending physician that a major incident occurred.
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PROTOCOL: INCIDENT REPORTING
PATIENTS: All patients to whom intern/resident physicians are NOT assigned; but to whom HOUSE PHYSICIANS(MOONLIGHTING PHYSICIANS) are assigned.
DEFINITIONS:
Incident: Any occurrence that happens to a patient that generates either a medication incident report or a quality control report.
Minor Incident: Any occurrence to a patient which results in the filing of a medication incident report or a quality control report, where the patient is not adversely affected and no treatment is required.
Major Incident: Any occurrence to a patient, which results in the filing of a medication incident report or a quality control report where the patient has been adversely affected or requires follow-up treatment.
PROTOCOL:
1. A house physician (moonlighting physician) must be notified of all incidents involving a patient.
2. A house physician (moonlighting physician) shall determine whether the incident is minor or major.
3. The attending physician shall not be notified by the house physician (moonlighting physician) if the incident is minor.
4. Nursing staff will flag the patient’s chart to alert the attending physician that a minor incident occurred.
5. The attending physician shall be notified by the house physician (moonlighting physician) if the incident is major.
6. Notification of the attending physician must be documented in the patient’s record.
7. Nursing staff will flag the patient’s chart to alert the attending physician that a major incident occurred.
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PROTOCOL: INCIDENT REPORTING
PATIENTS: All patients to whom intern/resident physicians are NOT assigned; and to whom HOUSE PHYSICIANS (MOONLIGHTING PHYSICIANS) are not assigned.
DEFINITIONS:
Incident: Any occurrence that happens to a patient that generates either a medication incident report or a quality control report.
Minor Incident: Any occurrence to a patient which results in the filing of a medication incident report or a quality control report, where the patient is not adversely affected and no treatment is required.
Major Incident: Any occurrence to a patient, which results in the filing of a medication incident report or a quality control report where the patient has been adversely affected and requires follow-up treatment.
PROTOCOL:
1. The attending physician of record must be notified of all major and minor incidents involving a patient.
2. Notification of the attending physician of record of all major and minor incidents involving a patient is to be documented on the patient record by the nurse in charge.
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Infection Control
Post Exposure Prophylaxis (PEP)http://oaknet/documents/PolsNProcs/IC/602.pdf
HIV/HBV/HCV Infected Healthcare Workershttp://oaknet/documents/PolsNProcs/IC/603.pdf
Exposure Control Plan – Blood Borne Pathogenshttp://oaknet/documents/PolsNProcs/IC/205.pdf
Employee Health Services Exposure Procedureshttp://oaknet/documents/PolsNProcs/IC/601.pdf
Guidelines for Healthcare Workershttp://oaknet/documents/PolsNProcs/IC/201.pdf
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Internship/Residency Certification Policy
1. Upon successful completion of training, every intern/resident will receive a certificate verifying successful completion signed by the CEO, Chairman, Board of Trustees, Chief of Staff, Director of Medical Education, Chief of Service, and Program Director of the internship/residency.
2. A copy of this certificate will be marked “copy” and placed in the intern’s/resident’s permanent file (record).
3. If the intern/resident subsequently requests certification of training, Oakwood Southshore Medical Center will provide either a) a copy of the file copy of the certificate, b) a letter that certifies that the intern/resident successfully completed the program, signed by the current Program Director and current Director of Medical Education, or c) a diploma signed by the current CEO, Chairman Board of Trustees, Chief of Staff, Director of Medical Education, Chief of Service, and Program Director of internship/residency with the duplicate reissue date noted on the certificate.
4. A period of 30 days is required from the time the request is received to mailing of documentation to allow for location and review of file to determine that the physician making the request successfully completed training at Oakwood Southshore Medical Center. A fee of $100 will be required for duplicate diplomas to be created. Copies of diplomas and letters are free of charge.
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Policy & Procedure on Intern and Resident Licenses
Introduction
Interns and residents are not allowed to practice medicine or write prescriptions unless they have valid licenses from the State of Michigan. A valid license is an MD, DO or DPM Limited Educational License or an MD, DO or DPM Permanent License, and Controlled Substance License.
Procedure for Limited Educational and Controlled Substance License:
When an intern matches or is hired into a program, Oakwood Southshore Medical Education will provide information to apply for a limited educational license. Medical Education will submit the Certification of Training form with Director of Medical Education’s signature. The application must be completed by the intern and submitted to the address on the application, along with any fees required. Fees will be reimbursed at a maximum of $170 within guidelines of Accounts Payable policy. You must submit your receipt or cancelled check for reimbursement after your start date. The hospital address must be used on the application. This avoids any confusion of moving and/or address changes.
It is the responsibility of the intern to have his/her medical school fill out the school’s form. The school must mail the form in to the State of Michigan, along with a copy of original transcripts. Delays will result if the form is not sent in directly by the school.
When the license has been received, Medical Education must keep the large original in the intern’s file. The small wallet license must be given to the intern.
Interns are required to carry a copy of their licenses on their person while on duty in the hospital or clinic.
A resident may have a limited license for 5 years. After 5 years they must apply for a permanent license.
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Procedure for Resident Permanent Licenses
Once an intern completes the internship and enters a residency program, they may apply for a permanent license. A permanent license is not required to work in their residency program.
If a resident would like to apply for a permanent license, they can log onto the www.michigan.gov website to obtain an application.
The resident must pay for their permanent license. The resident can be reimbursed from money in their license allowance account. They can ONLY use the medical license allowance. No other allowance allocations may be used.
If the resident receives a permanent license, they must bring in a copy to Medical Education and have it placed in their file. The wallet license must remain on their person at all times while on duty in the hospital or clinic.
Licensure Verification Policyhttp://oaknet/documents/PolsNProcs/HR/518.pdf
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Maternity, Paternity, Adoption Leave Policy
GENERAL GUIDELINES:
1. Due to the specific characteristics of housestaff training and the impact of an intern’s/resident’s absence on patient care and the training of fellow housestaff, notification of the Program Director of pregnancy should occur as soon as possible. This should ordinarily be at least 5 months prior to an intern’s/resident’s or spouse’s estimated “due date”.
2. Specific requirements of each specialty training program governs the amount of time permitted away from continuous internship/residency training per year. Therefore, specific make-up time may be required before the intern/resident advances to the next training level and the projected date of completion of the internship/residency extended. This can also affect eligibility for Board exams.
3. With adequate advance notice, efforts to rearrange rotations will be directed towards: a) early scheduling of demanding rotations, b) elective rotations near “due date.” Adjustments in on-call responsibilities will be negotiated with the Program Director. The goals will be to maintain patient care, provide a reasonable workload for a pregnant intern/resident, and avoid unacceptable increases in other intern’s/resident’s workloads. Specific arrangements may include “make-up call” before or after the leave period. (All vacation and educational leave will be allocated to pregnancy leave for the academic year.)
4. Moonlighting will not be approved by the Program Director during maternity/paternity/adoption leave.
MATERNITY LEAVE:
1. Time away from internship/residency training for maternity leave can consist of both paid and unpaid leave. The ordinary period of leave for pregnancy and delivery is up to 6 weeks.
2. The resident is eligible to apply for time off under the Family Leave Act (FMLA) which allows the resident up to 12 weeks of time off, under the FMLA. If the resident would like to apply for FMLA , it is important to meet with your program director to determine the effect of the FMLA on the projected date of completion of the training program and human resources to determine how much will be covered under the sick and vacation time.
3. Childbirth is treated the same as disability due to other medical conditions. The determination of disability is made by the resident's personal physician. If the resident would like to apply for a medical leave of absence, they will be required to use accrued sick and vacation time prior to the 14 days not covered by short term disability.
4. The resident must obtain a physician's certification stating that she may return to work without restrictions prior to returning to work.
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5. Combined time off days do not accrue year-to-year and may not be used in advance of the next academic year.
PATERNITY LEAVE:
1. An intern/resident may elect to take up to 5 working days of paid leave within the first four weeks of (the birth) life of his baby or the first four weeks of adoption. If an intern/resident would like paid leave, this time will be composed of available combined time off days. If all available days are expended, this leave may be taken as unpaid leave.
In order to take such leave the intern/resident must:
a) Give advance notice to the Program Director as in “Guidelines” above.b) Obtain approval of supervising faculty and Program Directorc) Arrange coverage for any on-call responsibilities and scheduled outpatient
responsibilities, (acceptable to the Program Director).
ADOPTION/FATHER AS PRIMARY CARETAKER:
1. A female intern/resident adopting a child or a male intern/resident who will be primary or sole caretaker of a new child may take a maximum of four weeks leave to begin within one week of birth or adoption.
2. The paid portion of this leave will be composed of available combined time off days with any remainder being unpaid.
3. The scheduling, notification and leave guidelines are the same as for maternity leave above.
(See Human Resources Leave of Absence Policy) http://oaknet/documents/PolsNProcs/HR/207.pdf
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Medical Education Communication Modes
All students, interns, residents have access to E-mail through Oakwood Healthcare System. E-mail can be checked from any location. When you become a student/intern/resident, you are automatically signed up for e-mail. If you have not accessed your e-mail in 90 days, the password will need to be reset. This can be done through the IT department. All housestaff are given VPN access, which allows you to check Oakwood e-mail from a remote location. Please review this process as all e-mail from both medical education and the Oakwood Healthcare Corporation will only be sent to your Oakwood account.
Internet
All interns and residents are automatically signed up for Internet access when they become Housestaff. If you do not access the Internet in 90 days, the password will need to be reset. This can be done through the IT department.
Pagers
Pagers are given to the students, interns and residents during orientation by Telecommunications. Instructions are given to the student/ interns/residents at that time. Batteries can be obtained through the operator. If you are on-service you are required to answer pages between the hours of 7:00 am and 7:00 pm.
Directories
Directories can be found on OakNet.
I have read this policy and understand that it is mandatory that I check my Oakwood e-mail account daily. I understand that Oakwood e-mail can be accessed from any location via Oakwood.org. I also understand that it is mandatory that I carry my pager any time I am on service and respond to pages in a timely manner. I realize that I will be held responsible for communications sent to me.
Printed Name
Signature of Student/Intern/Resident Date
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Moonlighting Policy for Housestaff
1. Only physicians with permanent licenses are allowed to provide patient care without supervision.
2. Trainees are to track all hours in New Innovation, and that includes Moonlighting. All trainees are required to comply with the AOA mandated 80-hour work rule.
3. Trainees are not covered under Oakwood Healthcare System’s Liability Insurance while moonlighting.
4. PGY 1 trainees are not allowed to moonlight.
I have read the moonlighting policy and understand that failure to comply may result in disciplinary action.
Printed Name
Signature Date
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Medical Education Policy on Order Writing and Co-Signing
(Interns and Residents are licensed physicians)
All Progress notes, History and Physicals, Consultations, etc. have to be co-signed by the attending for all students, interns and residents.
History and Physicals and Progress notes are required to be edited and completed by the next daily visit.
Operative Reports, L & D Summaries and Discharge Summaries are to be edited and completed within 24 hours.
Orders by interns and residents do not have to be co-signed.
Students are not allowed to enter orders or take phone orders.
All Medical Records entries will be automatically dated and timed, per CMS and Joint Commission requirements.
Medication Prescribing Guidelineshttp://oaknet/documents/PolsNProcs/Medication/117.pdf
Organizational Code of Conducthttp://oaknet.ohsnet.ad.oakhealth.net/flipbooks/2010-code-of-conduct/index.html
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Personal Data Assistant (PDA) Policy and Agreement
1. Medical Education will process the reimbursement for the resident purchase of a PDA, smart phone, or laptop. The resident may use their book, travel or membership allowance funds to reimburse the cost of the items. If there are insufficient funds in the resident’s allowances, the resident is responsible for the remaining cost.
2. Resident will be responsible for maintenance and technical support of the PDA, smart phone or laptop.
3. Oakwood Healthcare Inc. and Medical Education will not be responsible for phone services or any other services associated with these devices. These services shall be the responsibility of the resident.
4. Lost or broken devices will be the responsibility of the resident.
5. Residents must complete the attached Resident PDA Program Form for Reporting Taxable Income form in order to receive reimbursement for the item (form located on “F” drive) and Resident Handbook Policies.
Revised 12/16/10
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Oakwood Healthcare SystemResident PDA Program
Form for Reporting Taxable IncomeDear Employee,
The Internal Revenue Service considers your PDA reimbursement as taxable wages in the year the reimbursement was received. Oakwood Healthcare System will pay, on your behalf, all withholding taxes generated by the reimbursement.
Example:Award Value $250.00Social Security Taxes 24.43Medicare Taxes 5.71Federal Withholding Taxes 98.50State of Michigan Withholding 15.37Total Amount Added to Form W-2 $394.01
The taxable amount will be added to the wages on your W-2 at the end of the year. If you have any questions regarding the Employee PDA program please contact me at (313) 791-4839.
Sincerely,
Lillian F. Sayles, CPPCorporate Payroll ManagerOakwood Healthcare System Department Manager: Please complete the following data and forward the completed form to Lillian Sayles in the Payroll Department at Village Plaza (Site #44). A copy of the completed form must also be sent over with all check requests for reimbursement of PDA expenditures:
Description of Reimbursement:
Monetary Value of PDA $ Date of Purchase
Employee’s Name
Employee ID#
Business Unit Department Number
Employee Signature:
Department Manager (please print):
Department Manager Phone Number:
Revised 12/16/10
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Vendor Interaction Policy
I. PurposeTo establish guidelines for resident and faculty interactions with industry representatives at Oakwood sites.
II. PolicyInteractions with industry occur in a variety of contexts, including marketing of new pharmaceutical products, medical devices, research equipment and on-site training of newly purchased devices. Although many aspects of these interactions are positive and important for promoting the educational and clinical mission of Medical Education, these interactions must be ethical and cannot create conflicts of interest that could endanger patient safety, data integrity, and the integrity of the education programs. Any interaction with industry and its vendors should be conducted so as to avoid conflicts of interest.
1. Residents and faculty should not accept of gifts of any substantial value from industry vendors.
2. Textbooks, modest meals and other gifts are appropriate only if they serve an educational function.
3. Residents and faculty may not accept gifts or compensation for listening to a sales talk by an industry representative.
4. Residents and faculty may not accept gifts or compensation for prescribing or changing a patient’s prescription.
5. Residents and faculty must consciously separate clinical care decisions from any perceived or actual benefits expected from any company.
6. It is unacceptable for patient care decisions to be influenced by the possibility of personal financial gain.
7. Vendor support of educational conferences involving the resident may be used only if the funds are provided directly to the institution, not to the resident or faculty. The program director should determine if the funded conference or program has educational merit.
8. The resident will be informed by teaching faculty of the potential conflicts of interest during interactions with industry vendors.
9. Residents, faculty and programs must also comply with the Oakwood Vendor Interaction Policy and must pay special attention to gift and meal limit values in that policy (sections IV.I.4., IV.K., IV.L., IV.M., IV.P., and IV.R.).
See OHI Vendor Interaction Policy athttp://oaknet/documents/PolsNProcs/OHI/1113.pdf
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Physician Impairment
Refer to human resources policy on Fitness for Duty.
Resident acknowledges and agrees that his/her acceptance into the residency program is conditioned on resident submitting to a drug test prior to beginning their residency program. Refusal to submit to drug testing will result in the immediate termination of their agreement.
If the test is positive, the resident shall be given the opportunity to discuss the test results and to submit information demonstrating authorized use of the drug(s) in question. A substantiated positive drug test will result in immediate termination of their agreement.
The foregoing notwithstanding, resident will be required to submit to alcohol/drug testing whenever reasonable cause exists to believe that the resident’s ability to fulfill his/her obligations under their agreement may be impaired by alcohol and/or drugs. A positive test result will be handled in accordance with the guidelines set forth in Oakwood’s Human Resources Policy and Procedure Manual.
And also refer to the contract Section 3 Resident’s Obligation, number 3.4.
(See Human Resources Policy on Fitness for Duty)
http://oaknet/documents/PolsNProcs/HR/417.pdf
(See OHS Policy #417 Fitness for Duty)
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Professionalism
Personal Pledge Formhttp://oaknet/documents/services/SE/Behavior_Standards_Personal_Pledge.pdf
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Policy on Use of Paid Time-Off for Interns/Residents
Interns/Residents are entitled to 20 combined time-off days per year including vacation time, personal days, sick time and holidays. Holidays off are not guaranteed.
Conference Day Allowance is as follows:
PGY 1 5 daysPGY 2 5 daysPGY 3 5 daysPGY 4 5 daysPGY 5 5 daysPGY 6 5 days
1. All Interns will take either the week of Christmas or New Year’s off (-5 days).
2. The week they are working they will be assigned to cover essential services in the hospital.
3. No more than 5 paid days off can be used during a single rotation.
4. No vacations during out-rotations and nights.
All requests for vacation and conferences must be pre-approved by your program director. This form must then be filed in the Medical Education Office. All sick time needs to also be reported to Medical Education.
Note: Required “conferences” such as Statewide Campus, attending a meeting so that in-training exams can be taken, etc….do not count as combined time off days or count against the conference day allowance.
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Sentinel Event
http://oaknet/documents/PolsNProcs/OHI/1033.pdf
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Visiting Residents and Interns
Purpose:
This policy is intended to verify and credential the qualifications of interns and residents who rotate at OHS. This process also guarantees that OHS will receive appropriate reimbursement and insures that all rotations have professional liability insurance.
Procedure:
1. Residents and Interns from non-Oakwood residency programs must complete the Rotation Application Form 60 days prior to start of desired rotation, according to directions on page 1 of the application (Oakwood.org\Health Education: Osteopathic Program\Policies & Forms\Application for Visiting Resident-Osteopathic).
2. Resident will complete Part I and forward to their Program Director. Program Director will complete Part II and mail to Medical Education by mail or fax as indicated on front of application.
3. Resident must also furnish copies of these documents 60 days before rotation begins:
Copy of actual Michigan Educational Limited License OR Michigan Permanent Physicians License and DEA license
Copy of actual Michigan Controlled Substance License Proof of current ACLS and BLS certification Proof of current TB skin test Proof of Liability Coverage Copy of Medical School Diploma Copy of NPI Letter Program Approval Letter
4. The Medical Education office will review the materials submitted and inform residents and their program directors if the requested rotation has been approved.
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