House Staff Manual · 2015-09-09 · House Staff Manual 2012-2013 What you will find in this guide...

MEDSTAR GEORGETOWN UNIVERSITY HOSPITAL

MEDSTAR NATIONAL REHABILITATION HOSPITAL

Physical Medicine & Rehabilitation Residency Training Program

Brain Injury Fellowships Training Program

Sports Medicine Fellowships Training Program

House Staff Manual

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M E D S T A R G U H - N R H P M & R R E S I D E N C Y T R A I N I N G P R O G R A M

House Staff Manual

Adding Physiatrists who Care©

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A word from the residency program director & chair of GME

On behalf of the faculty, I welcome you to the MedStar National Rehabilitation Hospital and wish you every success. We believe that each house officer contributes directly to the MedStar NRH’s growth and prosperity, and we hope you will take pride in being a member of our team. This manual was developed to describe some of the expectations of our house staff and to outline the policies, programs and benefits available to you. All house officers should familiarize themselves with the contents of this manual as soon as possible, for it will answer many questions about employment with MedStar NRH. The Graduate Medical Education Committee, the Residency &Fellowship Training Office, the administration and professional staff are committed to delivering a top-quality educational experience. Input from the house staff is welcomed and solicited on a continuous basis. Postgraduate medical training is the basis for your future practice. It is the foundation on which you will build your approach to patient care. These years will be among your most challenging, rewarding and enjoyable. I look forward to working with you. Again, welcome!

Chair, Graduate Medical Education Committee Program Director – MedStar GUH/NRH PM&R Residency Training Program

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ACKNOWLEDGMENT FORM

The House Staff Manual describes important information about the MedStar National Rehabilitation Hospital, and I understand that I should consult the Graduate Medical Education Office regarding any questions not answered in the manual. Since the information, policies and benefits described here are necessarily subject to change, I acknowledge that revisions to the handbook may occur. All such changes will be communicated through official notices, and I understand that revised information may supersede, modify or eliminate existing policies. Only the Program Director or the Graduate Medical Education Committee has the ability to adopt any revisions to the policies in this handbook. Furthermore, I acknowledge that the House Staff Manual is neither a contract of employment nor a legal document. I have received the handbook or been informed of how to access electronically (through the www.medstarnrh.org website or New Innovations,) and I understand that it is my responsibility to read and comply with the policies contained in this handbook and revisions made to it.

RESIDENTS’ RESPONSIBILITIES:

To develop a personal program of learning to foster continued professional growth with guidance from the teaching staff.

To participate in safe, effective and compassionate patient care, under supervision, commensurate with their level of advancement and responsibility.

To participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other resident s, fellows and students.

To participate as appropriate in institutional programs and medical staff activities and adhere to established practices, procedures, and policies of the institution.

To have appropriate representation on institutional committees and councils whose actions affect their education and/or patient care

NAME (printed): ___________________________________________ SIGNATURE: _____________________________________________ DATE: _________________

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What you will find in this guide

In this manual, you will get information on policies and procedures that impact house staff in our PM&R residency and fellowship training programs. These policies and procedures help us deliver a high quality educational experience for the resident and fellow physician in our training programs.

Introduction

Employment

Compensation/Benefits Programs

Conduct & Disciplinary Action

Ancillary Systems and other institutional policies.

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Table of Contents

A word from the residency program director & chair of GME ................................................................ 2

ACKNOWLEDGMENT FORM .................................................................................................................. 3 RESIDENTS’ RESPONSIBILITIES: .......................................................................................................... 3

WHAT YOU WILL FIND IN THIS GUIDE ........................................................................................ 4

TABLE OF CONTENTS .................................................................................................................. 5

INTRODUCTION ............................................................................................................................ 10

MEDSTAR NATIONAL REHABILITATION HOSPITAL .................................................................. 10

“America’s Best Hospitals” ........................................................................................................................ 10

MISSION ..................................................................................................................................................... 11 Quality patient care .................................................................................................................................... 11 Rehabilitation research ............................................................................................................................... 11 Education and training ............................................................................................................................... 11 Assistive technology .................................................................................................................................. 11 Advocacy ................................................................................................................................................... 11

VISION ......................................................................................................................................................... 11

VALUES ....................................................................................................................................................... 11

MEDSTAR NATIONAL REHABILITATION HOSPITAL EXECUTIVE STAFF: ........................... 13

MEDSTAR NATIONAL REHABILITATION HOSPITAL RESIDENCY TRAINING OFFICE: ... 14

EMPLOYMENT .............................................................................................................................. 15

SELECTION OF HOUSE OFFICERS FOR CLINICAL TRAINING .................................................. 15

DISMISSAL FROM A GME TRAINING PROGRAM AND TERMINATION OF EMPLOYMENT

....................................................................................................................................................................... 19

ADVANCED CARDIAC LIFE SUPPORT .............................................................................................. 20

BASIC LIFE SUPPORT TRAINING........................................................................................................ 20

BUSINESS ETHICS AND CONDUCT ..................................................................................................... 20

CHECK OUT PROCEDURE .................................................................................................................... 21

COMMITTEES ........................................................................................................................................... 22

RESIDENT STRESS and/or FATIGUE ................................................................................................... 22

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DISABILITY ACCOMMODATION ........................................................................................................ 25

DRESS CODE ............................................................................................................................................. 25

DUTY HOURS ............................................................................................................................................ 26

IN PATIENT ROTATION CAPS: ............................................................................................................ 27

EVALUATION POLICY ........................................................................................................................... 28

Evaluation of House Officers ...................................................................................................................... 28

GENERAL RESPONSIBILITIES ............................................................................................................. 29 General Responsibilities of House Staff .................................................................................................... 30

IMMIGRATION LAW COMPLIANCE .................................................................................................. 30

LEVELS OF EDUCATIONAL TRAINING ............................................................................................ 31 House Staff rotating from other hospital for Elective rotation (JCAHO accredited): ................................ 32 House Staff from Other Hospital during Mandatory Rotations: ................................................................ 33

MEDICAL LICENSURE ........................................................................................................................... 33 Medical Licensure for House Staff ............................................................................................................ 33

MOONLIGHTING and Outside Professional Employment ................................................................... 35

PERSONNEL DATA CHANGES .............................................................................................................. 40

PERSONNEL FILES OF HOUSE OFFICERS........................................................................................ 40

PHYSICAL EXAMINATIONS AND DRUG TESTING ........................................................................ 41

PROMOTION OF HOUSE OFFICERS ................................................................................................... 42

REDUCTION IN FORCE .......................................................................................................................... 43

RESTRICTIVE COVENANTS ................................................................................................................. 44

SUPERVISION OF HOUSE OFFICERS ................................................................................................. 48

Resident Competencies: .............................................................................................................................. 52 Patient Care: ............................................................................................................................................... 52 Medical Knowledge: .................................................................................................................................. 53 Practice-Based Learning and Improvement: .............................................................................................. 53 Interpersonal and Communication Skills: .................................................................................................. 54 Professionalism: ......................................................................................................................................... 54 Systems-Based Practice: ............................................................................................................................ 55

COMPENSATION AND BENEFITS .............................................................................................. 57 CAFETERIA/MEAL ALLOWANCE ....................................................................................................... 58 Cafeteria Hours for general purposes: ........................................................................................................ 58

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COMPUTER, E-MAIL USAGE, ELECTRONIC HEALTH RECORDS & CLINICAL DECISION

SUPPORT SYTEM SECURITY ACCESS ............................................................................................... 59

NETWORK SECURITY VIOLATIONS .................................................................................................. 59

CREDIT UNION ......................................................................................................................................... 61

EMPLOYEE ASSISTANCE PROGRAM ................................................................................................ 61

EMERGENCY HOUSE STAFF LOANS ................................................................................................. 61

FINANCIAL PLANS .................................................................................................................................. 62 FlexFund .................................................................................................................................................... 63 Tax Sheltered Annuity ............................................................................................................................... 63

HOUSE STAFF REIMBURSEMENT FUND .......................................................................................... 63

Travel Reimbursement: .............................................................................................................................. 64

INSURANCE PLANS ................................................................................................................................. 64 Life Insurance ............................................................................................................................................ 64 Long-Term Disability................................................................................................................................. 65 Malpractice Liability Coverage Limits ...................................................................................................... 65 Medical and Dental Insurance .................................................................................................................... 65 Short-Term Disability ................................................................................................................................ 66 Workers’ Compensation Insurance ............................................................................................................ 66

LEAVE OF ABSENCE ............................................................................................................................... 66 Family Leave.............................................................................................................................................. 66 Leave Due to Illness ................................................................................................................................... 67 Leave Due to Vacation ............................................................................................................................... 67 Administrative Leave ................................................................................................................................. 68 House Staff Medical Leave of Absence ..................................................................................................... 68

LOAN DEFERMENT ................................................................................................................................. 68

ON-CALL QUARTERS ............................................................................................................................. 69

Replacement of Keys ................................................................................................................................... 69

PAGERS ....................................................................................................................................................... 69 House Staff Pagers ..................................................................................................................................... 69

PARKING .................................................................................................................................................... 71

PHARMACY ............................................................................................................................................... 71

SCHEDULES ............................................................................................................................................... 71 Rotation Schedule: ..................................................................................................................................... 71 On-Call Schedule: ...................................................................................................................................... 71

SECURITY .................................................................................................................................................. 71

SMOKING ................................................................................................................................................... 72

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STIPENDS/PAYCHECKS ......................................................................................................................... 72

TIMESHEETS ............................................................................................................................................. 72

LAUNDRY SERVICES .............................................................................................................................. 73

CONDUCT & DISCIPLINARY ACTION ........................................................................................ 74

ACADEMIC IMPROVEMENT POLICY ................................................................................................ 74

DUE PROCESS POLICY ........................................................................................................................... 76 I. Purpose ............................................................................................................................................. 77 II. Scope ................................................................................................................................................ 77 III. Definitions ........................................................................................................................................ 77 IV. Academic Matters .......................................................................................................................... 77 V. Misconduct Matters .......................................................................................................................... 77

GRIEVANCE POLICY .............................................................................................................................. 77

HOUSE OFFICER MISCONDUCT POLICY ......................................................................................... 79

SEXUAL AND OTHER UNLAWFUL HARASSMENT ........................................................................ 82

ANCILLARY .................................................................................................................................. 83

ANNUAL REQUIREMENTS .................................................................................................................... 83

Mandatory Courses ..................................................................................................................................... 83 Completing a Course .................................................................................................................................. 83 Viewing/Printing a Transcript .................................................................................................................... 84

LIBRARY AND MEDIA SERVICES ....................................................................................................... 84

MEDICAL RECORDS ............................................................................................................................... 84

QUALITY IMPROVEMENT .................................................................................................................... 84

OTHER INSTITUTIONAL POLICIES ................................................................................................... 84

IMPAIRMENT POLICY ........................................................................................................................... 84

INTERNAL REVIEW ................................................................................................................................ 85

PHARMACEUTICAL RELATIONSHIPS .............................................................................................. 87

CONTACT INFORMATION ........................................................................................................... 89

INDEX ............................................................................................................................................ 90

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G U H - N R H P M & R R E S I D E N C Y

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Introduction

elcome to the MedStar National Rehabilitation Hospital’s graduate medical education training program in Physical Medicine & Rehabilitation and it’s subspecialties fellowship programs. The core PM&R program proudly started

in 1986 and had graduated over 130 Physiatrist as of June 2012.

Centered in the heart of Washington DC, the MedStar National Rehabilitation Hospital is ideally position to achieve its vision as the trusted leader in caring for people and advancing health. Our core PM&R program currently consists of 6 residents for each of the PGY2 to PGY4 years, one Brain Injury Fellow, one Sports Medicine Fellow and one Pediatric Fellow with plans to have fellowships in, Pain Management, Spinal Cord Injury and Cancer Rehabilitation.

MEDSTAR NATIONAL REHABILITATION HOSPITAL

“America’s Best Hospitals”

MedStar National Rehabilitation Hospital specializes in treating persons with physical disabilities caused by spinal cord and head injuries, stroke, arthritis, amputation, multiple sclerosis, post-polio syndrome, and other neurological and orthopedic conditions. It has grown from a single hospital to The MedStar NRH Medical Rehabilitation Network providing inpatient and outpatient care and day treatment programs. The network provides nearly 200,000 ambulatory visits annually in addition to the hospital’s more than 2,500 inpatient admissions. Physicians nationwide consistently rank MedStar NRH among, “America’s Best Hospitals,” as reported by U.S. News & World Report. MedStar National Rehabilitation Network now encompasses our ambulatory therapy network formerly known as MedStar NRH Regional Rehab, offering convenient and comprehensive outpatient rehabilitation services in the District of Columbia, Baltimore, Northern Virginia, Southern Maryland and suburban Maryland- eastern shore. Services are designed especially for people who are able to live at home but require ongoing or

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periodic medical care, therapy or other treatment. These services focus on evaluation treatment, functional restoration, injury prevention, and safe return to work, recreational, and other activities. MNRN’s board-certified physicians and teams of physical and occupational therapists, speech-language pathologists, psychologists, vocational rehabilitation counselors, and other clinicians have the credentials needed to meet the needs of patients with a wide range of neurologic, orthopedic and musculoskeletal conditions.

MISSION

The mission of the MedStar National Rehabilitation Hospital and the MedStar National Rehabilitation Network is to serve the community as a regional and national leader in rehabilitation services through 5 major areas:

Quality patient care

Quality patient care in inpatient, outpatient and day treatment programs

Rehabilitation research

Education and training

Education and training of rehabilitation professionals and the community

Assistive technology Assistive technology that helps persons with disabilities live productive lives

Advocacy

Advocacy - working with persons with disabilities to communicate their needs to policymakers at the local, state and national levels

VISION

To be the trusted leader in caring for people and advancing health.

VALUES

Service – We strive to anticipate and meet the needs of our patients, physicians and co-workers.

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Patient First – We strive to deliver the best to every patient every day. The patient is the first priority in everything we do.

Integrity – We communicate openly and honestly, build trust and conduct ourselves according to the highest professionalism and integrity.

Respect – We treat each individual, those we serve and those with whom we work, with the highest professionalism and dignity.

Innovation – We embrace change and work to improve all we do in a fiscally responsible manner.

Teamwork – System effectiveness is built on the collective strength and cultural diversity of everyone, working with open communication and mutual respect.

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MEDSTAR NATIONAL REHABILITATION HOSPITAL EXECUTIVE STAFF:

John Rockwood ………………………………………………………..………………..x1700 President & Chief Operating Officer, NRH Edward Eckenhoff ……………………………………………………..……………….x1674 President Emeritus, NRH Michael Boemmel ………………………………………………………..……..……..x1737 Senior Vice President & Chief Financial Officer, NRH Michael Yochelson, MD ……………………………………………………………….x1504 Vice President & Medical Director, Medical Affairs Robert Bunning, MD ……………………………………………………………..……..x1660 Associate Medical Director - Inpatient, Medical Affairs Curtis L. Whitehair, MD ………………………………………………………………..x1609 Associate Medical Director – Regional Physiatry, Medical Affairs Alexander Dromerick, MD ……………………………………………………..……..x1039 Associate Medical Director - Academic Affiliations, Medical Affairs John Brickley …………………………………………………………………….…………..(301) 581-8054 Vice President, Ambulatory Network Rosemary Welch ………………………………………………………..………………...x1197 Vice President, Patient Care Services Paul Rao, Ph.D. ………………………………………………………………………………x1438 Vice President, Clinical Services & Corporate Compliance Robert Hartman …………………………………………………………….…………….x1776 Vice President, Communications, Development, International & Volunteer Services John Toerge, DO ……………………………………………………………………………(301) 581-8131 Vice President, Medical Affairs Pamela Ashby ……………………………………………………………………………...x1908 Assistant Vice President, Human Resources & Customer Service Linda Briggs, Ph.D….……………………………………….…………………………….x1012 Assistant Vice President, Referrals & Case Management

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MEDSTAR NATIONAL REHABILITATION HOSPITAL RESIDENCY TRAINING

OFFICE:

Curtis L. Whitehair, MD…………………………………………….…………….x1627 Program Director, Physical Medicine and Rehabilitation Cynthia Pineda, MD……………………………………..……….……………….x1627 Assistant Program Director, Physical Medicine and Rehabilitation Jennifer Perianayagam………………………………………………………….x1627 GME Coordinator, Physical Medicine and Rehabilitation


Employment

SELECTION OF HOUSE OFFICERS FOR CLINICAL TRAINING

1. The Director of the Residency or Fellowship Training Program is

responsible for assuring that all appropriate selection criteria for

house officers have been met.

2. The Director of the Residency or Fellowship Training Program shall

give final approval for all contractual offers for house officer

employment. For those applying for residency or fellowship training

positions, the following selection process will be established:

a. Medical School Diploma: The applicant shall be a

graduate (or pending graduate) from the United States

or Canadian Medical School whose program is

accredited by the LCME or the AOA. If the applicant is

a graduate of a medical school outside of the U.S. or

Canada, he/she must possess a currently valid

certificate from the ECFMG or have a full and

unrestrictive license to practice in the U.S. licensing

jurisdiction.

b. For Residency training: The applicant also must have

had significant medical experience in the U.S. either as

a medical student or a PGY1 resident. The PGY1 of

any applicant must be that which satisfies the

requirements of the ABPM&R. The Residency Training

Program Director, with the approval of the

Subcommittee on Promotions, has the ability to waive

the above in special circumstances as long as ACGME

guidelines are followed.

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c. The applicant for PM&R residency training position

must provide the following documents:

1. Original Dean's Letter

2. 3 Letters of recommendation

from physicians practicing in

the U.S. and Canada who

have personally supervised

the applicant in the

performance of medical

duties. If the candidate has

previously been in

postgraduate training

program, one letter must be

from the candidate’s

former/current program

director, and two letters

must be from supervisory

attendings with whom the

candidate has rotated with

in the preceding 12 months

and/or most recent Post

Graduate Year. Additional

letters may be requested.

3. Official Medical School

Transcripts

4. Personal Statement (signed)

5. Curriculum Vitae (or equivalent)

6. ECFMG Certificate (if applicable)

7. Copy of Medical School Diploma (if applicable)

8. USMLE or COMLEX Transcript

d. The applicant for fellowship training position must

provide the following documents:

2. 3 Letters of recommendation

from physicians practicing in

the U.S. and Canada who

have personally supervised

the applicant in the

performance of medical

duties. If the candidate has

previously been in


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postgraduate training

program, one letter must be

from the candidate’s

former/current program

director, and two letters

must be from supervisory

attendings with whom the

candidate has rotated with

in the preceding 12 months

and/or most recent Post

Graduate Year. Additional

letters may be requested.

3. Official Medical School

Transcripts

4. Official Summative Evaluation

from ACGME accredited

Residency Training program

(acceptable residency

training is specified by board

eligibility)

5. Personal Statement (signed)

6. Curriculum Vitae (or equivalent)

7. ECFMG Certificate (if applicable)

8. Copy of Medical School Diploma (if applicable)

9. Copy of Residency Training Program Diploma

10. USMLE or COMLEX Transcript

As applicable, all documents noted above must be submitted with

official certified translations in English.

e. The applicant must appear for a personal interview (except in extraordinary

circumstances).

f. The MedStar MedStar NRH selects candidates from

among eligible applicants on the basis of their

preparedness, ability, aptitude, academic credentials,

communication skills and demonstrated personal

qualities such as motivation and integrity. The

MedStar MedStar NRH does not discriminate with

regard to sex, race, age, religion, color, national origin,

sexual orientation, disability or veteran’s status.


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g. As the mission of the MedStar MedStar NRH at this time is to care for

predominantly adult patients, any resident entering the MedStar MedStar

NRH PM&R Residency Training Program as a PGY2 must have had a

substantial adult medicine/surgical experience in their PGY1. Residents who

question their clinical PGY1 schedule in light of this requirement may enquire

of the MedStar NRH Program Director as to its suitability.

3. All access to personal information in the files of a training

applicant is restricted to the resident/fellow him/herself and

the Program Director of the Training Program, as well as

his/her immediate supervisor and any faculty participating

in the selection process.

4. The MedStar National Rehabilitation Hospital participates

in the National Resident Matching Program and abides by

its rules and regulations.

5. Consistent with United States Immigration Law, applicants

to the Residency Training Program must be presently

authorized to work in the United States for any employer

on a full-time basis or be eligible to participate in the J1

Exchange Visitor Program sponsored by the Educational

Commission for Foreign Medical Graduates. Effective July

1, 1998, the MedStar NRH will no longer sponsor new

residency applicants for H-1 B visas, except when required

by business necessity.


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DISMISSAL FROM A GME TRAINING PROGRAM AND TERMINATION OF

EMPLOYMENT

Graduate Medical Education Institutional Policy Approved by GMEC: March 7, 2006

I. Purpose To establish a policy for all post graduate training programs within the MedStar Health System (Washington Division) for use in dismissal of house staff from a residency program, and the corresponding the termination of house staff employment prior to the date of contract expiration. II. Scope This policy will apply to all house staff in the MedStar Health System (Washington Division). All information contained in this policy shall be read in conjunction with the house staff agreement. III. Definitions House Staff or House Officer – refers to all interns, residents and fellows enrolled in a post-graduate training program. Dismissal – refers to the termination of participation in a residency or fellowship training program prior to the completion of the academic course of study. Termination – the act of severing employment prior to the date of expiration of the house officer’s contract or the non-renewal of a house officer’s contract prior to the completion of an academic course study.

IV. Responsibilities/Requirements A. Withdrawal or dismissal from a house officer’s academic program prior to

the completion of an academic course of study may be done at either the discretion of the house officer or the hospital, or at the mutual agreement of the house officer and the hospital.

B. Resignation

1. If the house officer desires to withdraw from his or her

program, the house officer must submit a letter of

resignation to the Program Director, at least 30 days in

advance, stating the reason for the action. The 30 days’

notice may be waived, in whole or in part, at the discretion

of the Program Director.


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2. An exit interview may be requested by the Program Director and/or the Director of Medical Education/VPMA (or designee).

C. Dismissal

1. The Hospital may elect to dismiss a house officer from enrollment in a program prior to the established completion date due to:

a) Academic Failure to Progress b) Misconduct c) Abandonment of position/employment d) Any other reason set forth in the house staff

agreement

2. The decision to dismiss should be made consistent with the “Academic Improvement Policy” or the “House Officer Misconduct” Policy. 3. When a house office is informed of dismissal, he/she has the

right to request due process as delineated in the “Due Process” policy.

D. Non Renewal of Contract:

1. The Program Director may elect not to renew a house officer’s contract in accordance with the Promotion Policy (i.e., deny promotion to the next level of education) consistent with the Academic Improvement Policy or House Staff Misconduct Policy.

2. Non-renewal of contract is an action that allows the resident to request due process (See policy for “Academic Improvement” and “House Staff Misconduct”.

3. The GME Training Office should be notified immediately upon the Program Director’s decision to not renew an employment contract.

ADVANCED CARDIAC LIFE SUPPORT

BASIC LIFE SUPPORT TRAINING

Current ACLS Provider status is mandatory for all house staff and renewed on a yearly basis. The Residency Training Program Office will maintain records for the house staff. A current copy of an ACLS/BLS certification card must be provided to the Residency Training Office. Re-certification classes will be offered on a yearly basis.

BUSINESS ETHICS AND CONDUCT


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The successful business operation and reputation of the MedStar National Rehabilitation Hospital is built upon the principles of fair dealing and ethical conduct of our employees. Our reputation for integrity and excellence requires careful observance of the spirit and letter of all applicable laws and regulations, as well as a scrupulous regard for the highest standards of conduct and personal integrity. The continued success of the MedStar National Rehabilitation Hospital is dependent upon our patients’ trust and we are dedicated to preserving that trust. Employees owe a duty to the MedStar National Rehabilitation Hospital, its customers, and shareholders to act in a way that will merit the continued trust and confidence of the public. The MedStar National Rehabilitation Hospital will comply with all applicable laws and regulation and expects its directors, officers, and employees to conduct business in accordance with the letter, spirit and intent of all relevant laws and to refrain from any illegal, dishonest, or unethical conduct. In general, the use of good judgment, based on high ethical principles, will guide you with respect to lines of acceptable conduct. If a situation arises where it is difficult to determine the proper course of actions, the matter should be discussed openly with your Program Director and, if necessary, with the GME Training Office for advice and consultation. Compliance with this policy of business ethics and conduct is the responsibility of every MedStar National Rehabilitation Hospital employee. Disregarding or failing to comply with this standard of business ethics and conduct will lead to disciplinary action, up to and including possible termination of employment.

CHECK OUT PROCEDURE

House Staff are responsible for items issued to them by the MedStar National Rehabilitation Hospital or in their possession or control, including the following:

Identification badges Keys (lockers) Pagers Control Access Card Phones Laptops/Computers

All house staff are required to complete a Resident Check out List prior to leaving the Hospital. Check out forms can be picked up in the Residency Training Office. All MedStar National Rehabilitation Hospital property (ID badges, Keys, Pagers and Control Access Card) must be returned by resident on or before their last day of work. Final paychecks will be distributed through the GME Training Office pending successful completion of checkout. Where permitted by applicable laws, the MedStar National


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Rehabilitation Hospital may withhold from the employee’s check or final paycheck the cost of any items that are not returned when required. The MedStar National Rehabilitation Hospital may also take all action deemed appropriate to recover or protect its property.

COMMITTEES

Utilization Review Emergency Response Medical Records Infection Control Pharmacy and Therapeutics Bioethics Hospital QI Committee Pressure Ulcer Falls Resident’s participation in assigned committees work is strongly encouraged.

RESIDENT STRESS and/or FATIGUE

Graduate Medical Education Institutional Policy Approved by GMEC: March 7, 2006 I. Purpose

The MedStar GUH-NRH PM&R Residency Program seeks to optimize the training environment for patient care, resident and fellow learning and well-being. As an institution, we recognize that symptoms of stress and/or fatigue are normal and expected to occur periodically with the resident population, just as it would in other professional settings. However, house staff may on some occasion, experience the negative effects of excessive stress and/or fatigue. The program has adopted the following policy that ensures that stress and/or fatigue among house staff are minimized while providing quality patient care and acquiring optimal resident education.

II. Scope This policy will apply to all MedStar Georgetown University-MedStar National Rehabilitation Hospital house staff.

III. Responsibilities/ Requirements


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A. Residents 1. Residents and Fellows who perceive that they are manifesting excess stress and/or fatigue have the responsibility of immediately notifying their attending physician, chief resident, and the program director without fear of reprisal. 2. Residents and Fellows who recognize excess stress and/or fatigue in colleagues should report their observations and concerns immediately to the chief resident and program director. Reports will be kept confidential.

B. Attending Physician 1. Attending physicians who recognize that a resident or fellow is demonstrating evidence for excess stress/and or fatigue should consider the immediate release of the resident or fellow from any further patient care responsibilities at the time of recognition. 2. The attending physician should privately discuss this with the resident or fellow in the attempt to identify the reason for excess stress and/or fatigue. 3. The attending physician should notify the program director immediately of the decision to release the resident or fellow from patient care responsibilities at that time. 4. If excess fatigue or lack of sleep is an issue, the attending physician must advise the resident or fellow to rest for a period that is adequate to relieve fatigue before operating a motorized vehicle. The resident or fellow may also be advised to consider calling someone to provide transportation home. The attending should document that this advice was given. 5. A resident or fellow who has been released from patient care because of excess stress and/or fatigue cannot appeal the decision of the supervising attending. 6. A resident or fellow who has been released from patient care cannot assume patient care duties without permission of the program director.

C. Program Director (PD) 1. The PD will meet with the resident or fellow personally as soon as it can be arranged to discuss the cause(s) of excessive stress and/or fatigue and determine when the resident can assume patient care responsibilities. 2. The PD will review the resident’s or fellow’s call schedules, work hours, patient care load or any known personal problems contributing to excess stress and/or fatigue. The PD will contact the Chief resident or fellow and make adjustments to the call schedule if needed. 3. The PD will counsel the resident or fellow on methods to reduce stress and/or fatigue. The PD can also refer the resident or fellow for further counseling if needed. 4. The PD will contact the Attending Physician to discuss methods to reduce the resident’s or fellow’s stress and/or fatigue and adjustment to patient care load, if applicable. 5. Extended periods of release from patient care responsibilities that exceed requirements for completion of training must be made up to meet RRC and ABPMR training guidelines.


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D. Allied Health Personnel Allied health care professionals in patient service areas are instructed to report observations of apparent excess resident stress and/or fatigue to their immediate supervisor who will then be responsible for reporting the observation to the Program Director. Reports will be kept confidential.

IV. Education A. Residents, Fellows and Faculty should be able to recognize the signs and symptoms of excess stress and/or fatigue which may include but are not limited to the following:

-Forgetfulness -Emotional lability -Mood swings -Increased conflicts with others -Inattentiveness to details -Lack of attention to proper attire or hygiene

-Impaired awareness

B. Stress and Fatigue education is provided annually through lectures and interactive group sessions as part of the didactic curriculum. These sessions are mentored by faculty. Dissemination of evidence-based information regarding the prevention, recognition and management of stress and fatigue is also done during these sessions. C. House Staff and faculty are required to review an educational module regarding sleep, alertness and fatigue. This includes:

1. American Academy of Sleep Medicine Presentation- “Sleep, Alertness and Fatigue Education in Residency” 2. Duke University Life Curriculum- “Learning to Address Impairment and Fatigue to Enhance Patient Safety” B. Monitoring/Surveillance

1. The Program Director and Assistant Program Director meet monthly with the Competency Committee at which time concerns about resident performance, well-being, and individual problems with excess stress and/or fatigue are discussed.

2. Each house staff is assigned a faculty mentor who meets with them at least on a quarterly basis, providing another opportunity to elicit concerns about stress, fatigue and house staff well-being.

3. The Program Director meets with each house staff at least biannually to assess

overall progress in training and well-being including any concerns about stress and fatigue.

4. House Staff spend a minimum of 3 hours each day in face to face interactions with

the supervising attending. The supervising faculty by observation has the


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opportunity to assess levels of stress and fatigue and can confirm this with the house staff at any time.

5. When a house staff, faculty or allied health personnel is concerned about a house

staff’s well-being, they are encouraged to confidentially contact the program director or assistant program director at any time. They are assured that reports will be kept confidential.

6. If the house staff is found with excess stress or fatigue while on call, he/she is sent

home and the “GOAT” list is activated. The PD contacts the chief resident and assigns another house staff to complete the call based on the list. This will be considered an emergency call switch and the Chief Resident will modify the call schedule accordingly.

DISABILITY ACCOMMODATION

The MedStar National Rehabilitation Hospital is committed to complying fully with the Americans with Disabilities Act (ADA) and ensuring equal opportunity in employment practices and activities are conducted on a non-discriminatory basis. Post-offer medical examination is required only for those positions in which there is a bona fide job-related physical requirement. They are given to all persons entering the position only after conditional job offers. Medical records will be kept separate and confidential. Reasonable accommodation is available to all disabled employees, where their disability affects the performance of job functions. All employment decisions are based on the merits of the situation in accordance with defined criteria, not the disability of the individual. This policy is neither exhaustive nor exclusive. The MedStar National Rehabilitation Hospital is committed to taking all other actions necessary to ensure equal employment opportunity for persons with disabilities in accordance with the ADA and all other applicable federal, state, and local laws.

DRESS CODE

Dress, grooming, and personal cleanliness standards contribute to the morale of all employees and affect the business image the MedStar National Rehabilitation Hospital presents to its patients and visitors. House Staff are expected to present a clean and neat appearance and to dress according to the requirements of their positions. All HR dress code rules must be followed as well as all house staff must wear a long, white lab coat. Men must wear shirts with ties, and women, shirts, blouses or sweaters with skirts or pants. Hospital identification cards are issued to all new employees, and must be worn whenever on duty. House Staff are allowed to wear scrub suits when performing


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procedures, pre-call, post-call and during night call only or with approval of attending faculty.

DUTY HOURS

Graduate Medical Education Institutional Policy2-2 I. Purpose To establish a policy the MedStar Georgetown University Hospital/MedStar National Rehabilitation Hospital Residency and Fellowship Training Programs in order to monitor and schedule appropriate work/duty hours of house officers, ensuring that the educational goals of the program and learning objectives of the house staff are not compromised by reliance on house staff to fulfill institutional service obligations. II. Scope This policy will apply to all Georgetown University Hospital/MedStar National Rehabilitation Hospital residents and fellows. All information contained in this policy shall be minimum criteria for house officer duty hours. III. Definitions House Staff or House Officer – refers to all residents and fellows enrolled in the Georgetown University Hospital/MedStar National Rehabilitation Hospital Residency or Fellowship Training Programs. Post-Graduate Training Program – refers to a structured residency educational program, accredited by the ACGME, which is recognized by its specialty board, for purposes of clinical education, a structured fellowship educational program, accredited by the ACGME, which is recognized by its (sub)specialty board, for purposes of clinical education and a structured fellowship educational program, not accredited by the ACGME, which is recognized by the core GUH/NRH PM&R residency training program, for purposes of clinical education. Duty Hours – Defined as work time scheduled for all clinical and academic activities related to the residency or fellowship program, including, but not limited to patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities and scheduled academic activities such as conferences. Duty hours do not include time for a program of self-study, e.g., reading and preparation time spent away from the duty site. IV. Responsibilities/Requirements A. The Chief resident is responsible for the residency on-call schedule and code pager schedule. The Program Director or Assistant Program Director is responsible for making the ultimate decisions regarding scheduling of all duty hours for residents or fellows within their scope of supervision.


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B. On-call rooms are provided on the 2nd floor for house staff with night time duty hours or for fatigue related sleep. The call rooms should remain locked at all times. The rooms should be cleaned daily, should this not occur contact the GME Training Office or Housekeeping.

C. House staff schedules will be tailored to be consistent with the residency and fellowship requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME) in the Institutional Requirements, Common Program Requirements and Program Requirements. 1. Duty hours must be limited to 80 hours per week, averaged over a four-week

period, inclusive of all in-house activities. 2. House Staff must be provided with 1 day in 7 free from all educational and

clinical responsibilities when averaged over a four-week period, inclusive of call. 3. A 10-hour time period should be provided between all daily duty periods and after

in-house call. 4. In-house call must occur no more frequently than every third night, averaged

over a four-week period. 5. Continuous on-site duty, including in-house call, must not exceed 24 consecutive

hours. House Staff may remain on duty for up to four additional hours (for a total of 28 continuous hours) to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical care.

6. No new patients may be accepted after 24 hours of continuous duty. 7. House Staff are required to appropriately sign-out their patients to the faculty

attendings and leave the floors by 11:00AM on the post call day. 8. House Staff are required to leave the hospital by 12:00pm on post call days.

D. All House Staff are required to enter their number of daily duty hours in the online GME residency management system (New Innovations). This is reviewed by the Program Director or Assistant Program Director to ensure compliance with the duty hour regulations. E. Any house staff working in excess of the hours mentioned in item IV.C.1-8 should, and is strongly encouraged to report the situation the their Chief Resident, Program Director, Assistant Program Director, or the Senior Vice President, Medical Affairs. Violations may also be reported to the Duty Hours Compliance Hotline: 1-877-MD-WK-HRS.

IN PATIENT ROTATION CAPS:

Each resident will carry a patient load ranging from 8 to 12 patients (Stroke, TBI, and SCI services) and 8 to 14 patients in the MSK service, depending on the overall census and the complexity/education value of the individual patients. It is expected that the resident will follow a patient throughout their hospital stay; however occasionally, at the attending’s discretion, one patient may be substituted for another (if the resident has reached a cap of 12 patients (Stroke, TBI, SCI services) and 14 patient (MSK service) in order to maximize the house staff learning experience. The resident should notify the Program Director/Assistant Program Director if there are any problems regarding this issue.


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EVALUATION POLICY

Graduate Medical Education Institutional Policy Approved/Revised by GMEC: March 7, 2006

Evaluation of House Officers

Purpose To establish a policy for all post-graduate training programs within the MedStar Health System to use in the formal evaluation of house officers’ performance and for the house officers’ evaluation of the hospital and the program. Evaluation is utilized to enhance the educational process.

Scope This policy will apply to all Graduate Medical Education (GME) training programs at the MedStar National Rehabilitation Hospital. All information contained in this policy shall be used as minimum criteria for evaluation. More detailed evaluation criteria shall be delineated by the clinical departments in their respective Departmental Evaluation Policies.

III. Definitions

A. House Staff or House Officer – refers to all interns, residents and fellows participating in a MedStar Hospital post-graduate training program.

B. Post-Graduate Training Program – refers to a residency or fellowship educational program.

IV. Responsibilities/Requirements

A. Evaluation of House Officers

1. To enhance the educational process and keep all house officers apprised of their educational progress/advancement, all Program Directors (or designees) must formally evaluate each house officer at six (6) month intervals. These evaluations shall be in writing, dated, and signed by the Program Director, attesting that he/she has verbally discussed the evaluation with the house officer.

2. All formal evaluations must be kept as part of the House Officer’s

personnel file and be available upon request of the house officer at all times.


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3. At the conclusion or termination of each house officer’s training, a formal summation of performance throughout the duration of training will be completed by the Program Director and maintained as permanent documentation of the program. A copy of this final evaluation will be forwarded to the Office of Graduate Medical Education for permanent archiving.

4. All documentation of house officers’ performance by the faculty, formal or informal, must be maintained as permanent documentation by the department.

5. The Program Director shall be responsible for communicating the Departmental Policy for Evaluation to all house staff and faculty.

6. Evaluations will be one of the tools utilized in determining promotion, as specified in the Policy for the Promotion of House Officers.

B. Evaluation by House Officers

1. Each Program Director shall assure that at least annually, each house officer formally evaluates the teaching faculty and the program in writing.

2. These evaluations should be anonymous and confidential. Program Directors must assure house officers are free to comment frankly and openly without fear of intimidation or retaliation.

3. In addition to the departmental evaluation process, the Office of Graduate Medical Education will conduct an annual end-of-the-year summary evaluation of the program, the institution and the overall educational experience. All house officers are required to complete the institutional evaluation. Reports of the evaluation will be communicated to the Program Directors and the Graduate Medical Education Committee.

C. Failure to Meet Expected Standards

House Officers are expected to meet and adhere to academic, clinical and professional standards set forth by the Institutional and Program Requirements, as well as the Institution and the Department. If at any time a House Officer exhibits unsatisfactory performance, the situation will be handled in accordance with the Hospital’s Academic Improvement Policy or the House Officer Misconduct Policy.

GENERAL RESPONSIBILITIES

Graduate Medical Education Institutional Policy


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Approved by GMEC.

General Responsibilities of House Staff

I. Purpose To establish a policy for all Georgetown University Hospital/MedStar National Rehabilitation Hospital House Staff providing guidelines to house staff regarding their general responsibilities as post-graduate trainees. II. Scope This policy will apply to all GUH-NRH House Staff participating in the program. III. Definitions House Staff – refers to all residents and fellows in the post-graduate training program. IV. Responsibilities/Requirements A. Each house officer is expected to avail himself/herself of the education opportunities offered within the institution, provide medical treatment to the hospital’s patients in a competent and caring manner, and conduct himself/herself in a moral, ethical and professional manner at all times. B. To meet these responsibilities, the house officer is expected to: 1. Attend and actively participate in all conferences and teaching rounds. 2. Render appropriate medical care to our patients in a kind and caring manner

under the supervision of the attending physician. 3. Participate in the evaluation of the program, his/her peers and teaching faculty

as requested by the Program Director. 4. Do independent study using the services and resources offered through the

medical library. 5. Participate in research projects and quality improvement activities of the

Hospital. 6. Document care and complete/sign patient’s medical records in a timely manner.

9. Volunteer to serve as a member of various staff and hospital committees. 10. Be on time and present for all assignments. 11. Respond to pages promptly. 12. Conduct himself/herself in an ethical and moral manner. 13. Maintain a professional appearance and comportment. 14. Assume progressive responsibilities as he/she gains experience.

IMMIGRATION LAW COMPLIANCE

MedStar National Rehabilitation Hospital is committed to employing only United States citizens and aliens who are authorized to work in the United States for any employer on a full-time basis, and does not unlawfully discriminate on the basis of citizenship or national origin.


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In compliance with the Immigration Reform and Control Act of 1986, each new house officer, as a condition of employment, must complete the Employment Eligibility Verification Form I-9 and present documentation establishing identity and employment eligibility. Former employees who are rehired must also complete the form if they have not completed an I-9 with the MedStar National Rehabilitation Hospital within the past three years, or if their previous I-9 is no longer retained or valid. House staffs with questions or seeking more information on immigration law issues are encouraged to contact the Residency Training Office. Employees may raise questions or complaints about immigration law compliance without fear or reprisal.

LEVELS OF EDUCATIONAL TRAINING

Graduate Medical Education Institutional Policy I. Purpose To establish a policy for all education training within the NRH, to document appropriate types and levels of training in the institution. II. Scope This policy will apply to all graduate medical education teaching programs within the NRH. III. Definitions House Staff or House Officer – refers to all interns and residents participating in the National Rehabilitation Residency Training Program. IV. Responsibilities/Requirements A. Medical Students: Medical students rotate through the MedStar National Rehabilitation Hospital on one of two levels: 1. Clerkship: Rotation during the third year of medical school, to fulfill core

clerkship or elective clerkship requirements. Will require the following documentation:

- Demographic Information Form (Found on the MedStar National Rehabilitation Hospital website) - Student school’s affiliation agreement completed and signed by the appropriate personnel - Proof of recent physical examination (within one year) - Malpractice coverage provided by the supporting medical school - Medical School Transcript - Current USMLE/COMLEX Scores - Evaluation of clinical ability during rotation – forms supplied by the supporting

medical school 2. Elective: Rotation during the fourth year of medical school, to fulfill academic

requirements. Requirements are the same as clerkship.


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Institutional Benefits for medical students will include:

Free Parking Access to Call room

B. Resident: A physician must have completed at least one year of an ACGME accredited post graduate educational year in an Internal Medicine, Family Medicine, Surgery or Transitional Medicine Program as well as successful completion of USMLE part 1 & part 2 before beginning residency training. All house staff will be issued one-year contracts at the beginning of the academic year, July 1. Admission: Prior to admission and contract, the GME Training Office must have received the following original documents: - ERAS/Universal Application - Medical Student Performance Evaluation - Letters of Recommendation (3) - Official Dean’s Letter - Official Medical School Transcripts - Personal Statement (signed) - Curriculum Vitae (or equivalent) - ECFMG Certificated (if applicable) - Copy of Medical School Diploma - USMLE Transcript or NBOME Transcript

House Staff rotating from other hospital for Elective rotation (JCAHO

accredited):

They must provide the GME Training Office with the following items prior to beginning their rotation:

- A letter from the Director of Medical Education or Program Director at the sponsoring hospital stating that the house staff is in good standing

- Proof of recent Physical examination (within one year) - Proof of recent immunizations (within one year) - Proof of malpractice coverage - Copy of ECFMG certificate (if applicable) - Copy of DC License or Postgraduate Physician Enrollment (not required if rotation is less than 90 days - Proof of recent immunizations (within one year) - Proof of malpractice coverage - Copy of Evaluation form - Copy of Goals and Objectives Institutional Benefits for House Staff will include:

Meals Free parking


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House Staff from Other Hospital during Mandatory Rotations:

- A letter from the Director of Medical Education or Program Director at the sponsoring hospital stating that the house staff is in good standing

- Copy of ECFMG certificate (if applicable) - Copy of DC License or Postgraduate Physician Enrollment (not required if rotation is less than 90 days - Copy of Evaluation form - Copy of Goals and Objectives. Institutional Benefits for House Staff will include:

Meals Free parking Access to all Electronic Health Records(EHR) and Clinical Decision Support

Systems (CDSS) used by MRNR

MEDICAL LICENSURE

Graduate Medical Education Institutional Policy Revised/Approved by GMEC: February 7, 2006

Medical Licensure for House Staff

I. Purpose To establish a policy for all MedStar Georgetown University Hospital House Officers within the MedStar Health System (Washington Division) to be used in the determination of medical licensure for house officers. II. Scope This policy will apply to all house staff in the MedStar Health System (Washington Division). All information contained in this policy shall be used as criteria for medical licensure.

III. Definitions House Staff or House Officer – refers to all interns, residents and fellows enrolled in a MedStar Hospital postgraduate training program. Post-Graduate Training Program – refers to a residency or fellowship educational program. Practice of Medicine – as defined by the Department of Health, the application of scientific principles to prevent, diagnose, and treat physical and mental disease, disorders, and conditions and to safeguard life and health. Court decisions and board policy do not limit the above to patient care. IV. Responsibilities/Requirements


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A. In order to begin training, all house staff must either:

hold a unrestricted medical training license(MTL) in the District of Columbia or

hold a unrestricted medical license in the District of Columbia.

B. House staff who are in the following categories must have an unrestricted DC License in order to begin training:

5 years past medical school (for US graduates);

5 years from the beginning of ACGME-accredited, postgraduate training (for international graduates);

have completed a residency program;

enrolled in unaccredited/unapproved programs;

licensed in another jurisdiction (excluding training or temporary licenses in another jurisdiction).

C. House staff who are not required to obtain an unrestricted medical license in

DC, as detailed above, must DC Medical Training License prior to the start of their training.

D. International residents and fellows are not eligible for licensure in DC unless they have completed 3 years of ACGME-accredited training. In addition, international residents seeking an unaccredited/unapproved, clinical program, are not eligible for the MTL.

E. In order to be employed, international candidates must either be enrolled in ACGME-accredited training or in a program pre-approved by the DC Medical Board.

F. Failure to apply for licensure within a reasonable timeframe prior to the contract effective date shall result in termination of the employment agreement.

G. Failure to renew an existing license, resulting in an expiration of license, shall result in termination of the employment agreement.

H. House staff who have taken Step III, and have submitted their DC License application can work while they await their results.

I. All house officers who are required by law to have a DC license must keep that license current for the duration of their training program.

J. Residency Training Program Office Responsibilities:

Maintain current licensure information on all house staff, including copies of all applicable licenses.

Conduct an annual audit to ensure that house staffs are licensed according to DC regulations.

Notify Program Directors of their house staff who require licensure.

Pay license application or renewal fee when a license is mandated by law and required by the Residency Program.

K. The GME Office will not be responsible for house officers who do not submit

licensure applications in a timely manner. L. House Staff Responsibilities:

Obtain DC license application online.

Complete licensure applications in full and submit accordingly.


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Submit copies of all licenses to the Residency Training Program Office.

House staff is ultimately responsible for submitting their licensure applications within the time limits, and will be held responsible for fines incurred as a result of late application.

MOONLIGHTING and Outside Professional Employment

Graduate Medical Education Institutional Policy Approved by GMEC: August 5, 2010

I. Purpose To establish guidelines for employment outside of the MedStar Health System academic curriculum for residency and fellowship training.

II. Scope This policy will apply to all house officers participating in post-graduate training programs at MedStar Heath hospitals.

III. Definitions House Staff or House Officer – refers to all interns, residents and fellows enrolled in a MedStar Health hospital’s post-graduate training program. Post-Graduate Training Program – refers to a structured residency or fellowship educational program accredited by the ACGME, CPME, ADA or other recognized accrediting body, or a non-accredited program which is recognized by the American Board of Medical Specialties, for purposes of clinical education (collectively “approved programs”). For purposes of this policy, Post-Graduate Training Programs also include structured educational programs that are unapproved and unaccredited (collectively “unapproved programs”). Moonlighting – refers to any and all clinical activities outside of the scope of the defined post-graduate training program. External Moonlighting – refers to moonlighting on behalf of an employer other than the sponsoring institution and any of its academically affiliated sites. Internal Moonlighting - refers to moonlighting on behalf of the sponsoring institution or any of its academically affiliated sites.


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Outside Professional Employment – refers to any non-clinical employment a house officer engages in outside of the defined post-graduate training program.

IV. Conditions/Requirements

A. General Restrictions

1. No house officer may moonlight without having first obtained, at their own cost, an unrestricted license to practice medicine in the jurisdiction in which the moonlighting activity will take place.

2. No house officer may moonlight without first having been appropriately credentialed by the medical staff office of the facility where the moonlighting is to occur.

3. Any house officer holding an H-1B or J-1 visa, by virtue of USCIS regulations and/or ECFMG sponsorship, is not allowed to accept work or receive income in any capacity other than that of a resident physician in the specific residency identified on the DS2019 issued by the ECFMG or the visa petition approved by the USCIS.

4. Moonlighting, whether internal or external, is prohibited if it is inconsistent with providing residents and fellows sufficient time for educational activities. Moonlighting will only be approved if, in the judgment of the Program Director, the proposed moonlighting activity will not interfere with the house officer’s ability to meet his/her educational obligations in a satisfactory manner. The Program Director must prospectively approve, in writing, all moonlighting of house officers within their scope of supervision. This written approval will be noted in the house officer’s institutional personnel (GME) file. The Program Director may withdraw permission for moonlighting activities if he/she determines the moonlighting activities are having an adverse effect upon participation in educational activities.

5. Moonlighting without approval from the Program Director is cause for immediate dismissal from the training program (see the policy on Dismissal from GME Training Program and Termination of Employment.)

B. House Staff in Approved (Accredited) Programs.

1. A house officer in an approved program is never required to moonlight, but moonlighting may be permissible under certain circumstances.

2. External Moonlighting

a) A house officer may moonlight externally if: (i) the house officer is fully licensed and credentialed by the facility where


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the moonlighting is to occur; and (ii) the house officer has the prior written permission of the Program Director.

b) A house officer who moonlights outside of the MedStar Health System is not provided coverage of professional liability insurance by MedStar Health or its affiliates. It is the responsibility of the moonlighting house officer to obtain appropriate professional liability insurance for any moonlighting activity outside of the MedStar Health System.

3. Internal Moonlighting

a) Any moonlighting occurring within the sponsoring institution (or its academically affiliated sites) must be counted toward duty hour limits (80 hour rule, 28 hour rule, and 10-hour rest period). It is the responsibility of the program director and the institution to monitor and comply with all duty hour regulations.

b) A house officer may only moonlight within the sponsoring institution (including any of its academically affiliated sites) if: (i) the house officer is fully licensed and credentialed by the medical staff office of the facility where the moonlighting is to occur; (ii) the services to be performed can be distinguished from those services that are part of the house officer’s training program; (iii) the services will be performed in an outpatient department or emergency department of the sponsoring institution;1 and (iv) the house officer has the prior written permission of the program director.

(i) House staff in post-graduate training programs may not moonlight within the sponsoring institution or any academically affiliated site, unless the services to be provided during moonlighting are clearly distinguishable from the services furnished by the house officer in his/her approved or recognized medical training program. Any proposed services that fall within the scope of the house officer’s training program or within the house officer’s department is presumptively forbidden. Factors to be considered in determining whether proposed services are distinguishable from the services furnished by the house officer in an approved or recognized medical training program include, but are not limited to:

1 If these criteria are not met, there can be no reimbursement for the house officer’s moonlighting activities under Medicare Parts A or B. The house officer cannot bill Medicare Part B, and in order for the attending physician to bill Medicare Part B the attending physician must have: (1) participated in the service; and (2) the attending physician’s provision of services must be properly documented in accordance with applicable reimbursement guidelines. In addition, all costs associated with the house officer’s moonlighting activities must be separated out and not included on the cost report line relating to residency training on the Hospital’s Medicare cost report.


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(One) Whether the house officer is working on the same unit during moonlighting activities and during the activities of the training program;

(Two) Whether the house officer is seeing the same patients during moonlighting activities and during the activities of the training program;

(Three) Whether the house officer is performing work for which he/she would require supervision if the work were performed during the regularly scheduled hours of the residency training program

(Four) Whether the house officer will be evaluated for the moonlighting activities through the residency/fellowship program evaluation process; and

(Five) Whether the house officer is using any of the patients seen during the moonlighting activities as case studies for residency/fellowship program papers.

4. The VPMA of the hospital must review the aforementioned five criteria to determine if services are separate and distinguishable. If the determination is made, then the decision should be memorialized by way of a memo to the file and made available for future review.

5. House staff in approved programs who meet all of the above criteria and who wish to moonlight must have a separate contract that specifies the services they are permitted to provide independently. The contract must specify that these services are not part of their residency/fellowship program. The contract also must indicate a separate salary that will be paid at fair market value for these services. The contract must be terminable at the discretion of the training Program Director, if at any time he or she concludes that the moonlighting services are interfering with the house officer’s educational responsibilities. Such contracts must meet all requirements of the Hospital’s Contract Administration Policy, including review by the Legal Department, as necessary.

6. A house officer who engages in internal moonlighting activities at an academically affiliated site that is not part of the MedStar Health System is not provided coverage of professional liability insurance by MedStar Health. It is the responsibility of the moonlighting house officer to obtain appropriate professional liability insurance for any moonlighting activity outside of the MedStar Health System.

C. House Staff in Unapproved (non-Accredited) Programs.

1. External Moonlighting


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a) A fellow who is enrolled in an unapproved program may moonlight externally if: (i) the fellow is fully licensed and credentialed by the facility where the moonlighting is to occur; and (ii) the fellow has the prior written permission of the Program Director.

b) A fellow who is enrolled in an unapproved program who moonlights outside of the MedStar Health System is not provided coverage of professional liability insurance by MedStar Health or its affiliates. It is the responsibility of the moonlighting fellow to obtain appropriate professional liability insurance for any moonlighting activity outside of the MedStar Health System.

2. Internal Moonlighting

A fellow who is enrolled in an unapproved program may moonlight within the sponsoring institution (or its academically affiliated sites) under the following circumstances:

a) A fellow who is enrolled in an unapproved program may moonlight in any position within the institution for which he or she is qualified, if (a) the house officer is fully licensed and credentialed; and (b) the house officer’s position is not included in the sponsoring institution’s GME Cost Report.

b) In the judgment of the Program Director, the proposed moonlighting activity does not interfere with the fellow’s ability to meet his/her educational obligations in a satisfactory manner.

c) Any moonlighting occurring within the sponsoring institution (or its academically affiliated sites) must be counted towards the 80-hour weekly limit on duty hours.

3. Fellows enrolled in an unapproved program who meet all of the above criteria and who wish to moonlight internally must have a separate contract that specifies the services they are permitted to provide independently. The contract must specify that these services are not part of their fellowship program. The contract also must indicate a separate salary that will be paid at fair market value for these services. The contract must be terminable at the discretion of the training Program Director, if at any time he or she concludes that the moonlighting services are interfering with the house officer’s educational responsibilities. Such contracts must meet all requirements of the Hospital’s Contract Administration Policy, including review by the Legal Department, as necessary.

4. Fellows enrolled in an unapproved program who meet all of the above criteria and engage in moonlighting may bill for any services within the scope of his or her license and employment contract.


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PERSONNEL DATA CHANGES

It is the responsibility of each employee to promptly notify the MedStar National Rehabilitation Hospital of any changes in personnel data. Personal mailing addresses, telephone numbers, number and names of dependents, individuals to be contacted in the event of an emergency, and other such status reports should be accurate and current at all times. If any personnel data has changed, notify the Residency Training Program Office in writing of any changes. All house staff are encouraged to continue updating the GME office after graduation so that the MNRN may keep them up-to-date on Alumni activities.

PERSONNEL FILES OF HOUSE OFFICERS

Graduate Medical Education Institutional Policy Approved by GMEC: September 17, 1996 I. Purpose To establish a policy for all post-graduate training programs at the MedStar National Rehabilitation Hospital outlining the maintenance and retention of house staff personnel files.

II. Scope This policy will apply to the management of all personnel files for the house staff who are enrolled in a graduate medical education (GME) training program at the MedStar National Rehabilitation Hospital. III. Definitions House Staff or House Officer – refers to all interns, residents and fellows participating in a MedStar Hospital post-graduate training program. Post-Graduate Training Program – refers to a residency or fellowship educational program. IV. Responsibilities/Requirements

A. The Residency or Fellowship Training Program Office serves as the personnel office for the house officers. To that end, all employment documents and verifications shall be received, reviewed, and filed by the Residency or Fellowship Training Program Office in the house staff personnel files.

B. House Staff shall have access to their files upon request. C. The following information will be contained in each personnel file:


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CURRENT HOUSE OFFICER Files:

Personal History/Personnel Information

Contracts & Diplomas in chronological order; Universal Application; Official Transcripts; Personal Statement; Dean’s Letter; Three Letters of Recommendation; USMLE Step 1 & Step 2 Scores (if applicable)

All ECFMG/Visa paperwork (if applicable); MedStar National Rehabilitation Hospital Application

Loan Deferment forms; All correspondence to, from, or about the house officer D.C. License, when obtained

All Procedure Logs

All Evaluations Upon conclusion of the training period, the GME Training Program Office shall house all alumni files. All requests for verification for residents and fellows that requires the Program Director comment on clinical performance will be forwarded to the appropriate person with the respective file.

PHYSICAL EXAMINATIONS AND DRUG TESTING

To help ensure that house staff are able to perform their duties safely, physical examinations and drug screen are required. Prior to the first day of work, a physical examination will be performed either through Occupational Health provided for the MedStar National Rehabilitation Hospital or through a private physician. The offer of employment and assignment to duties is contingent upon satisfactory completion of the exam. If the physical examination reveals any physical or mental disorder that would prevent the house officer from completing the essential duties of the position and reasonable accommodation cannot be made, then the contract may be terminated. All house staff is also required by the District of Columbia to have a yearly physical examination and tuberculosis screening. Physicals and lab tests can be performed by appointment in Occupational Health or by a private physician with a completed attestation form. Failure to complete the annual physical will result in disciplinary action.

Current employees may be required to take medical examinations to determine fitness for duty. Such examinations will be scheduled at reasonable times and intervals and performed in Occupational Health. Information on medical condition or history will be kept separate from other house staff information and maintained confidentially. Access to this information will be limited to those who have a legitimate need to know. It is the MedStar National Rehabilitation Hospital desire to provide a drug-free, healthful, and safe workplace. To promote this goal, all employees are required to report to work in appropriate mental and physical condition to perform their jobs in a satisfactory manner.


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To help ensure a safe and healthful working environment, all new house staff will be asked to provide body substance samples (such as urine and/or blood) to determine the illicit or illegal use of drugs and alcohol. While on MedStar National Rehabilitation Hospital premises and while conducting business-related activities on MedStar National Rehabilitation Hospital premises, no employee may use, possess, distribute, sell, or be under the influence of alcohol or illegal drugs. The legal use of prescribed drugs is permitted on the job only if it does not impair an employee’s ability to perform the essential functions of the job effectively and in a safe manner that does not endanger other individuals in the workplace. Smoke Free MedStar.

PROMOTION OF HOUSE OFFICERS

Graduate Medical Education Institutional Policy Approved by GMEC: March 7, 2006 I. Purpose To establish a policy for all post-graduate training programs within the MedStar NRH to use in the promotion and appointment of house officers to the next level of post-graduate training. II. Scope This policy will apply to all post-graduate training programs in the NRH. All information contained in this policy shall be used as minimum criteria for promotion. III. Definitions House Staff or House Officer – refers to all interns, residents and fellows participating in a MedStar Hospital post-graduate training program. Post-Graduate Training Program – refers to a residency or fellowship educational program. Letter of Deficiency – refers to the process of formally providing “notice and opportunity to cure” as described in the “Academic Improvement” Policy.

IV. Responsibilities/Requirements Promotion: A. All resident physicians are required to have passed the USMLE Step III examination

prior to being promoted to the PGY3 level. Failure to do so will result in dismissal from the training program at the end of their current contract. No contracts for the PGY3 year or later may allow resident training without successful completion the USMLE Step III examination.

B. The decision as to whether or not to re-appoint and promote a house officer to the

next level of post-graduate training shall be made annually by the Program Director

upon review of the house officer’s performance.


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C. The Program Director shall consider all feedback and evaluations of the house

officer’s performance (refer to the Policy for Evaluation of House Officers) and any other criteria deemed appropriate by the Program Director.

D. Each year, the GME Training Office will request promotional decisions from the

Program Director by February 1st. Per the ACGME’s Institutional Requirements, programs must provide, “their residents with a written notice of intent not to renew a resident’s contract, no later than 4 months prior to the end of the resident’s current contract.” The GME Training Office should be notified immediately upon the Department’s decision to not renew an employment contract.

E. If necessary, a Program Director may decide to defer a final decision on whether to

promote a house officer. In this situation, the Program Director should issue a Letter of Deficiency to the house officer pursuant to the Academic Improvement Policy.

F. The Program Director may elect to extend the house officer’s contract pending

satisfactory completion of academic requirements. In this event, the decision to promote will be deferred until satisfactory completion of the educational program is confirmed.

G. A decision not to promote a resident, or extend a resident’s contract, should be

preceded by a Letter of Deficiency pursuant to the Academic Improvement Policy. H. If a Program Director elects not to promote a resident, or extends a determined

period of training, the house officer has a right to due process in accordance with the Academic Improvement Policy or the House Officer Misconduct Policy.

I. Upon successful promotion of all PGY2-4 years, the resident will be certified for

eligibility of the American Board of Physical Medicine & Rehabilitation written

examination. Upon successful completion of the written board exam, the

MedStar MedStar NRH will provide certification of training as needed for oral

examination of the ABPMR and any other credentialing board requesting this

information.

II. Upon successful promotion of all fellowships, the fellow will be certified for

eligibility of the respective board of exam, the MedStar NRH will provide

certification of training as needed for the examination of the sub-specialty

board and any other credentialing board requesting this information.

V. Non-Renewal of Contract See Policy for “Dismissal and Termination”

REDUCTION IN FORCE



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Revised/Approved by GMEC: February 7, 2006 I. Purpose To establish a policy for all post-graduate training programs within the MedStar (Washington Division) System in the event of reduction or elimination of the resident physician work force. II. Scope This policy will apply to all post-graduate training programs in the MedStar Health System (Washington Division).

III. Definitions House Staff or House Officer – refers to all interns, residents and fellows enrolled in a MedStar Hospital post-graduate training program.

Post –Graduate Training Program – refers to a residency or fellowship educational program, accredited by the ACGME, for purposes of clinical education. IV. Responsibilities/Requirements

A. In order to protect and assist house staff in the event of unforeseen changes or closures of post-graduate training programs, the following policy is provided and supported by the institution.

1. All current contracts will be honored. 2. House staff will be notified in writing as soon as possible of any major

change in the residency program. 3. Every effort will be made to ensure residency programs will only be

eliminated or downsized at the end of the academic year. 4. Every effort will be made to help each house officer find alternative training

in an ACGME-accredited program.

RESTRICTIVE COVENANTS

I. Purpose To outline the institution’s position on the use of restrictive covenants in house staff employment contracts. II. Policy In accordance with ACGME requirements, the institution prohibits the use if restrictive covenants in any house staff employment contract. This includes the official contract offered by the GME Office as well as any communications from the residency program.


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SELECTION AND CREDENTIALING OF HOUSE OFFICERS Graduate Medical Education Institutional Policy I. Purpose To establish a policy for all post-graduate training programs within the MedStar NRH to use in the selection of house officers. To further establish a procedure for the credentialing of house officers. II. Scope This policy will apply to all post-graduate training programs in the NRH. All information contained in this policy shall be used as minimum criteria for selection. More detailed selection criteria shall be delineated by each clinical department in its respective Departmental Selection Policy. III. Definitions House Staff of House Officer – refers to all interns, residents and fellows enrolled in the MedStar National Rehabilitation Hospital post-graduate training program. Match – refers to the formal process of matching house staff to hospitals, administered by the National Residency Matching Program (NRMP).

IV. Responsibilities/Requirements A. All applicants for a house staff position must be (pending) graduates of:

1. An LCME (Liaison Committee on Medical Education) accredited medical school; or

2. An AOA (American Osteopathic Association) accredited medical school; or 3. A medical school listed in the World Health Organization Directory of Medical

Schools; or 4. Completion of a Fifth Pathway program provided by an LCME-accredited

medical school.

B. All applications for House Staff positions must be submitted by one of the following methods:

1. The Electronic Residency Application Service (ERAS); or 2. The Universal Application for Residency Training; or 3. Approved Hospital employment application for residency training. Department specific policies may designate other means of application during a post-match period; however, original applications must still be submitted.

C. The Program Director, or designee, will evaluate and select the candidates he/she believes to be the most qualified for the positions available within the training program.

D. PROCEDURE. Once an applicant is selected for an interview, the following procedure must be employed by all programs:

1. The following credentials must be collected for each candidate: a) Application and Personal Statement, completed and signed.


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b) Original Dean’s Letter c) Original (certified) Medical School Transcript d) Verification of graduation from the Medical School and successful

completion of PGY-1 year or pending. (Appointments to PGY-1 positions may be made prior to graduation, however, it is the responsibility of each Program Director to verify graduation before the intern begins in the program and file documentation in the personnel file)

e) Three letters of reference from attending physicians familiar with the individual’s performance. If the candidate has previously been in a post-graduate training program, one letter must be from the candidate’s former Program Director.

f) Documentation of successful completion of Steps 1 and 2 (CS and CK) of the United States Medical Licensure Examination (USMLE), If an applicant has not received the results of both components (CS and CK) of Step 2 at the time of interview, successful completions will become a “Condition of Employment”.

2. Candidates of medical schools that are not accredited by the LCME, the AOA or other accredited college for specialty training must have the following additional documentation:

a) Official translations of all documents listed above in English; and b) Certification by the Educational Commission of Foreign Medical

Graduates (ECFMG). c) All residency programs are expected to participate in the National

Residency Matching Program (NRMP) and to follow all rules and requirements as set forth by that organization.

3. TRANSFERS: House officers applying to transfer from another program must provide a signed release statement authorizing MedStar National Rehabilitation Hospital to obtain verification of completion of previous training, copies of all past evaluations, and applicable procedure logs. This information must be reviewed by the GME Training Office prior to any offers of employment. Additionally, the Program Director from the previous program must provide a written statement regarding the house officer’s status in the program (house officer must be in good standing) and a complete assessment of his/her clinical competence including summative performance in the educational program to date.

4. All candidates should interview with the Program Director (or designee) and one or more members of the faculty. Telephone interviews will only be grated in lieu of a personal interview in the event of business necessity.

5. All residency programs are expected to participate in the National Residency Matching Program (NRMP) and to follow all rules and requirements as set forth by that organization

6. All candidates should be evaluated based on the following minimum criteria:

a) Preparedness


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b) Ability c) Aptitude d) Academic credentials e) Communication skills f) Personal qualities, such as motivation and integrity

7. All candidates interested in the program will be provided through our

website: a) Salary and benefits information b) Current copy of employment contract c) Any conditions of employment

8. Upon selection (or after the Match), contracts shall be prepared by the Residency Training Office, signed by the Medical Director.

9. If any of the required credentials documentations, as identified above, is missing on the effective date of the contract, the contract may be void.

10. If a prospective house officer fails to graduate, the contract will be made null and void.

11. MedStar Health is an equal opportunity employer. Residency programs will not discriminate with regard to sex, race, age religion, color, national origin, disability, or veteran status.

12. CONDITIONS OF EMPLOYMENT: Offers of employment and/or acceptance into the educational program are contingent upon certain conditions, including but not limited to:

a) Pre-employment health examination and drug screen b) Criminal background check, pursuant with Human Resources

procedure c) Primary source verification of medical school completion and any

previous accredited residency program experience d) Successful completion (pass) of USMLE Steps 1 and 2, if not

completed at the time of interview.


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SUPERVISION OF HOUSE OFFICERS

Graduate Medical Education Institutional Policy Approved by GMEC: January 6, 2004 Revised: May 2004 I. Purpose To establish a policy for all post-graduate training programs at the MedStar National Rehabilitation Hospital to ensure increasing amounts of responsibility, appropriate supervision and procedural competency of house officers and other educational trainees. II. Scope This policy will apply to all post-graduate training programs at the MedStar National Rehabilitation Hospital. All information contained in this policy shall be used as minimum criteria for supervision. More detailed supervision criteria shall be delineated by each clinical rotation as specified in the Integrated Competency Based Curriculum Manual. III. Definitions Licensed Independent Practitioner – a physician with an unrestricted license to practice medicine in the appropriate state. House Staff/House Officer – refers to all interns, residents and fellows enrolled in the MedStar National Rehabilitation Hospital post-graduate training program.

PGY – refers to “Post Graduate Year”, or the year of training the house officer is currently enrolled in past completion of medical school. IV. Responsibilities/Requirements Supervision of Overall Clinical Competency: A. Every house officer is assigned to a designated clinical service. On call schedules and rotation schedules are developed by the residency/fellowship training office and the chief resident. B. House Staff are provided increase responsibility for patients care as they progress through each year level, but remain under the direct supervision of their faculty and more senior house staff. C. Residents in their senior year of training may direct their own clinical service under the supervision of an attending faculty. D. Fellows who have completed their residency training program and are licensed independent practitioners may direct their own clinical service under the supervision of an attending faculty.


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E. In all house staff care cases, the ultimate responsibility for patient care activities rests with the attending faculty, who supervises all resident or fellow activities. F. The requirements for on-site supervision are established for and by each department in accordance with sub-specialty guidelines G. It is the responsibility of each Rotation Director to establish detailed written policies for supervision in their respective program. All departmental policies must be reviewed and approved by the GME Training Office. H. SUPERVISION RESPONSIBILITIES OF MEDICAL STAFF AT NRH

MedStar NRH resident and fellow physicians are supervised in their clinical care delivery according to their level of education, competence and experience. The major methods of supervision include direct clinical supervision by faculty attending physicians, senior residents or fellows, record review for appropriate documentation, access to consultants, access to faculty attending physicians or administrators when on-call, feedback via Morbidity and Mortality Conferences and other peer review case conferences, the continuous quality improvement program, and clinical pertinence record reviews.

Direct Clinical Supervision -- On the inpatient services residents and fellows are required to round with their faculty attending physicians daily Monday through Friday to discuss clinical, medical and rehabilitative care for all patients on their service. Residents or Fellows on-call have available to them faculty attending physicians Saturdays and Sundays to discuss medical or other concerns. All MedStar NRH inpatients are seen within 24-hours by a member of the attending staff and discussed with the resident or fellow.

Some or all aspects of the physical examination are performed with the faculty attending physician present for guidance and feedback until the faculty attending physician is comfortable with the resident's or fellow’s clinical skills. Thereafter the faculty attending physician will supervise the resident or fellow directly as needed.

In the outpatient clinics resident and fellow physicians are supervised directly in accordance with their level of knowledge and skill.

Supervision of House Staff On-Call -- New PGY2 residents are initially on-call for the first month of residency training with a more senior resident for guidance. On-call residents or fellows are expected to notify the attending physician on-call either in person or via phone for any questions or problems regarding MedStar NRH patients whom he/she does not feel comfortable handling alone.

Each in-house program (MSK, SCI/Cardiac, TBI) has a core group of physicians who attend to those patients who require physician review over the weekend and during off-hours of the week. These physicians are called “On-call Attendings”. Each of these physicians are required to be available to the house staff by


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phone/pager on off-hours and to make rounds sometime during the weekend on designated patients in their individual program. Therefore, three physicians round each weekend. The purpose of the on-call attending is to allow the house staff to discuss (at the bedside if needed) any patient that he/she desires with an attending physician. These attending physicians therefore provide hands-on advice to the weekend on-call house staff.

As noted above, each on-call attending is to be physically present at the MedStar NRH sometime during their scheduled weekend. While in the hospital, the on-call attending must contact the house staff on-call, and ask him/her if any patient needs to be seen while the attending is in-house. Furthermore, it is expected that each attending on-call will contact the house staff on-call before 10:00 a.m. on each weekend/holiday call day. The attending on-call is to ask the house staff whether he/she has any immediate problems that require discussion over the phone, as well as to alert the house staff whether the attending will be in the house on that given weekend/holiday day.

All on-call attendings are expected to answer their beepers in a timely fashion. It is required that the on-call attending maintain his/her beeper in the “on position” 24 hours a day.

Some attendings have Nurse Practitioners cover their patients on the weekends/off-hours. Each NP has physician back-up. Therefore, the house staff will equate speaking with the NP the same as speaking with the attending

Urgent care issues are handled according to policy that has been determined (see this document: Urgent Care of Outpatient & Visitors). Should the urgent care house staff require attending backup, he/she may call the appropriate on-call attending for that week.

At all times an administrator is available to the on-call house staff either in person or via phone for administrative issues.

Consultants -- More complex medical issues may be referred to a member of the consulting medical staff at the house staff or attending physician's request.

Formal Feedback -- A more formal mechanism of feedback and house staff supervision is provided through the Morbidity and Mortality Conference monthly as well as clinical pertinence reviews of medical records performed quarterly. Significant morbidities, all deaths, adverse drug reactions, and quality improvement and risk management issues may be discussed at the Morbidity and Mortality Conference. Decisions regarding cases/topics presented are made by the Continuous Quality Improvement Committee or the Chair of the Morbidity and Mortality Conference.

House Staff are supervised at affiliated institutions mainly by direct clinical supervision by attending physicians, including monitoring of written/dictated correspondence/records.


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TEACHING RESPONSIBILITIES OF ATTENDING PHYSICIAN Teaching Rounds -- Bedside teaching rounds are made with all house staff and their supervisory attending at least 5 times per week. These teaching rounds may be visited by the Medical Director of MedStar NRH and/or the Director of the Residency Training Program and/or their designees in order to support the educational efforts of the Residency Training Program. New Patient Reviews -- All new admissions are reviewed between the attending and service house staff in a timely manner. During these reviews, the history and physical exam as well as the management program for the patient should be discussed. In addition, the pathophysiologic mechanism of injury to the patient as well as the evidence based practices for his/her rehabilitation management need to be reviewed. Attending Participation in GME Activities -- It is expected that all attending physicians at the MedStar NRH will participate in at least 12 educational opportunities involving the house staff during the academic year. These educational activities include: Wednesday Morning Didactic Lecture Series, Journal Club, M&M, and/or Ortho/Rheumatology/PM&R Rounds. Didactic Teaching on Inpatient Rotations -- The SCI, TBI, MSK, & CVA Services at the MedStar NRH are expected on a weekly basis to provide the campus house staff with a didactic lecture at a specified time and day. These lectures are to represent the essential aspects of the medical/physiatric care and management of the patients on each service. Included in these discussions would be the pathophysiologic mechanism of injury to the patient, evidence based practices for management options, and discussions regarding the prevention of further illness, injury, or disability to the patient. These lectures will repeat on a rotational basis throughout the year. It would be expected that the service house staff would present introductory material on these subjects being discussed for any individual day. However, the major portion of the presentation would be offered by the supervisory attending who is mentoring the educational activity. It is the responsibility of the individual program directors to assure the presence of a service attending at each appropriate seminar activity. These didactic teaching sessions may be visited by the Medical Director of MedStar NRH and/or Program Director of the Training Program and/or their designees in order to support the educational efforts of the Residency Training Program. The curriculum for the educational sessions of each service will be presented to the Program Director on a yearly basis. Attending Teaching Units -- Each house staff is to be assigned to only one attending teaching unit at any given time. On appropriate rotations, the house staff will switch to a second attending teaching unit on a given service halfway through the rotation in order to receive a balanced educational experience. Supervision of Procedural Competency:


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A. House Staff must be instructed and evaluated in procedural techniques by a licensed independent practitioner (LIP) who is certified by their training Program Director as competent to independently perform that procedure or who has been credentialed by the MedStar National Rehabilitation Hospital to perform that procedure. B. The Program Director is responsible for identifying the number of procedures must be completed successfully prior to the house staff receiving the designation of competence in that procedure. For procedures performed by house staff in multiple departments, there should be a uniform policy for the minimum number of procedures necessary to achieve competence. C. The Program Director for each department will be responsible for maintaining an up to date list of house staff who have been certified as competent to perform procedures independent of direct supervision. This list will also be maintained in the nursing office for review by nurses. D. The Program Director must also develop a method for surveillance of continued competency after it is initially granted. E. Once the house staff has been evaluated as competent to perform a specific procedure or set of procedures by an LIP, s/he may perform that procedure independently after consultation with the patient’s treating physician. A house staff who is determined to be competent in a specific procedure (the senior resident) may also teach the procedure to another house staff (the junior resident) and provide immediate supervision. This immediate supervision by the senior resident; however, does not replace the required, but not necessarily immediate, supervision by an LIP. F. The ability to obtain and document informed consent is an essential component of procedural competency. The supervising LIP must also supervise and attest to the trainee’s competence in obtaining and documenting informed consent. Until a trainee is judged competent in obtaining informed consent, s/he may only obtain informed consent while supervised by an individual with credentials in that procedure. It is recommended that a minimum of five observed IC discussions be the criteria for each different procedure. G. Eligible house staff should be licensed by the District of Columbia, as soon as possible. This requirement will be directed at a departmental level.

Resident Competencies:

Patient Care:

House Staff must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of the healthcare problems of their patients and the promotion of their health status. House Staff are expected to:

1. Gather accurate information about their patients.


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2. Make informed decisions about diagnostic/therapeutic interventions based on patient information and their preferences, current scientific evidence, and clinical judgment.

3. Develop and carry out patient management plans 4. Counsel and educate patients and their families. 5. Use information technology to support and advance patient care decisions as

well as patient education. 6. Perform all medical and invasive procedures competently for the practice of

Physical Medicine and Rehabilitation. 7. Provide healthcare services aimed at preventing health problems and/or

maintaining health status. 8. Work with healthcare professionals from all disciplines to provide patient focused

care. 9. Modify history taking and physical exam skills to include date critical to the

recognition of functional abilities, and physical and psychosocial impairments, which may cause functional disabilities.

10. Perform the general and specific physiatric examinations, including electro diagnostic studies, and other procedures common to the practice of PM&R.

11. Make sound clinical judgements. 12. Design and monitor rehabilitation treatment programs to minimize and prevent

impairment and maximize function abilities.

Medical Knowledge:

House Staff must demonstrate knowledge about established and new biomedical, clinical, and cognitive sciences and apply this knowledge to patient care. House Staff are expected to:

1. Demonstrate analytical thinking as they approach clinical situations. 2. Know and apply the basic/clinical support sciences, which are appropriate to

Physical Medicine and Rehabilitation or area of specialty for fellowship. 3. Include knowledge about the diagnosis, pathogenesis, treatment, prevention, and

rehabilitation of those neuromusculoskeletal, neurobehavioral, cardiovascular, Pulmonary and other system disorders common to this specialty in patients of both sexes and all ages.

4. Apply the principles of bioethics to medical care and participate in the decision making process involving ethical issues that arise in the diagnosis and management of their patients.

Practice-Based Learning and Improvement:

House Staff must be able to investigate and evaluate their patient care practices as well as appraise and assimilate scientific evidence to perform. House Staff are expected to:

1. Analyze practice experiences and perform practice-based improvement activity using systematic methodology.

2. Analyze and assimilate evidence from scientific study in order to promote their patients health status.

3. Obtain and use information about their own population of patients in order to treat larger populations from which their patients are drawn.


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4. Apply knowledge of study design and statistical method to the analysis of clinical studies and other scientific information, which concerns diagnostic/therapeutic effectiveness of treatment.

5. Use information technology to manage information, to find medical information, and to support their own education.

6. Facilitate the learning of students, themselves, and other healthcare professionals, both during the residency training program and after graduation.

Interpersonal and Communication Skills:

House Staff must be able to demonstrate interpersonal and communication skills that result in effective information exchange as well as team communication with patients and all professional associates. House Staff are expected to:

1. Create and sustain a therapeutic and ethically sound relationship with patients. 2. Communicate effectively and demonstrate caring and respectful behaviors when

interacting with patients. 3. Engage in active listening, provide information using appropriate language, ask

clear questions and provide an opportunity for input and questions from/with staff and patients.

4. Work effectively as a member or leader of a healthcare team or other professional group.

5. Develop the necessary written and verbal communication skills essential to the efficient practice of physiatry or sub-specialty.

Professionalism:

House Staff must demonstrate a commitment to carrying out the professional responsibilities and adhere to the ethical principles of medicine. House Staff must also be able to demonstrate sensitivity to a diverse patient population. House Staff are expected to:

1. Assume responsibility and act responsibly. 2. Demonstrate commitment to ethical principles regarding the provision/withholding

of clinical care, confidentiality of patient information, informed consent, business practices.

3. Demonstrate sensitivity and responsiveness to cultural perspectives and biases. 4. Demonstrate respect, integrity and responsiveness to the needs of patients, and

the disabled community that supersedes self interest. 5. Demonstrate participation in community service, professional organizations,

and/or institutional committee activities. 6. Demonstrate the qualities of courtesy, integrity, respect and compassion to

patients needs for comfort and encouragement. 7. Demonstrate appropriate professional attitude and behavior towards colleagues. 8. Demonstrate the spirit of collegiality in the work situation, being helpful to

colleagues and peers. 9. Demonstrate high standards of moral behavior in the care of patients, education

of peers and students, conduct research and interaction with funding organizations.


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Systems-Based Practice:

House Staff must demonstrate and awareness of the responsiveness to the larger context and system of healthcare in this country as well as demonstrate the ability to effectively call upon system resources to provide care that is of optimal value for the patient. House Staff are expected to:

1. Understand how their professional practices affect the healthcare system in general (local professional/organizational/societal level).

2. Understand how the healthcare system (local professional/organizational/societal level) affects their own practice.

3. Understand how different systems of delivery and medical care differ from one another/affect one another.

4. Understand how different systems of medical care affect healthcare costs and the allocation of resources.

5. Practice cost effective healthcare/resource allocation without compromising quality of care.

6. Advocate for quality patient care and assist patients through the system complexities.

7. Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system.

8. Understand the principles, objectives and implementation of both the performance improvement and risk management processes.

9. Develop understanding of each allied health care professional’s role in the rehabilitation team and be able to provide leadership skills to this group in order to provide optimum patient outcome.

The house staff is expected to achieve these competencies by:

a. Progressing through the educational program appropriate to the specific PGY level and achieving the goals and objectives of each specific rotation.

b. Attending didactic lectures and interactive conferences. c. Attending educational conferences such as Grand Rounds, Journal Clubs,

Morbidity and Mortality Conference, Physiatry Rounds and other appropriate educational opportunities.

d. Achieving proficiency in research skills and the evaluation of the medical literature.

e. Obtaining hands on experience in the practice of Physical Medicine and Rehabilitation through the accomplishment of his/her service requirements including the attendance of team/family conferences and multidisciplinary rounds.

f. Developing and maintaining a program of self study to include readings from provided standard texts and suggested references, as well as from networking with the interdisciplinary team.

The competency of each house staff in the GUH/NRH Program is evaluated by the following measures:


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A. Evaluation of Clinical Competence: After each rotation, the house staff is evaluated by his/her clinical attending in the category of:

1. General skills (history and physical exam) 2. Physiatric skills (functional evaluation, exercise and modality prescription,

therapeutic and diagnostic injections, electro diagnostics, medical equipment prescriptions)

3. Clinical judgement 4. Patient care 5. General knowledge and physiatric knowledge 6. Practice-based learning and improvement 7. Interpersonal and communications skills 8. Professional attitudes 9. Humanistic qualities 10. Systems-based practice 11. Over clinical competence

Evaluation scores are provided to the house staff in each category as documented elsewhere (see Evaluation of Resident policy).

B. Evaluation of Academic Competence: House Staff are rated through objective testing in the following areas:

1. General Knowledge 2. Physiatric Knowledge 3. Problem-based learning and improvement

Objective testing is performed (for the most part) quarterly from entrance into the program through the PGY 4 year. Residents must also demonstrate the potential to successfully pass a Board Examination type test during his/her residency training.

C. Evaluation of Professionalism and Interpersonal Communication Skills: The house staff skills in these areas are evaluated not only by the Clinical Evaluation, but through information obtained by the Quality Assurance Team of the MedStar National Rehabilitation Hospital. This team gathers information regarding patient/physician interactions via face to face interviews with inpatients during the First Impression Surveys. The QA Team also provides the Program Director with house staff related information obtained from post discharge telephone surveys performed by professional research consultants.

Furthermore, the house staff professionalism/interpersonal/communication skills are also evaluated through 360 evaluations performed by their Team Member colleagues during their MedStar NRH based rotations (both inpatient and outpatient).


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Compensation and Benefits

ouse staff at the MedStar National Rehabilitation Hospital are provided a wide range of benefits. A number of the programs (such as Social Security, workers’ compensation, state disability, and unemployment insurance) cover all employees in the manner prescribed by law. Details of many of these programs can be obtained

from the Human Resources Department.

The following benefits are available to eligible employees: Cafeteria/Meal Tickets Computer, E-mail Usage Credit Union Employee Assistance Program Emergency House Staff Loans Financial Plans

Flex Fund Tax Sheltered Annuity

House Staff Association Insurance Plans

Medical & Dental Insurance Life Insurance Long-Term Disability Insurance Malpractice Liability Insurance Short-Term Disability Insurance Worker’s Compensation Insurance

Leave of Absence Family Leave Medical Leave

On-call Quarters/Lounge/Gym Opticians Shop Parking Pharmacy Discount tickets to area Recreational Activities White Lab Coats/Laundry Stipends/Paychecks Travel/Book Allowances

Chapter

3

H


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Notary Services (work related) Some benefit programs require contributions from the employee, but most are fully paid by MedStar National Rehabilitation Hospital.

CAFETERIA/MEAL ALLOWANCE

Resident meals are currently being provided to the house staff on-call. The on-call house staff is entitled to one meal ticket per call.

Meal cards are obtained each month from the Residency Training Office. When used, the meal card is presented to the cafeteria cashier. A meal allotment of $8.00 per on-call has been approved by Administration and loaded on the call at the beginning of each year. On-call residents may obtain dinner on weekdays as well as lunch and dinner on weekends/holidays in the following manner:

For meals from Kitchen lunch/dinner menu is to be fill out in advance

without use of meal card. Alternatively use the meal card in the Starbucks at the lobby.

Alternatively Resident may choose to have private delivery of the food to the hospital at their own expense. On weekends/holidays, lunch and dinner from cafeteria must be picked up between 11:00 a.m. and 6:30 p.m. On weekdays, dinner must be ordered and picked up between 5:00 p.m. and 6:30 p.m. in room GO-74. Meals can be ordered from the menu, which is provided by the Residency Training Office.

Cafeteria Hours for general purposes:

Weekdays – Breakfast 7:00 to 10:00 a.m. Weekdays – Lunch 11:00 a.m. to 2:00 p.m. Closed after 2:00p.m. and weekends

Should the house staff not with to use the above meal arrangement while on-call, he/she may have food delivered to the hospital. However, the Residency Training Program is not responsible for any expense that a house staff might incur as he/she obtains food in this manner. It is expected that the Saturday afternoon house staff will only order lunch; the Saturday night house staff will only order dinner.


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If you experience any difficulties with obtaining your meals, contact the Residency Training Program Coordinator or supervisor of food service extension 1876 or pager 20855. All house staff receives a 5% discount on food from the hospital cafeteria.

COMPUTER, E-MAIL USAGE, ELECTRONIC HEALTH RECORDS &

CLINICAL DECISION SUPPORT SYTEM SECURITY ACCESS

Each house staff on an inpatient rotation will receive a laptop computer for official use only. These laptops are to never leave the MedStar NRH building. Formal education and training regarding the use of computers at the MedStar National Rehabilitation Hospital for e-mail/internet usage/patient care/educational knowledge will be given during your orientation session. Computers, computer files, the e-mail system and software furnished to employees are MedStar National Rehabilitation Hospital’s property intended for business use. Employees should not use a password, access a file, or retrieve any stored communication without authorization. To ensure compliance with this policy, computer and e-mail usage may be monitored. Resident physicians may use the MedStar NRH Guest Wireless Network while on call with their personal computers. The MedStar National Rehabilitation Hospital strives to maintain a workplace free of harassment and sensitive to the diversity of its employees. Therefore, the MedStar National Rehabilitation Hospital prohibits the use of computers and the e-mail system in ways that are disruptive, offensive to others, or harmful to morale. E-mail may not be used to solicit others for commercial ventures, religious or political causes, outside organizations, or other non-business matters. House Staff should notify their immediate supervisor, the Residency Training Program Office or any member of management upon learning of violations of this policy. Employees who violate this policy will be subject to disciplinary action, up to and including termination of employment. Should you in the future have any problems with the Information System Services at the MedStar National Rehabilitation Hospital, please call the MedStar IS Help Desk number to obtain a correction to your problem. The MedStar IS Help Desk number is 202-877-7731 or 1-877-777-8787.

NETWORK SECURITY VIOLATIONS

Graduate Medical Education Institutional Policy I. Purpose To establish a policy for all house staff at the MedStar National Rehabilitation Hospital outlining security precautions as related to Information Systems.


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II. Scope This policy will apply to all house staff who participate in a graduate medical education (GME) training program at the MedStar National Rehabilitation Hospital. III. Definitions House Staff or House Officer – refers to all residents participating in the MedStar National Rehabilitation Hospital post-graduate training program. Post-Graduate Training Program – refers to residency educational program. IV. Responsibilities/Requirements A. All employees, including house officers, are assigned a user identification code and password for HER & CDSS used by MNRN . This information is generated by Information Systems and is monitored through their security officer. B. Each house officer signs an acknowledgment statement agreeing to the following terms and conditions:

1. Data in databases will be accurately entered and maintained. 2. Passwords will be kept confidential; each individual is responsible for

notifying Information Systems if they believe confidentiality has been compromised.

3. Data either hard copy or machine readable, will not be provided to other

individuals if it compromises patient confidentiality, financial, competitive, or legal well-being of MedStar Health.

4. Data will not be provided to external organizations without prior approval of

the data base owner. This acknowledgment also states that violation of any of the above may involve disciplinary action up to and including termination. Copies of these forms are on file with the Information System security officer.

C. Violations of the signed agreement with Information Systems are communicated to the Program Director. The following measures will be taken with respect to house officer violations:

1. First Offense: Verbal Warning The Program Director will meet with the house officer to emphasize the serious nature of violation, as well as future expectations. This meeting should be documented. 2. Second Offense: Fine The Program Director will fine the house officer $100.00 for a second security violation. Fees will be contributed to the Special Purpose Fund for use in the Resident Loan Program. Documentation will be placed in the house officer’s file.


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3. Third Offense: Suspension The Program Director will suspend the house officer for seven (7) continuous days without pay. Written notification, including a “Job in Jeopardy”, letter will be given to the house officer, as well as being copied to the file. 4. Fourth Offense: Termination The house officer will appear before the Fair Hearing Committee for Graduate Medical Education. The Program Director will recommend termination, as stipulated by this policy.

CREDIT UNION

Healthcare Employees Mid-Atlantic (HEMA) Federal Credit Union membership is available to all hospital employees. Members may conduct business in person at the office located at 8701 Georgia Avenue #407 Silver Spring, Maryland or by phone by calling 301-588-1860. An application can be obtained at in the Human Resources Department.

EMPLOYEE ASSISTANCE PROGRAM

MedStar National Rehabilitation Hospital provides professional counseling assistance to all employees, including house staff, at no cost. Services provided include:

family or personal problems relationships or divorce emotional problems (depression, anxiety, etc.) substance abuse stress

Employee Assistance Program flyers can be obtained from the Human Resources Department.

EMERGENCY HOUSE STAFF LOANS


House Staff Emergency Loans

I. Purpose To establish an institutional policy for all house staff in the MedStar Health System (Washington Division) outlining guidelines for loans to cover emergency expenses.

II. Definitions House Staff or House Officer – refers to all interns, residents and fellows participating in a MedStar Hospital post-graduate training program.


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Post-Graduate Training Program – refers to a residency or fellowship educational program. Automatic Payroll Deduction – A process by which money is directly subtracted from the paycheck. Instant Check – A check request voucher that is processed by the Accounts Payable Department, for emergencies only, within 24 hours. Outstanding Loan – Funds that are owed to the GME Training Office for an emergency loan. Each house staff may have a maximum on one outstanding loan at any given time not to exceed $1000.00.

III. Responsibilities/Requirements A. An Application for House Staff Emergency Loan form must be completed

by the requesting house staff and delivered to the Residency Training Office. If the house staff does not have an outstanding loan with the Residency Training Office, the request, up to $1000.00, normally will be approved. The Application for House Staff Emergency Loan will be:

1. Faxed to the Payroll Department to begin automatic payroll

deduction. The maximum amount to be deducted from each paycheck will be designated by the house staff on the application form. The minimum deduction is $50.00 per pay period. The Payroll office will begin automatic payroll deduction, and will ensure that payroll deductions end when the balance due has been paid in full.

2. Forwarded to the Accounts Payable Department with a Check Request Voucher indicating the need for an instant check.

B. House staff is required to pay any balance due on an emergency loan

prior to their termination. Any outstanding balance that has not been repaid will be deducted automatically from the last pay check. If the balance due exceeds monies available in the last pay check, the house staff will be required to pay the balance upon check-out.

C. The Application for House Staff Emergency Loan is available in the Residency Training Office.

FINANCIAL PLANS


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FlexFund

House staff may set aside a portion of their income, tax free, for out-of-pocket health and dependent care expenses through the FlexFund Account. For more information regarding the FlexFund, please contact the Human Resources Department on extension 1710.

Tax Sheltered Annuity

Individuals employed by non-profit organizations are eligible to participate in a tax sheltered annuity plan. This is a non-taxed savings system through payroll deductions by which funds can be accumulated on a tax-deferred basis for long-term goals, including retirement. These funds are excluded from current taxable income. Options are available for both fixed and variable accounts. For more information regarding this plan, please contact the Human Resources Department on extension 1710.

HOUSE STAFF REIMBURSEMENT FUND

Graduate Medical Education Institutional Policy I. Purpose To establish a policy for the house staff within the MedStar National Rehabilitation Hospital training program to provide funding for educational expenses. II. Scope This policy will apply to all house staff who participates in a graduate medical education training program within the MedStar National Rehabilitation Hospital. III. Definitions House Staff – refers to all residents and fellows participating in the MedStar National Rehabilitation Hospital post-graduate training program. Post-Graduate Training Program – refers to a residency educational program. IV. Responsibilities/Requirements A. Residents will accrue $833.00 on July 1 of each year of training at MedStar National

Rehabilitation Hospital, to be used for education expenses including:

Books directly related to current training

Educational travel

Mobile Learning Devices

Stethoscopes

Pager replacement fees

Board review courses


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B. All requests for funds will be allocated at the discretion of the Program Director, and must be approved by the Program Director in writing prior to submission to the Residency Training Office.

C. Funds cannot be used until they are accrued. E. In order to be reimbursed for expenses, house staff must complete the Request for

House Staff Reimbursement Form, attach original receipts and submit them to their Program Director. For travel reimbursement, an expense report must also be completed (see G. Below). Once the Program Director has approved the expense, it should be submitted to the GME Training Office for processing. If funds are available, the GME Training Office will process the reimbursement, and will submit a check request voucher to Accounts Payable within 24 hours of receipt. Turnaround time for checks is normally 2 weeks. If funds are not available, the GME Training Office will advise as such.

Travel Reimbursement:

1. A Request for House Staff Reimbursement Form and a National Rehabilitation Travel Expense Form must be completed with the original receipts attached.

2. The GME Training Office will reimburse the following travel expenses:

Registration Fee

Roundtrip coach airfare

Hotel accommodations not to exceed $225 per night (rooms may be required to share with other house staff)

Meal allowance at a maximum of $50 per day

Reasonable roundtrip transportation to and from the airport

Airport parking fees (for personal car)

Personal mileage (if applicable) Rental cars will not be reimbursed. F. The GME Training Office will be responsible for tracking house staff reimbursement

funds. Program Directors and house staff may contact the GME Training Office at any time to determine remaining balances.

G. Additional funds for research presentations may be granted at the discretion of the

Program Director. Documentation of the resident’s presentation must be provided.

INSURANCE PLANS

Life Insurance


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Life insurance offers you and your family important financial protection. Eligible employees may participate in the life insurance plan subject to all terms and conditions of the agreement between the MedStar National Rehabilitation Hospital and the insurance carrier. Contact the Human Resources Department at extension 1710 for more information about life insurance benefits.

Long-Term Disability

The MedStar National Rehabilitation Hospital provides a long-term disability (LTD) benefits plan to help house staff cope with an illness or injury that results in a long-term absence from employment. LTD is designed to ensure a continuing income for employees who are disabled and unable to work. For more information about LTD benefits contact the Human Resources Department at extension 1710.

Malpractice Liability Coverage Limits

As agents of the hospital, and in accordance with the rules and regulations of the hospital and the Accreditation Council for Graduate Medical Education (ACGME), house staff are covered for professional liability by the MedStar Health, Inc. Risk Management Financing Plan for all work performed as outlined in the house staff agreement. You are covered under this plan for any incident that occurs while employed by the MedStar National Rehabilitation Hospital, even if the claim arises after employment terminates. All subpoenas and information relating to professional liability actions against the hospital or its staff should be referred to Risk Management or Legal Affairs.

Medical and Dental Insurance

The MedStar National Rehabilitation Hospital provides all house staff and their dependents access to medical and dental insurance benefits. Eligible employees may participate in the health insurance plan subject to all terms and conditions of the agreement between MedStar National Rehabilitation Hospital and the insurance carrier. A change in employment classification that would result in loss of eligibility to participate in the health insurance plan may qualify an employee for benefits continuation under the Consolidated Omnibus Budget Reconciliation Acct (COBRA). For more information about COBRA benefits contact the Human Resources Department at extension 1710.


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Short-Term Disability

The MedStar National Rehabilitation Hospital provides a short-term disability (STD) benefits plan to all house staff who are unable to work due to a non-work related injury or illness. Eligible employees may participate in the STD plan subject to all terms and conditions of the agreement between MedStar National Rehabilitation Hospital and the insurance carrier.

Disabilities arising from pregnancy or pregnancy-related illness are treated the same as any other illness that prevents an employee from working. Disabilities covered by workers’ compensation are excluded from STD coverage. Contact the Human Resources Department on extension 1710 for more information about STD benefits.

Workers’ Compensation Insurance

The MedStar National Rehabilitation Hospital provides a comprehensive worker’s compensation insurance program at no cost to employees. This program covers any injury or illness sustained in the course of employment that requires medical, surgical, or hospital treatment. House staff who sustains work-related injuries or illnesses should inform their supervisor immediately. No matter how minor an on-the-job injury may appear, it is important that it be reported immediately. This will enable an eligible employee to qualify for coverage as quickly as possible. Neither MedStar National Rehabilitation Hospital nor the insurance carrier will be liable for the payment of workers’ compensation benefits for injuries that occur during an employee’s voluntary participation in any off-duty recreational, social, or athletic activity sponsored by MedStar National Rehabilitation Hospital.

LEAVE OF ABSENCE

Family Leave

The MedStar National Rehabilitation Hospital provides family leaves of absence without pay to house staff who wish to take time off from work to fulfill family obligations relating directly to childbirth, adoption, or placement of a foster child; or to care for a child, spouse, or parent with a serious health condition. A serious health condition means an illness, injury, impairment, or physical or mental condition that involves inpatient care in a hospital, hospice, or residential medical care facility; or continuing treatment by a health care provider. House staff should make requests for family leave to their supervisors at least 30 days in advance of foreseeable events and as soon as possible for unforeseeable events, and


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make an appointment with the Human Resources Department to obtain the appropriate leave of absence forms and information. Subject to the terms, conditions, and limitations of the applicable plans, the MedStar National Rehabilitation Hospital will continue to provide health insurance benefits for the full period of the approved family leave. Benefit accruals, such as vacation, sick leave, or holiday benefits, will be suspended during the leave and will resume upon return to active employment. In the event that a family leave is prolonged, the training period may need to be extended in order to fulfill the department’s, specialty board’s or state licensing board’s requirements. Per the MedStar National Rehabilitation Hospital Human Resources Policy, house staff may also be eligible for personal and military leave by request. Greater than 30 days interruption of training per academic year may affect board eligibility status.

Leave Due to Illness

A house staff who is ill or has an emergency that prevents him/her from performing his/her duties, must notify both the supervising attending and the Training Program Office. This must be done as close as possible to the time that the illness and/or emergency interrupt the resident’s clinical activity. If personal communication is not possible with either the GME Training Office or the supervising attending, then messages should be left on the voice mail and the chief resident must be informed. Leave taken without the knowledge or approval of the Training Program Office and the supervising attending physician is unauthorized leave and may result in disciplinary actions including probation or termination.

Leave Due to Vacation

All house staff is eligible for a total of 20 paid days off per year referred to as Paid Time Off (PTO). These 20 days include both your sick leave and vacation time. Please use these days wisely. Unused PTO may not be carried over into the next year. It will not be paid out upon leaving the program. However, under no circumstances can more than 30 days total of leave be granted to any house staff in any given academic year. All requests for vacation must be made at least 30 days in advance of the planned time off. Given at least 30 days notice, all attendings will try to accommodate house staff request for planned leave. All requests for house staff leave must be in writing on the official form which is entitled Resident Leave Request Form. This form can be obtained from the Residency Training Office. All requests for vacation must be approved by both the supervising attending and the Residency Program Director. The covering house staff must also sign the leave request. The house staff coverage will be provided by his/her attending, expect in unusual/emergency cases.


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Administrative Leave

Administrative Leave is given to house staff at the discretion of the Program Director. It must be approved in writing on the Leave Request Form. Senior house staff may be granted up to 10 administrative days for job or fellowship interviews. PGY-3 residents may be allowed administrative leave at the discretion of the Program Director.

House Staff Medical Leave of Absence

A maximum of 4 weeks (20 days/160 hours) of paid leave is available to house staff for medical (or vacation combined total) leaves of absence. This paid leave can be carried over from year to year, but must be accrued at the time of medical leave of absence. Unused medical leave will not be paid at the conclusion of training. In order to receive pay for medical leaves of absence that exceed 4 weeks, house staff must apply for short-term disability through the Managed Disability Office. Per the MedStar National Rehabilitation Hospital Policy, a medical leave of absence is grated for illnesses that are at least 2 weeks (10 days) in duration. In the case of scheduled medical leave, the house officer should give the Program Director 30 days’ prior notice, if possible, or at least provide notice as soon as the need arises. For an unscheduled/emergency leave, a house staff will be placed on medical leave after two weeks of absence. In order to apply for a Medical Leave, the house officer must complete the Medical Leave of Absence Form, which can be obtained from the Managed Disability Office, and submit it to the Program Director for approval. Upon approval, the Program Director will forward the form to the GME Training Office for signature. The GME Training Office will submit the completed Leave of Absence Form to the Managed Disability Office. The house officer must provide notice to the Program Director prior to returning to work from a Leave of Absence. He/she must also obtain fitness for duty clearance through Managed Disability before returning to work. The GME Training Office must be notified by the house officer or the Program Director when a house officer returns to work, in order to place him/her back on Payroll, if the paid leave was exhausted. In the event of a medical leave of absence, the training period may need to be extended in order to fulfill the department’s specialty board’s or state licensing board’s requirements.

LOAN DEFERMENT

All applications for Loan Deferment must be authorized by the Residency Training Office.


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ON-CALL QUARTERS

The house staff on-call quarters, are located in the 2nd floor Residency Training & Medical Education Suite, room 2303 in the MedStar National Rehabilitation Hospital. The will remain locked at all times. Proper ID is required to gain entrance to the area. If admittance is necessary without hospital issued ID (which contains the key card access) please contact Security at 1708.

Replacement of Keys

Graduate Medical Education Institutional Policy I. Purpose To establish an institutional policy to ensure security and deter the frequent loss of keys for the house staff on-call quarters. II. Scope This policy will apply to all house staff who participate in the Physical Medicine and Rehabilitation residency training program at the MedStar National Rehabilitation Hospital. III. Responsibilities/Requirements

A. Keys for the house staff lounge/on-call rooms and book cabinet will be distributed to the house staff during their orientation at no cost. It is the responsibility of the house staff to ensure the security of their keys at all times.

B. House Staff will reimburse the GME Training Office at a cost of $10.00 for each key that is lost or stolen.

C. All lounge and on-call room keys must be returned to the GME Training Office following completion of the house officer’s training or rotation. If the keys are not available at check-out, the house officer will be required to pay $10.00 for each key.

PAGERS

To initiate a page dial 9+pager phone number and follow the paging instructions.

House Staff Pagers

Graduate Medical Education Institutional Policy I. Purpose To establish an institutional policy delineating the processes for acquiring, returning and maintaining hospital pagers, which are issued to all house staff for business use only.


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II. Scope This policy will apply to all house staff who participate in a graduate medical education (GME) training program at the MedStar National Rehabilitation Hospital. III. Definitions House Staff or House Officer – refers to all interns, residents and fellows participating in a MedStar Hospital post-graduate training program. Post-Graduate Training Program – refers to a residency or fellowship educational program IV. Procedure

A. Issuance of Pagers: 1. Pagers may distributed to house staff on the first day of orientation.

2. Residents may elect to have their pager number forward to their personal

cell phones and receive a $60 reimbursement per year for text

messaging. The pagers system used is one way and should not include

HPI.

B. Return of Pagers: After completion of their training program or upon termination, house staff are required to return their pagers to the Residency Program Coordinator or Program Director, who will then endorse the mandatory House Officer Check-out List. C. Loss/Damage/Theft of Pagers:

1. Loss/Damage: House staff will be held responsible for lost and/or damaged pagers, and will be required to pay the full cost for their replacement barring any unforeseen circumstances. Checks should be made payable to MedStar National Rehabilitation Hospital, and hand delivered to the Residency Training Office.

House staff will not be responsible for replacing pagers due to manufacturer’s defects.

2. Theft: Any pager that is stolen on or off Hospital grounds, will be replaced upon receipt of a written security report from Protective Services. If a security report is no provided, the house staff officer will be responsible to pay the full cost for replacement, following the steps as stated above.

3. Batteries for pagers can be obtained from either the GME Training Office or the Telecommunications office.

4. Any pager maintenance, other than replacement of batteries, should be

taken directly to the Telecommunications Department.


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PARKING

House staff members are issued parking cards for the MedStar National Rehabilitation Hospital parking garage at orientation.

PHARMACY

The Pharmacy is located in the first floor of the MedStar National Rehabilitation Hospital. Outpatient hours of operation are 9:30 a.m. to 6:00 p.m., Monday – Friday and Inpatient hours of operation are 8:30 a.m. to 8:30 p.m., Monday – Friday. MedStar National Rehabilitation Hospital employees are offered a discount on medical supplies, over the counter drugs and prescription drugs. Contact the pharmacy on extension 1732 for more information.

SCHEDULES

Rotation Schedule:

House staff are assigned to their duties and responsibilities by their department in accordance with the educational requirements of the Accreditation Council on Graduate Medical Education (ACGME). Annually, a schedule of rotations is prepared for each house staff by the Program Director. The rotation schedule may be altered somewhat during the year to meet individual needs or desires providing that residency requirements are met.

On-Call Schedule:

Yearly call schedules are developed by the chief resident prior to the beginning of each academic year. Due to this advanced scheduling, house staff vacation and conference requests are to be submitted to the chief resident at least six weeks in advance. On- Call Switches

A. Both parties are required to fill out a call-switch form with the exact dates of

switches between the two agreed upon house staff and is granted by the

signature of the Program Director, Assistant Program Director or designee.

B. Any call switches that occur without form and signatures are NOT to be

considered official changes and therefore all parties involved are

responsible for the call schedule in New Innovations. Failure to show up

for call will be consider a “leaving of post” and is possible cause for

immediate dismissal from the training program.

SECURITY

The Protective Services Department at the MedStar National Rehabilitation Hospital is committed to providing a safe and secure working environment for all employees. House staff should contact Protective Services immediately, on extension 1708, to report any suspicious activity. In the event that nay house officer is involved in a security-related incident, please report it immediately to both Protective Services and the Residency Training Office.


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SMOKING

Tobacco use remains the most significant preventable cause of death and disability in the United States today. The MedStar National Rehabilitation Network is committed to providing a completely tobacco free environment to promote a healing atmosphere for our patients and a healthy environment for our staff, volunteers, physicians, visitors, vendors, and the community it serves. It is the policy of the MedStar National Rehabilitation Network to provide an environment free of tobacco use and exposure to second hand smoke.

STIPENDS/PAYCHECKS

MedStar National Rehabilitation Hospital will provide house officers with a stipend as compensation for patient care services and support for the educational responsibilities of the training program. The appropriate stipend level will be reviewed by the Graduate Medical Education Committee annually. The stipends for this year are as follows:

Level Stipends (7/1/2012)

PGY 2 $51,500

PGY 3 $53,600

PGY 4 $55,700

PGY5 $58,750

All house staff are paid biweekly. Each paycheck will include earnings for all work performed through the end of the previous payroll period. In the event that a regularly scheduled payday falls on a day off such as a weekend or holiday, employees will receive pay on the Friday before the regularly scheduled payday. House staff are required to submit a time through duty hour management module of New Innovations to receive their pay check. House Staff will elect how to handle time not recorded by the required time. The following options are:

a. Not to be paid for time not recorded

b. Paid time off to be used for time not recorded to the equivalent of a 80 per

pay period, up to available PTO, (then not paid for remainder of balance)

Employees may have pay directly deposited into their bank accounts if they provide advance written authorization to the MedStar National Rehabilitation Hospital. Employees will receive an itemized statement of wages when MedStar National Rehabilitation Hospital makes direct deposits.

TIMESHEETS

Each resident expected to provide the residency training program completed time in the duty hours management in New Innovations on the Sunday prior to pay week.


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LAUNDRY SERVICES

White coats are laundered for you by the hospital. Your are not allowed to wash them at home by OSHA regulations. A dirty white coat can be placed in the hamper, which is located in room GO-92 on the ground floor of the MedStar National Rehabilitation Hospital. The clean white coat can be picked up approximately 2 weeks later. It is required that your name be placed in the inside collar of your white coat in indelible black ink.


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Conduct & Disciplinary Action

ACADEMIC IMPROVEMENT POLICY

1) Purpose To establish a policy and process for all programs at the MedStar National Rehabilitation Hospital (MedStar Health) to use in the normal process of evaluating and assessing competence and progress of house staff enrolled in programs of post-graduate medical education. Specifically, this policy will address the process to be utilized when a resident/fellow is not meeting the academic expectations of a program, and therefore, fails to progress.

2) Scope This policy applies to all Graduate Medical Education (GME) training programs at the MedStar National Rehabilitation Hospital.

3) Definitions a) House Staff or House Officer – refers to all interns, residents and fellows

participating in a program of post-graduate medical education. b) Post-Graduate Training Program – refers to a residency or fellowship educational

program.

4) Process a) Structured Feedback: All residents and fellows should be provided routine

feedback that is consistent with the educational program. Feedback techniques include verbal feedback, rotational evaluations and summative evaluations (See Evaluation Policy). Each residency program must have a Clinical Competency Committee (“CCC”)2, that is charged with routinely assessing house officer performance.

b) “Letter of Deficiency”: When a house officer has been identified as having a deficiency, it is expected that the s/he will receive routine structured feedback in order to identify and correct the issue. When the program director/CCC deems that routine structured feedback is not effecting the necessary improvement, or if the Program Director/CCC determines that the deficiency is significant enough to

2 The Clinical Competency Committee may be referred to as the “Progress and Promotions Committee” or

other terminology. This is a departmental committee that consists of the faculty and others as deemed appropriate by the department. This committee should meet regularly to assess resident/fellow performance and make recommendations to the program director regarding further action.

Chapter

4


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warrant something more than routine feedback, the Program Director/CCC may elect to issue a “Letter of Deficiency.” This letter provides the House Officer with (a) notice of the deficiency and (b) an opportunity to cure the deficiency. “Letters of Deficiency” must be co-signed by the Program Director (or Designee) and the Administrative Director of Medical Education. The issuance of a “Letter of Deficiency” does not trigger a report to any outside agencies. The program director will provide the house officer with feedback, consistent with the letter of deficiency. If the house officer satisfactorily resolves the deficiency(ies) noted in the Letter of Deficiency, and continues to perform acceptably thereafter, the period of unacceptable academic performance does not affect the house officer’s intended career development.

c) Failure to Cure the Deficiency: If the Program Director/CCC determines that

the house officer has failed to satisfactorily cure the deficiency and/or improve his/her overall performance to an acceptable level, the Program Director/CCC may elect to take further action, which may include one or more of the following steps:

i) Issuance of a new Letter of Deficiency ii) Election not to promote to the next PGY level iii) Requiring the repeat of a rotation that in turn extends the required

period of training iv) Extension of contract, which may include extension of the defined

training period v) Denial of credit for previously completed rotations vi) Dismissal from the residency or fellowship program

Reportable Actions: The decision not to promote a house officer to the next PGY Level, to extend a house officer’s contract, to extend a house officer’s defined period of training, to deny a house officer credit for a previously completed rotation, and/or to terminate the house officer’s participation in a residency or fellowship program are each considered “reportable actions.” Reportable Actions are those actions that the Program must disclose to others upon request, including without limitation, future employers, privileging hospitals, and licensing and specialty boards. House Officers who are subject to a Reportable Action may request a review of the decision as provided in this Policy.

d) Request for Review: A review of the decision to take a Reportable Action may be requested by the house officer. A Request for Review should be submitted to the Administrative Director of Medical Education within fourteen (14) days of learning of the Reportable Action. Upon receipt of a Request for Review, the Administrative Director will first determine whether the matter is reviewable under this Policy, and if so, the Administrative Director shall appoint a neutral physician reviewer who will: i) Review the complaint ii) Meet with the house officer iii) Review the house officer’s file


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iv) Meet with the program director v) Consider any extenuating circumstances vi) Consult with others, as appropriate, to assist in the decision making process;

and vii) Determine whether this Policy was followed, the house officer received notice

and an opportunity to cure, and the decision to take the Reportable Action was reasonably made.

The Administrative Director of Medical Education will:

i) Appoint the physician reviewer ii) Assist the physician reviewer to identify other potential participants, if warranted iii) Attend all meetings held by the physician reviewer iv) Coordinate communications between the physician reviewer and the house officer v) Monitor timely completion of the review process vi) Notify the Vice President of Medical Affairs of the request for review

e) Opportunity for a Final Review: If either the house officer or the program director disagree with the decision of the physician reviewer, either can request a final review of the decision to take a Reportable Action by the Vice President for Medical Affairs (VPMA). A request for final review shall be submitted to the Assistant Vice President for Academic Affairs within fourteen (14) days of learning of the Physician Reviewer’s decision. The VPMA will conduct a final review in conjunction with the Assistant Vice President for Academic Affairs. The roles of these individuals and the process are the same as described in the “Request for Review” above. The decision of the VPMA constitutes a final and binding decision. Upon conclusion of the review, a report of the final review will be provided to both the house officer and the program director.

DUE PROCESS POLICY



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I. Purpose

To establish a policy for all post-graduate training programs within the MedStar National Rehabilitation Hospital to use in reviewing all actions resulting in dismissal or otherwise altering the intended career path of the house officer.

II. Scope

This policy will apply to all house officers who participate in a graduate medical education (GME) training program within MedStar National Rehabilitation Hospital. Due Process, as described within, applies to actions that are taken as a result of academic deficiencies or misconduct (see related Academic Improvement Policy and House Officer Misconduct policy)

III. Definitions

House Staff or House Officer – refers to all residents enrolled in the Physical Medicine and Rehabilitation Residency Program at the MedStar National Rehabilitation Hospital. Graduate Training Program – refers to a residency program. Dismissal – The act of terminating a house officer’s participation in a training program prior to the successful completion of the course of training, whether by early termination of a contract or by non-renewal of a contract.

IV. Academic Matters

The Hospital’s Academic Improvement Policy affords due process to house officers who are dismissed from a residency program or whose intended career development is altered by an academic decision of a program. Academic Improvement Policy for delineation of the specific processes available to a house officer to challenge an academic decision made by his/her Department.

V. Misconduct Matters

The Hospital’s House Officer Misconduct Policy affords due process to house officers who are disciplined or dismissed from a residency program in a manner that alters their intended career development. See House Officer Misconduct Policy for delineation of the specific processes available to a house officer to challenge discharge or discipline decisions based on alleged misconduct by a house officer.

GRIEVANCE POLICY

Graduate Medical Education Institutional Policy I. Purpose

To establish a policy for all graduate training programs within the MedStar Health System for resolution of house officers’ complaints and grievances.


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II. Scope This policy will apply to all house officers who participate in a graduate medical education (GME) training program at the MedStar National Rehabilitation Hospital. This policy does not apply to actions arising out of the Academic Improvement Policy or the House Officer Misconduct Policy.

III. Definitions

House Staff or House Officer – refers to all interns, residents and fellows participating in a MedStar Health graduate training program.

Graduate Training Program – refers to a residency or fellowship educational program.

Grievance – a cause of distress (such as an unsatisfactory working condition) felt to afford reason for complaint or resistance.

IV. Responsibilities/Requirements:

A. Grievances must be dealt with in a confidential manner, and without fear of retaliation. Incidents should be reported directly to the house officer in charge at the time of the incident.

B. If the house officer in charge is unable to rectify the situation, the attending on the team should be consulted.

C. For an incident that is not resolved as stated above or that is not associated with a particular incident on a patient unit, house officer should proceed directly to their Chief Resident.

D. If the house officer does not feel as though the Chief Resident has effectively resolved the issue, he/she should take the problem to the Program Director for resolution.

E. If satisfactory resolution is still not apparent after the Program Director has become involved, then the house officer should provide a written grievance report directly to the Director of Medical Education outlining the issue. This report should describe the involvement of the Chief Resident and the Program Director.

F. The Director of Medical Education will review the written grievance report to ensure that all of the appropriate steps, as indicated above, were followed. A grievance committee will then be formed consisting of, at least, the following individuals:

a) The grievant’s Program Director

b) Director of Medical Education (or designee)

c) AVP of Academic Affairs (or designee)

d) A house staff not involved with the situation


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e) Any other department representative deemed necessary by management to perform a reasonable investigation and decision-making process

G. Upon hearing the grievance, the committee will investigate all issues associated with the complaint and will provide a final written decision to the house officer.

H. All proceedings and decisions of the grievance committee shall be reported to the Graduate Medical Education Committee and the applicable program director in a confidential manner.

HOUSE OFFICER MISCONDUCT POLICY

MedStar National Rehabilitation Hospital Graduate Medical Education Institutional Policy 1) Purpose

To establish a policy and process for all programs within the MedStar Health System to use when allegations of misconduct are made against a house staff officer.

2) Scope This policy applies to all Graduate Medical Education (GME) training programs at the MedStar National Rehabilitation Hospital.

3) Definitions a) House Staff or House Officer – refers to all interns, residents and fellows

participating in a program of post-graduate medical education

b) Post-Graduate Training Program – refers to a residency or fellowship educational program

c) Misconduct – Improper behavior; Intentional wrongdoing; Violation of a law, standard of practice, or policy of the program, department, or hospital. Misconduct may also constitute unprofessional behavior, which may trigger action under the Academic Improvement Policy. These actions may proceed simultaneously.

4) Process a) Allegations of Misconduct: A house officer, employee of the Hospital,

attending physician, patient, or any other person who believes that a house


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officer has engaged in misconduct of any kind should immediately report his/her concerns to his/her supervisor, or any other supervisor in the Hospital, who in turn should communicate the allegations to the house officer’s Program Director.

b) Upon receipt of a complaint regarding the conduct of a house officer, the Program Director should conduct an initial inquiry, as follows: i) Meet with the person complaining of misconduct.

ii) Meet with the house officer to advise the house officer of the existence of the complaint, to give the house officer an opportunity to respond to the allegations, and to identify any potential witnesses to the alleged misconduct.

iii) Consult with the Administrative Director of GME to determine whether the VPMA, Department Chairman, Legal Affairs and/or Human Resources should be contacted as appropriate based on the issues and the people involved.

iv) Upon request of the house officer, or if the Program Director, GME Director, VPMA, or Human Resources decide the incident warrants more investigation, then a “Full Inquiry” must be done.

v) All allegations of sexual harassment will be reported immediately to Human Resources in accordance with the Hospital’s policy against harassment.

vi) Upon consensus of the Program Director and GME, the accused house staff officer can be removed from duty (with or without pay) pending the outcome of a full inquiry.

c) Full Inquiry: A full inquiry is an internal investigation of the allegation/incident by appropriate individuals, which may include GME, the Program Director, the Department Chairman, Human Resources, Legal, or others. The inquiry process is administered by the Administrative Director of GME. Factual results of the inquiry will be prepared by the GME Director and/or other responsible individuals and reported back to the program director and the house officer for appropriate action.

i) If the full inquiry results in a finding that no misconduct occurred, no action

will be taken against the house officer. If the house officer was suspended pending the inquiry, the house officer will be reinstated with full benefits and pay.

d) If the full inquiry results in a finding that a house officer participated in misconduct, the Program Director shall determine, in conjunction with the VPMA, Department Chair, GME, Human Resources, Legal, or other appropriate individuals, what action is appropriate under all the circumstances, to remedy the situation. The Program may take actions including, without limitation, the following: i) A verbal or written warning ii) Election to not promote to the next PGY level


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iii) Non-renewal of contract iv) Suspension v) Termination from the residency or fellowship program Reportable Actions: The decision not to promote a house officer to the next PGY Level, not to renew a house officer’s contract, to suspend a house officer, and/or to terminate the house officer’s participation in a residency or fellowship program are each considered “reportable actions.” Reportable Actions are those actions that the Program must disclose to others upon request, including without limitation, future employers, privileging hospitals, and licensing and specialty boards. House Officers who are subject to a Reportable Action may request a review of the decision as provided in this Policy.

e) Request for Review: A review of the decision to take a Reportable Action may be requested by the house officer. A Request for Review should be submitted to the Assistant Vice President for Academic Affairs within fourteen (14) days of learning of the Reportable Action. Upon receipt of a Request for Review, the Assistant Vice President (AVP) will first determine whether the matter is reviewable under this Policy, and if so, the AVP shall advise the VPMA who will: i) Review the complaint ii) Meet with the house officer iii) Review the house officer’s file iv) Meet with the program director v) Consider any extenuating circumstances vi) Consult with others, as appropriate, to assist in the decision making process;

and vii) Determine whether this Policy was followed, the house officer received notice

and an opportunity to be heard, and the decision to take the Reportable Action was reasonably made.

The Assistant Vice President for Academic Affairs will:

i) Advise the VPMA of the request for review ii) Assist the VPMA to identify other potential participants, if warranted iii) Attend all meetings held by the VPMA iv) Coordinate communications between the VPMA and the house officer v) Monitor timely completion of the review process

The decision resulting from this review is a final and binding decision. A written report will be provided to the house staff and the program director, and others as appropriate. 5. No Retaliation: Initial and full inquiries will be conducted with due regard for confidentiality to the extent practicable. Under no circumstances may anyone retaliate against, interfere with or discourage anyone from participating in good faith in an initial inquiry or a full inquiry conducted under this policy. A house staff officer who believes he/she may have been retaliated against in violation of this policy should immediately


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report it to their supervisor, the Assistant Vice President of Academic Affairs, or any other supervisor.

SEXUAL AND OTHER UNLAWFUL HARASSMENT

The MedStar National Rehabilitation Hospital is committed to providing a work environment that is free to discrimination and unlawful harassment. Actions, words, jokes, or comments based on an individual’s sex, race, ethnicity, age, religion, sexual orientation, or any other legally protected characteristic will not be tolerated. As an example, sexual harassment (both overt and subtle) is a form of employee misconduct that is demeaning to another person, undermines the integrity of the employment relationship, and is strictly prohibited. Any employee who wants to report an incident of sexual or other unlawful harassment should promptly report the matter to his or her supervisor. If the supervisor is unavailable or the employee believes it would be inappropriate to contact that person, the employee should immediately contact the GME Training Office or any member of management. Employees can raise concerns and make report without fear of reprisal. Any supervisor or manager who becomes aware of possible sexual or other unlawful harassment should promptly advise the GME Training Office or any of management who will handle the matter in a timely and confidential manner. Anyone engaging in sexual or other unlawful harassment will be subject to disciplinary action, up to and including termination of employment.


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Ancillary

ANNUAL REQUIREMENTS

In addition to licensure and Occupational Health requirements, the following courses must be completed annually. These requirements can be met on-line through SiTEL.

Electrical Safety Emergency Preparedness Fire Safety General Compliance II HIPAA Hand Hygiene: Improving Practices Hazardous Materials Injury Prevention MRSA Education Security Management The SPIRIT of MedStar’s Diversity Workplace Violence General Compliance I

Mandatory Courses

The courses that are mandatory to every employee are assigned to your account, and found in the Current Training section. Click the Green Box with the White Arrow to launch the courses. *There may be additional courses that you are required to take, either site specific, or clinical. Always ask your manager if there are any additional courses. Exiting Modules to Save Your Place Each course has an Exit button located in the upper right corner, or found in the Menu button. Use those Exit buttons instead of the X in the upper right corner to close the course.

Completing a Course

It is important to make sure that you are waiting for the confirmation box from MeL when clicking Record Results. Not waiting can cause your score to not save. It’s white, and the writing says, You have completed all scheduled items.

Chapter

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Viewing/Printing a Transcript

Your Transcript is found by clicking View my training transcript on the left side of the Welcome Page in the blue box. A Print button appears in the upper right corner.

LIBRARY AND MEDIA SERVICES

A Library is located at the Washington Hospital Center in Room 2A-21 and is open Monday through Thursday from 7:0 a.m. to 7:00 p.m.; Friday, 7:30 a.m. to 5:00 p.m.; and Saturday, 9:00 a.m. to 1:00 p.m. The library provides services including Medline searches, interlibrary loans, and LATCH (Literature Attached to the Chart). A photocopier is also available in the library. Additional Departmental Library maintained in the second floor call room which holds a collection of basic Physiatry text books and Specialty related reference books available 24/7.

MEDICAL RECORDS

The Medical Records Department is located on the ground floor of the MedStar National Rehabilitation Hospital. House Officers are required to complete their charts in accurately and timely in order to successfully graduate. Charts required house staff signature or completions are located in the physicians charting room with the 24 hour access.

QUALITY IMPROVEMENT

Quality Improvement focuses on improving the performance of the hospital through supporting the Service Excellence philosophy and our tradition of “Patient First”. QI provides support and training for team leaders and facilitators in statistical process tools, decision-making tools, and group techniques. Other educational efforts address compliance with Joint Commision and other accrediting agencies. A database of the MedStar National Rehabilitation Hospital teams is viewable through the hospital’s intranet under Quality Improvement. The hospital-wide, interdisciplinary Quality Improvement Committee focuses on leadership/management development, quality management education, customer services, and patient/staff satisfaction. If you are interested in participating in a team or would like to register for a course please call Quality Resources at extension 1422.

OTHER INSTITUTIONAL POLICIES

House Staff Policy Statement:

IMPAIRMENT POLICY

I. Definition of an Impaired Practitioner


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An impaired Practitioner can be defined as one who has an illness or disability which interferes with the performance of professional duties and responsibilities. Some of the major impairments include alcoholism and other drug dependencies, habitually abusing drugs, mental illness, psychosexual disorders and disabilities associated with aging. II. Examples of Impairment The following list contains examples of behaviors that could be a sign of a serious medical condition: A decline in carrying out professional responsibilities, record keeping or attendance; Non-availability when on-call or difficulty begin found; Often late, absent, or ill; Writing poor or inappropriate orders; Increasingly irritable with staff and colleagues; Frequent request for colleagues to cover for him/her; Making rounds at unusual or inappropriate hours; Problems with recent memory/ Odor of alcohol on a Practitioners breath; Many prescriptions for self or family; Self-medication for anxiety or depression; Disorganized work schedule; Patient complaints of inattention, forgetfulness or inappropriate behavior or remarks; Excessive inventory of drugs for office use; Frequent office absences Slurred speech.

INTERNAL REVIEW

Graduate Medical Education Institutional Policy I. Purpose To establish an institutional policy for internal reviews of all post-graduate medical education training programs sponsored by the MedStar National Rehabilitation Hospital. II. Scope This policy will apply to all graduate medical education (GME) training programs within the MedStar Health System (Washington Division). III. Definitions House Staff or House Officer – refers to all residents participating in a MedStar Hospital post-graduate training program. Post-Graduate Training Program – refers to a residency or fellowship educational program. Graduate Medical Education Committee – an organized, administrative, oversight system for residency training programs sponsored by an institution.


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Internal Review – periodic quality assessment of all residency training programs. IV. Procedure A. The Graduate Medical Education Committee (GMEC) is responsible for the periodic review of all training programs, and assuring their compliance with institutional policies and program requirements as outlined in the Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements. B. The GMEC shall appoint a committee to review each residency program. The committee will include a chairperson (from an outside program), the applicable program director, internal and external program faculty, house staff of the program being reviewed, as well as one outside house staff representative, and appropriate administrators. C. The internal review will include appraisal of: educational objectives of the program (as defined by respective Residency Review Committee (RRC) guidelines); adequacy of available educational and financial resources to meet the objectives; effectiveness of each program in meeting its objectives; effectiveness in addressing citations from previous ACGME letters of accreditation and previous internal reviews; The internal review will also assess:

whether each program has defined, in accordance with the relevant Program Requirements, the specific knowledge, skills and attitudes required and provides the educational experiences for the house staff to demonstrate competency in the following areas: patient care skills, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning, and systems-based practice;

evidence of the program’s use of evaluation tools to ensure that the house staff demonstrate competence in each of the six areas;

the development and use of dependable outcome measures by the program for each of the general competencies; and,

the effectiveness of each program in implementing a process that links educational outcomes with program improvement.

Documentation to be used in the appraisal process must include: Institutional and Program Requirements from the Essentials of Accredited Residency Programs: letters of accreditation from previous ACGME surveys; reports from previous internal reviews of the program; and, interviews with the program director, faculty and house staff in the program and anyone outside of the program that is deemed appropriate. Process: An informal meeting will be held with the house staff of each program and the administrator(s) of Graduate Medical Education prior to the meeting of the full committee. At this time, the house staff will be asked to provide their perception on all


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areas of the program, as outlined in the Internal Review Resident Questionnaire. A summary of the house staff meeting will be provided to the Internal Review Committee. The Internal Review Committee will convene to, not only completely evaluate the program, but to improve the quality of the educational program and to promote constructive criticism. The evaluation shall also serve to educate the committee on the institutional and program requirements. Upon completion of the Committee’s evaluation, a succinct summary of the Internal Review Meeting will be documented, and mechanisms to correct identified deficiencies will be recorded. The complete summary report will be submitted to the GMEC for their next scheduled meeting, and presented by the Chair of the Internal Review Committee. The GMEC will vote to either fully endorse the evaluation and recommendations as reported, or to suggest additional evaluation. A copy of the final report will be maintained in the program’s file and in the Residency Training Office’s files. In most cases, the program director will be asked to follow-up after six months by preparing a report of the status of the program in relation to the recommendations of the internal review committee. This report will be submitted to the GMEC. Serious issues may warrant more frequent follow-up, or an immediate, additional internal review. Reviews will be conducted at least once, midway between ACGME program surveys.

PHARMACEUTICAL RELATIONSHIPS

Graduate Medical Education Institutional Policy I. Purpose Establish an institutional policy which provides direction on appropriate relationships among the house staff, pharmaceutical industries and their representatives. II. Scope This policy will apply to all house staff who participates in a graduate medical education (GME) training program at the MedStar National Rehabilitation Hospital. III. Definitions House Staff or House Officer – refers to all residents participating in a MedStar Health Hospital post-graduate training program. Post-Graduate Training Program – refers to a residency educational program. Grant – a gift for a particular purpose


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IV. Responsibilities/Requirements A. The GME Training Office will neither endorse nor support house staff interaction with pharmaceutical industries and their representatives, but will accept unrestricted grants from any source for the purpose of medical education. B. The GME Training Office will not sponsor house staff-related functions with pharmaceutical industries and their representatives. C. Speakers sponsored by pharmaceutical representatives will not be scheduled during assigned house staff didactic series mandated by GME. D. Employed physicians of MedStar Health and MedStar National Rehabilitation Network or MedStar National Rehabilitation Hospital are NOT allowed to participate in offsite pharmaceutical dinners, during or not during work hours. Physicians may attend “educational program” only if they pay for their own meals, beverages and travel to and from the event. And do not accept any gifts (pens, paper, medical devices, books, etc).


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Contact Information

You may contact us by the following:

Phone: (202) 877-1627

US Mail: MedStar GUH-NRH PM&R Residency Training Program MedStar National Rehabilitation Hospital

102 Irving Street, NW Washington, DC 20010

E-mail: [email protected]

Or lastly through the contact page on our web site www.medstarnrh.org.

Chapter 6

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Index

“

“America’s Best Hospitals” · 11

A

A verbal or written warning · 112 ACADEMIC IMPROVEMENT POLICY · 105 Administrative Leave · 96 ADVANCED CARDIAC LIFE SUPPORT · 23 ANNUAL REQUIREMENTS · 115 Assistant Program Director · 15 Assistive technology · 12

B

BASIC LIFE SUPPORT TRAINING · 23 BUSINESS ETHICS AND CONDUCT · 23

C

CAFETERIA · 81 Cafeteria Hours · 82 CHECK OUT PROCEDURE · 24 COMMITTEES · 25, 26 Completing a Course · 116 CREDIT UNION · 86 Current Outcomes · 115, 124 Curtis L. Whitehair, MD · 15 Cynthia Pineda, MD · 15

D

DISABILITY ACCOMMODATION · 30 Dismissal · 22 DRESS CODE · 31 DUE PROCESS POLICY · 108 DUTY HOURS · 32

E

Election to not promote to the next PGY level · 112

E-mail · 124 EMERGENCY HOUSE STAFF LOANS · 87

EMPLOYEE ASSISTANCE PROGRAM · 86 EVALUATION POLICY · 35

F

Failure to Cure the Deficiency · 106 Family Leave · 94 FINANCIAL PLANS · 89 FlexFund · 89 Full Inquiry · 112

G

General Responsibilities of House Staff · 38 GRIEVANCE POLICY · 109

H

HOUSE OFFICER MISCONDUCT POLICY · 111 HOUSE STAFF REIMBURSEMENT FUND · 89 Human Resources Department · 80

I

IMMIGRATION LAW COMPLIANCE · 39 IMPAIRMENT POLICY · 117 IN PATIENT ROTATION CAPS: · 34 INSURANCE PLANS · 92 INTERNAL REVIEW · 118 Interpersonal and Communication Skills: · 75

J

Jennifer Perianayagam · 15

L

LAUNDRY SERVICES · 104 Leave Due to Illness · 95 Leave Due to Vacation · 96 LEAVE OF ABSENCE · 94 Letter of Deficiency · 105 LIBRARY AND MEDIA SERVICES · 116 Life Insurance · 92 LOAN DEFERMENT · 98


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Long-Term Disability · 92

M

Malpractice Liability Coverage Limits · 92 Mandatory Courses · 115 Medical and Dental Insurance · 93 Medical Knowledge: · 74 MEDICAL LICENSURE · 43 MISSION · 12 MOONLIGHTING · 53

N

No Retaliation · 113 Non Renewal of Contract · 23 Non-renewal of contract · 112 Non-Renewal of Contract · 59

O

ON-CALL QUARTERS · 98 Opportunity for a Final Review · 107

P

PAGERS · 99 PARKING · 101 Patient Care: · 73 PAYCHECKS · 103 PHARMACEUTICAL · 122 Phone: · 124 Practice-Based Learning and Improvement: · 75 Professionalism: · 76 Program Coordinator · 15 Program Director · 15 PROMOTION OF HOUSE OFFICERS · 57

Q

QUALITY IMPROVEMENT · 117 Quality patient care · 12

R

Reportable Actions · 106, 112 Request for Review · 106, 113 Resident Competencies: · 73 Residents from Other Hospital · 42 Resignation · 22 RESTRICTIVE COVENANTS · 61 rotating · 42 Rotation Schedule: · 101 Rotations · 80

S

SECURITY VIOLATIONS · 84 SEXUAL AND OTHER UNLAWFUL HARASSMENT · 114 Short-Term Disability · 93 STIPENDS · 103 STIPENDS/PAYCHECKS · 103 Structured Feedback · 105 SUPERVISION OF HOUSE OFFICERS · 66 Suspension · 112 Systems-Based Practice: · 77

T

Tax Sheltered Annuity · 89 Termination from the residency or fellowship

program · 112 TIMESHEETS · 104 Travel Reimbursement · 91

U

US Mail · 124

V

VALUES · 13 VISION · 13

W

Workers’ Compensation Insurance · 94

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