Resident Training Environment Policies

Duty Hour Oversight and Monitoring in the Learning and Working Environment (IR.III & IR I.V.J.)

GMEC approved: March 2007
GMEC revised: July 2011
GMEC updated and approved: August 2014

Purpose

To ensure an appropriate learning and working environment and compliance with duty-hour requirements.

Definition

Duty hours are defined as all clinical and academic activities related to the training program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during callactivities and scheduled academic activities such as conferences. Duty hours do not include reading, studying or academic preparation time such as time spent away from the patient care unit preparing for presentations or journal club.

Policy

WSU GME is committed to providing a supportive learning environment where sound academic and clinical education is carefully planned and balanced with concerns for patient safety and residents well-being. WSU GME fosters a culture of professionalism that supports patient safety and personal responsibility. WSU GME is committed to providing an educational and work environment which encourages residents to raise and resolve concerns in a confidential and protected manner without fear of intimidation or retaliation.

The clinical responsibilities for each residents is based on PGY-level, patient safety, education, severity and complexity of patient illness/condition and available support services. Residents care for patients in an environment that maximizes effective communication, utilizes inter-professional teams and ensures effective hand-over processes. Residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.

Residents and core faculty members are educated concerning the fulfillment of educational and professional responsibilities of physicians that include: scholarly pursuits, accurate completion of required documentation, the identification of resident mistreatment and to appear for duty appropriately rested and fit to provide the services required by their patients. Physicians must recognize that under certain circumstances, the best interests of the patient may be served by transitioning that patient’s care to another qualified and rested provider.

Each program must ensure that the learning objectives of the program are accomplished through an appropriate blend of supervised patient care responsibilities (see Supervision policy), clinical teaching and didactic educational events; and are not compromised by excessive reliance on residents to fulfill non-physician service obligations. Didactic and clinical education must have priority in the allotment of residents’ time and energies. Duty hour assignments must recognize that faculty and residents, collectively, have responsibility for the safety and welfare of patients. Programs may adopt more restrictive duty hour requirements which also apply to residents rotating in that program.

Duty hours must be limited to 80 hours per week, averaged over a four week period, inclusive of all in-house call activities and all internal and external moonlighting. The maximum duty period is 16 hours for a PGY1 and 24 hours for PGY2 and above (24 hours plus four hours transition and education) for a total of 28 hours.

Residents are required to have time off from all educational and clinical responsibilities. Intermediate-level residents should have 10 hours off and must have eight hours off after a 12- hour shift and 14 hours off after a 24-hour shift, inclusive of call. One day is defined asone continuous 24-hour period from all clinical, educational and administrative activities. While it is best practice that residents in their final years of education have eight hours of duty free time between scheduled duty periods, there may be circumstances (as defined by the residency review committee) when these residents must stay on duty to care for their patients. These circumstances will be monitored by the program director.

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

Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.

Procedure

Resident duty hours are self-reported through the residency management software.

Faculty and residents are educated to recognize the signs of fatigue and sleep deprivation and to employ procedures to prevent and counteract its potential negative effects on patient care and learning. Mandatory educational requirements on fatigue are assigned to residents assigned an on-line course prior to their first year. The program must have and educational program that educates Faculty and residents/fellows about duty hours and fatigue mitigation.

Each program adopts fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, including naps and back-up call schedules. In addition, each program must have a process to ensure continuity of patient care in the event that a resident may be unable to perform his/her patient care duties. Programs will encourage residents to use alertness management strategies in the context of patient care. Strategic napping, especially after 16 hours of continuous duty, is strongly suggested.

The WSU GME ensures that all residents/fellows have access to call rooms at each participating site and/or safe transportation options for residents who may be too fatigued to return home safely.

Monitoring

The GMEC reviews and monitors working conditions, residents supervision, duty hours for residents/fellows and ancillary support, and residents participation in department scholarly activity as set forth in the ACGME institutional, common and applicable specialty program requirements.

  • Bi-monthly review of duty hour reports from each program at the GMEC meeting. The GMEC will request a report from the program director of any violations identified as patterns of non-compliance.
  • Program policies: Copies of program-specific policies and procedures are maintained on residency management software.
  • Annual GME resident evaluation of program: Residents are asked to complete a confidential (only the program is identified) web-based survey. Included in the survey are questions about program compliance with duty hours and other work environment issues.
  • Annual GME faculty evaluation of program: Faculty are asked to complete a confidential (only the program is identified) web-based survey. Included in the survey are questions about program compliance with duty hours and other work environment issues.
  • ACGME resident survey: The ACGME surveys residents about their clinical and educational experiences. This survey is not administered in conjunction with a program’s site visit, although the information gathered will be used at the time of the program’s site visit.
  • ACGME resident survey: The ACGME surveys residents about their clinical and educational experiences. This survey is not administered in conjunction with a program’s site visit, although the information gathered will be used at the time of the program’s site visit.
  • Anonymous contact: Residents are encouraged to contact the anonymous hotline at 248-457-5120 to report violations of the duty hour policy or any other grievance. They can also access the Confidential Complaint Form on the WSU GME website
  • Special review: Questionnaire includes specific questions regarding program policies on duty hours and compliance with requirements. Special review committee members meet with residents and ask for their confidential assessment of program compliance with requirements.
  • Resident Council – residents/fellows have the opportunity to report any complaints to their council representative or to bring the matter to the attention of the council directly. The council will address the issue with the GMEC and provide information back to the resident on any resolutions that may occur.

E-Mail Policy

GMEC approved: March 2007
GMEC updated & approved: July 2011
GMEC updated & approved: March 2015

Purpose

Communication between residents, fellows, faculty, program directors, coordinators and the GME office is critical to the functioning of training programs. Frequently, important information and announcements are disseminated to training programs and their participants. In addition, protectedinformation often needs to be shared to enhance patient care and training requirements (i.e., case conferences and/or morbidity and mortality, etc.). Having this information transmitted on a secure server is of utmost importance.

The purpose of this policy is to:

  • Help assure that communications among School of Medicine faculty, staff, and residents aresecure, especially those communications via electronic means that may contain Personal Health Information (PHI).
  • Provide a reliable and consistent means of exchanging official communications via email among administration, faculty, residents, and staff.
  • Facilitate communication among School of Medicine faculty, residents, and staff with outside entities by providing official, institution-sponsored and identified email accounts to all.

Policy

All faculty, residents, fellows, staff and administrators must have an assigned wayne.med.edu or wayne.edu email address.

  • All official communications will go through that address. ï‚· PHI can only be transmitted to a user who is authorized to view the PHI and who also has a med.wayne.edu or wayne.edu email address.
  • All faculty, residents and/or staff may not send any communication that contains PHI and/or confidential resident information through a commercial email account such as Hotmail, Gmail, Yahoo or AOL.
  • Program directors and coordinators must use school of medicine email addresses in all correspondence to faculty, residents, fellows and school administration.
  • Residents, fellows and faculty must check their school of medicine accounts regularly to ensure that they are not missing important information. Failure to meet deadlines etc. because of failure to check School of Medicine email will be addressed by program directors as a professionalism deficiency during semi-annual evaluations.

Definitions under this policy

Protected Health Information (PHI): PHI is considered to be any information that is created or received by WSUPG as a health care provider and relates to an individual’s past, present or future physical or mental condition, healthcare, and payment for health-related services. PHI also includes any data that clearly identifies the individual (i.e. Name, SSN, MRN or credit account numbers) or can be used to find the person’s identity (i.e. address, telephone number, DOB, e-mail address, names of relatives, employer).

Monitoring

The GMEC will monitor compliance with the institutional policy through the following venues:

  • ACGME Annual Resident Survey
  • Annual GME Resident evaluation of the program
  • ACGME Annual Faculty Survey
  • Annual GME Faculty evaluation of the program
  • Resident Quality Council
  • Anonymous contact via hotline and/or online complaint form

References

WSUPG Policy for Emailing Patient Information
WSU SOM policy for official communication
WSU C & IT Policy for Access IDs, Electronic Mail and Directory Services

Hand-offs and transition of care (IR III.B.3.)

GMEC Approved: January 2013
GMEC updated and approved: September 2014

Purpose

To establish protocol and standards within the WSUSOM GME residency and fellowship programs to ensure the quality and safety of patient care when transfer of responsibility occurs during duty hour shift changes and other scheduled or unexpected circumstances.

Definition

A handoff is defined as the communication of information to support the transfer of care and responsibility for a patient/group of patients from one provider to another. Transitions of care are necessary in the hospital setting for various reasons. The transition/hand-off process is an interactive communication process of passing specific, essential patient information from one caregiver to another. Transition of care occurs regularly under the following conditions:

  • Change in level of patient care, including inpatient admission from an outpatient procedure or diagnostic area or emergency room and transfer to or from a critical care unit
  • Temporary transfer of care to other health care professionals within procedure or diagnostic areas
  • Discharge, including discharge to home or another facility such as skilled nursing care
  • Change in provider or service change, including change of shift for nurses, resident sign-out and rotation changes for residents.

Policy

Programs must design clinical assignments to minimize the number of transitions in patient care (CPR VI.B.1) and maximize the learning experience for residents, ensure quality care and patient safety, and adhere to general institutional policies concerning transitions of patient care. Schedule overlaps must include time to allow for handoffs, ensure availability of information and an opportunity to clarify issues.

The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents responsible for each patient’s care (CPR VI.B.4).

Programs must ensure that residents are competent in communicating with team members in the handoff process (CPR VI.B.3).

Each program must include the transition of care process in its curriculum. Each residency program must develop components ancillary to the institutional transition of care policy that integrate specifics from their specialty field.

Procedure

The optimal transition/handoff process shall involve face-to-face interaction with both verbal and written/computerized communication, with opportunity for the receiver of the information to ask questions or clarify specific issues. The transition process shall include, at a minimum, the following information in a standardized format that is universal across all services:

  • Identification of patient, including name, medical record number and date of birth
  • Identification of admitting/primary/supervising physician and contact information
  • Diagnosis and current status/condition (level of acuity) of patient
  • Recent events, including changes in condition or treatment, current medication status, recent lab tests, allergies, anticipated procedures and actions to be taken
  • Active issues, including pending studies, what needs to be followed up during shift
  • Contingency plans (“if/then” statements)

If a face-to-face handoff is not possible the handoff process may be conducted by telephone conversation or other electronic communication (e.g. Skype, Facetime). Telephonic handoffs must follow the same procedures as face-to-face handoffs and both parties to the handoff must have access to an electronic or hard copy of the handoff information. Patient confidentiality and privacy must be guarded in accordance with HIPAA guidelines.

Programs are strongly encouraged to follow the SAIF-IR acronym during the handoff process:

S=Summary statements or synopsis
A=Active Issues
I=If/Then contingency planning
F=Follow up activities
I=Interactive questioning
R=Read backs

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

  • Didactic sessions on communication skills, including in-person lectures, web-based training modules, review of curricular materials and/or knowledge assessment.
  • Programs can utilize additional educational resources available at: http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groupssections/resident-fellow-section/rfs-resources/patient-handoffs.page
  • Occupational safety, health and environment training conducted at the beginning and repeated at least once throughout the academic year.
  • Direct observation of a handoff session by a faculty member, peer or a more senior resident.
  • Evaluation of written handoff materials by a faculty member, peer or a more senior resident.
  • Assessment of handoff quality in terms of ability to predict overnight events.
  • Assessment of adverse events and relationship to sign-out quality.
  • Participation in the institutional Observed Structured Handoff Evaluation (OSHE) which is used to assess resident application of handoff education. The OSHE consists of a didactic session on handoffs, and then residents complete a written and verbal handoff exercise to a participating senior resident using a standardized case – specialty based – that is scored by faculty for educational feedback.

Programs are required to develop scheduling and transition/handoff procedures to ensure that:

  • Residents comply with specialty-specific/institutional duty hour requirements.
  • Faculty members are scheduled and available for appropriate supervision levels according to the requirements for the scheduled residents. Faculty oversight of the handoff process may occur directly or indirectly, depending on training level and experience of the residents involved in the handoff.
  • All parties (including nursing) involved in a particular program and/or transition process have access to one another’s schedules and contact information. All call schedules shall be available electronically (i.e. in Outlook or on New Innovations) and with the hospital operators.
  • Patients are not inconvenienced or endangered in any way by frequent transitions in their care.
  • All parties directly involved in the patient’s care before, during and after the transition have opportunity for communication, consultation and clarification of information.
  • Safeguards exist for coverage when unexpected changes in patient care may occur due to circumstances such as resident illness, fatigue or emergency.
  • Programs shall provide an opportunity for residents to both give and receive feedback from each other or faculty physicians about their handoff skills.

Monitoring

Program Monitoring
Programs must develop and utilize a method of monitoring the transition of care process and update as necessary. Monitoring of handoffs by the program shall ensure:

  • There is a standardized process in place that is routinely followed.
  • There is consistent opportunity for questions.
  • The necessary materials are available to support the handoff (including, for instance, written sign-out materials, access to electronic clinical information).
  • A quiet setting free of interruptions is consistently available for handoff processes that include face-to-face communication. Handoffs are done on protected time, i.e. residents must be released from any clinical duties or interruption, including surgery and non-emergent patient care.
  • Patient confidentiality and privacy are ensured in accordance with HIPAA guidelines.
  • Examples of monitoring checklists including these items are attached to the end of this policy and will be available in New Innovations.

Institutional Monitoring

  • Compliance with the individual program’s Transitions of Care policy will be monitored by the GMEC via:
    • Annual Program Evaluations
    • Special Review of the program
    • Annual GME resident evaluation of the program
    • Annual GME faculty evaluation of the program
    • Annual ACGME Faculty Survey
    • Annual ACGME Resident Survey
    • Resident Council
    • Anonymous contact via hotline and/or online complaint form.

Moonlighting

GMEC approved: July 2011
GMEC updated and approved: September 2015

Purpose

The purpose of this policy is to specify the circumstances under which residents/fellows may engage in moonlighting, as well as the criteria which must be satisfied by the resident who engages in such activities. The criteria for such activities takes into account the legal, regulatory and accreditation requirements, patient care needs, the residents/fellows’ educational goals and WSU GME policy requirements.

Policy

Residents are not required to engage in Moonlighting. Residents/fellows shall devote themselves conscientiously to the performance of their full-time professional efforts as defined by GME institutional policies and graduate medical education program (Program) requirements. Because resident education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the ability of the resident to achieve the goals and objectives of the educational program.

Residents must be in good standing within their Program to be granted permission to moonlight. All moonlighting must be reported as duty/work hours and total duty/work hours may not exceed the ACGME requirements. Both the institution and program director must closely monitor all activities.

Moonlighting when (a) it’s not authorized, (b) will create a conflict of interest, (c) results in impaired efficiency, absenteeism or tardiness, or (d) is performed during scheduled Program hours, will subject the Resident to disciplinary action up to and including dismissal. Individual programs may have additional requirements or restrictions.

Procedure

The resident must receive prior written approval from the program director or designee. The program director may withhold or withdraw consent at any time, as he/she, in his or her sole discretion, deems appropriate.

PGY1 residents are not permitted to moonlight.

Under ECFMG regulations, J-1 visa holders are not eligible to moonlight under any circumstances. Moonlighting is considered extracurricular activity that is not part of the training program curriculum for which compensation is provided.

Moonlighting candidates must possess a permanent Michigan medical license with corresponding controlled substance license. An educational limited license in not valid for moonlighting activities.

Residents are not covered by the WSU GME-provided insurance when moonlighting. Malpractice coverage must be provided for moonlighting activities. Residents who wish to moonlight must submit the appropriate insurance program request forms to their programcoordinator. It is the responsibility of the resident to ensure that appropriate liability coverage is in place for his/her moonlighting activities.

Monitoring

Programs will assure residents compliance with approval, reporting and monitoring of the moonlighting processes. The GMEC will monitor moonlighting activities compliance through resident self-reported duty hours through New Innovations.

Professionalism Policy (formerly Professional Expectations policy)

GMEC approved: March 2007
GMEC updated & approved: July 2011
GMEC updated & approved: February 2015

Purpose

Professionalism is one of the core competencies of the ACGME as evidenced by the Common Program Requirements (CPR IV.A.5.e.1-5) which state: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles, Residents are expected to demonstrate: compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society and the profession; and, sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. Professionalism is also included in the ACGME CLER Pathways to Excellence with the following four pathways: Formal educational activities are essential to creating a shared mental model of professionalism that contributes to high quality patient care; Resident attitudes, beliefs, and skills related to professionalism directly impact the quality and safety of patient care; Faculty members’ engagement in training on professionalism directly impacts the quality and safety of patient care; Periodic monitoring of physician professionalism is essential to identifying vulnerabilities and designing and implementing actions to enhance patient care.

It is the responsibility of the institution, WSU SOM GME, to provide systems for education in and monitoring of residents and core faculty members’ fulfillment of educational and professional responsibilities, including scholarly pursuits; accurate completion of required documentation by residents and identification of resident mistreatment.

Policy

Each program must have a program level professionalism policy which describes how the program provides professionalism education to residents and how professionalism is evaluated. That policy should include but not be limited to the following WSU School of Medicine Professional Values and Attributes:

  • Professional Responsibility: Sound medical practice and good medical care of patients are the resident’s and the physician’s highest priority. The resident shall be internally motivatedat all times and in all settings to place the patient’s concerns before his or her own. He or she will always help to create a positive learning environment, be appropriately dressed, be punctual and prepared, and attend all required activities in their entirety. The resident is to be reliable and honest in completing all tasks, which include duty hour reporting, evaluation completion and other tasks required by their training program.
  • Competence and Self-Improvement: It is the expectation that residents will be committed to the learning and mastery of medical knowledge, skills, attitudes, and beliefs. The motivation for this learning is the optimal care of all patients. The resident will know the limits of his or her abilities and appropriately seek help to improve the care of patients while continuously expanding his or her knowledge base. This commitment extends to life-long learning; an acknowledgement that what begins in the residency never ends as long as the physician is committed to the practice of medicine.
  • Respect for others and professional relationships: Residents always respect their patients as individuals. There is respect for the patient’s dignity, privacy, cultural values, and confidentiality. Residents demonstrate sensitivity, respect, compassion, emotional support, and empathy at all times—to patients, patients’ families, other health care team members, and peers. In this context, a fundamental component of professionalism is altruism; putting the best interests of patients and colleagues over self-interest. Respect and altruism are attributes that must extend outside of the clinical setting as the resident is a constant representative of the School of Medicine and of the profession itself.
  • Honesty including academic integrity: Residents are committed to honesty at all times. This commitment extends beyond the office, examination room, or operating room in his or her training environment. Absolute honesty in written notes entered into patient’s records and in oral presentation of findings is expected; medical findings are true, complete, and verifiable. This attribute includes the responsibility for reporting the dishonesty of others. As with other core values, honesty is not limited to the School of Medicine and its affiliated teaching sites because the public expects honesty in its physicians as much as the School of Medicine expects it in its residents.
  • Personal responsibility: The resident is responsible for maintaining his or her own health and wellness. Drug and alcohol abuse are prohibited. Residents are expected to seek care as needed to maintain physical and mental health. The resident should freely access resources for help in managing health or personal issues that are negatively impacting performance in their residency program. Residents need to be proactive in recognizing those of their peers who are affected by drug abuse, alcohol abuse, or other personal issues detrimental to health, well-being, and/or safety, their safety, or the safety of patients. Residents with such concerns about their peers should notify their program director, a faculty member, or administrator.
  • Social responsibility: Societies place physicians in positions of power and authority. Physicians and residents must always conduct themselves in a manner to be worthy of that trust. Residents must demonstrate concern for and responsiveness to social ills and other factors which detract from the medical, cultural, spiritual, and emotional health of society.

In observing the above Professional Values and Attributes residents are expected behave professionally by:

  • Demonstrating appropriate sensitivity to patients and their families
  • Completing tasks in a timely manner
  • Demonstrating honesty and integrity
  • Maintaining a professional demeanor, including:
    • Having an appearance and dress that are in line with professional standards as established by departmental policies
    • Exhibiting respectful and courteous behaviors
    • Being responsive to questions and accommodating to requests
    • Adhering to professionally accepted boundaries for patient relationships
    • Conforming to sexual harassment and discrimination policies

Unprofessional conduct, to include but not limited to the following, is unacceptable and may be subject to performance improvement actions.

  • Failure to be truthful in all circumstances
  • Violation of state and federal rules/laws as standards of practice
  • Chronic lateness and/or failure to complete tasks in a timely manner
  • Failure to complete duty hour logs, evaluations and other tasks assigned by the program
  • Disregard for other team members
  • Disrespect for authority
  • Inappropriate behavior with patients, families or other members of the health care team
  • Failure to follow up on clinical activities
  • Abuse of power
  • Failure to respect policies of the WSU School of Medicine and affiliated hospitals
  • Unexplained absences
  • Failure to adhere to departmental dress standards

Procedure

The WSU SOM GME Professionalism policy will be provided to each incoming resident during the onboarding process via the GME Trainee Manual and Benefits Guide. Residents will be asked to verify their receipt of the manual via the onboarding checklist in the residency management system.

The policy will also be available electronically on the WSU SOM GME website and in the residency management software.

The institution will verify that each program has a program level professionalism policy which describes how the program provides professionalism education to residents and how professionalism is evaluated, and will ensure that all program policies relating to professionalism are distributed to Residents and Faculty.

Program directors will be responsible for investigating any complaints/reports involving professionalism and if a violation of the policy is identified he/she will confer with the Clinical Competency Committee to develop a performance improvement plan if one is indicated, as specified in the Performance Improvement Policy and Due Process.

Monitoring

The GMEC will monitor compliance with the institutional and program policies through the following venues:

  • Reporting of successful completion of online modules during the onboarding process for incoming residents on Professionalism, Impairment, Duty Hours and Fatigue Mitigation and any other modules as determined by the GMEC.
  • Annual Program Evaluation
  • Special Review of the Program
  • ACGME Annual Resident Survey
  • Annual GME Resident evaluation of the program
  • ACGME Annual Faculty Survey
  • Annual GME Faculty evaluation of the program
  • Resident Quality Council
  • Anonymous contact via hotline and/or online complaint form

Resources

WSU School of Medicine Professionalism information
ACGME CLER Pathways to Excellence information

Social Media Policy

GMEC approved: February 2015

Purpose

This Policy is intended to assist WSUSOM GME Residents with the appropriate use of Social Media either in or outside of the workplace and in compliance with regulations such as HIPAA and WSUSOM Policies and Procedures, as they relate to the use of Social Media. “Social Media” shall mean Facebook, YouTube, Twitter, Foursquare, MySpace, Tumblr, blogs, podcasts, discussion forums and other online social networks. This policy is based in the principle: Recoverable data isdiscoverable data. A violation of this Policy may result in disciplinary action, up to and including dismissal.

Policy

WSUSOM GME recognizes that Residents may have their own personal Social Media accounts or participate in Social Media forums outside of the workplace. Nothing in this section will interfere with or otherwise be used to discriminate against Residents who use personal Social Media on nonworking time for discussion of wages, hours or other terms and conditions of employment or for political, or other lawful purposes. Residents should always consider WSUSOM’s mission, vision, and core values and policies before discussing work-related activities on their personal Social Media website or other Social Media forums.

Residents may not use their own social media accounts for the following:

  • Patient experiences and information are prohibited from being digitally recorded or posted on the internet. Use of the internet includes posting on blogs, instant messaging [IM], social networking sites (e.g., Facebook, MySpace, Twitter), email, posting to public media sites, mailing lists and video-sites.
  • In addition, patient information should never be saved on personal USB memory devices or recording devices. Patient information may only be emailed within a hospital’s secured network or within WSU SOM’s secured network. Patient information must not be emailed outside of these systems. Such actions are a direct violation of the patient’s privacy and confidentiality per the Health Insurance Portability and Accountability Act (HIPAA). The HIPAA Privacy Rule protects all “individually identifiable health information” and requires that individuals involved in health care maintain the security of patient records in any form (i.e., electronic, paper, or oral). Disclosure of patient information on social media may violate state and federal laws and lead to enforcement actions by agencies such as the State Board of Medical Examiners and the U.S. Department of Health and Human Services
  • Information (written or digital) about colleagues and co-workers should not be posted anywhere.
  • Residents must not represent or imply that they are expressing the opinion of the organization by using hospital or institution proprietary information such as logos or mastheads. Trainees must comply with the current hospital or institutional policies with respect to such information.

When posting information on the internet, consider the following:

  • The impact of the information you disseminate via social networking sites prior to posting material. Respect for one’s colleagues, co-workers, and institution is essential to maintaining a professional work environment.
  • The permanency of published material on the internet – once posted on the internet, things live forever.
  • The fact that patients regularly Google their physicians and that posts reflect WSUSOM asan institution.
  • The patient-physician relationship relies on mutual respect and professionalism. Social networking with patients, including communicating with patients or giving medical advice via social networking sites should not be done.

If residents create blogs, clear disclaimers that the views expressed by the author in the blog are the authors’ alone and do not represent the views of the hospital or school of medicine must be posted. Such posts must:

  • Be clear and write in the first person;
  • Make the writing clear and that it is coming from an individual and not on behalf of either the respective hospital or school of medicine; and
  • Be compliant with policies in the GME Trainee Manual and Benefits Guide including, but not limited to, provisions concerning discrimination, harassment, and professionalism.

Procedures

Inappropriate use of the internet and social networking sites may result in:

  • Professionalism academic remediation
  • Discipline for breach of hospital or institutional policy
    • Loss of computer privileges at hospital or WSUSOM
    • Potential suspension
    • Potential dismissal
    • Other assignments and/or remediation plans based upon the infraction

Any violation of HIPAA can result in potential dismissal from program as well as possible criminal and/or civil penalties. A violation of HIPAA may also negatively impact your license to practice medicine.

Monitoring

Compliance with the institutional and individual program’s policy will be monitored by the GMEC via:

  • Annual Program Evaluation
  • Special Review of the Program
  • ACGME Annual Resident Survey

Supervision (IR IV.I.)

GMEC approved: March 2007
GMEC revised: July 2011
GMEC updated and approved: September 2014

Purpose

To ensure an appropriate learning and working environment and compliance with supervision requirements.

Policy

The WSU GME programs recognize and support the importance of graded and progressive responsibility in graduate medical education. This policy outlines the requirements to be followed when supervising residents. The goal is to promote assurance of safe patient care, and the resident’s maximum development of the skills, knowledge, and attitudes needed to enter the unsupervised practice of medicine. Residents are expected to graduate as accomplished physicians capable of functioning competently and without supervision. Specialty specific milestones will govern resident advancement from one year of education to another, providing guidance about the authority and responsibility granted to residents.

In the clinical learning environment, each patient must have an identifiable, appropriatelycredentialed and privileged attending physician (or licensed independent practitioner as approved by each Resident Review Committee) who is ultimately responsible for that patient’s care. Residents and faculty will inform all patients of their respective role.

Each program will demonstrate the appropriate level of supervision is in place for all residents who care for patients. A supervisor may be a member of the medical staff or a more senior resident designated by the program director.

Levels of supervision:

  • Direct supervision – the supervising physician is physically present with the resident and patient
  • Indirect supervision with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide direct supervision.
  • Indirect supervision – the supervising physician is not physically present within the hospital or other site of patient care. However, the supervisor will be available by means of telephonic and or electronic modalities and is available to provide direct supervision.
  • Oversight – The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered

Procedure

Residents:
All residents will know their scope of authority and the circumstances under which they are permitted to act with conditional independence. All residents, regardless of year of training, must communicate appropriately with the supervising physician.

The clinical responsibilities for each resident must be based on PGY level, patient safety, resident education, severity and complexity of patient illness, and available support services. The privilege of progressive authority and responsibility, conditional independenceand a supervisory role in patient care delegated to each resident must be assigned by the program director with input from the Clinical Competency Committee. The program director will evaluate each resident’s abilities based on specific criteria. When available, evaluation shall be guided by specific national standards-based criteria.

The minimum amount/type of supervision required in each situation is determined by the definition of the type of supervision specified, but is tailored specifically to the demonstrated skills, knowledge, and ability of the individual resident. In all cases, the faculty member functioning as a supervising physician should delegate portions of the patient’s care to the resident, based on the needs of the patient and the skills of the resident.

PGY1 residents shall be supervised either directly or indirectly with direct supervision immediately available.

Residents will have resources for reporting inadequate supervision in a protected manner that is free of reprisal.

Supervising Physician:
Faculty members who function as supervising physicians shall delegate portions of care to residents based on the needs of the patient and the skill level of the resident. Faculty supervision assignments will be of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility.

It is a responsibility of the program director to approve the selection of teaching faculty. Residents must be supervised by attending physicians who are credentialed in that setting for the patient care and diagnostic and therapeutic for which they are providing supervision.

In every level of supervision, the supervising faculty member must review progress notes, sign off procedural and operative notes and discharge summaries.

Faculty members must be continuously present to provide supervision in ambulatory settings, and be actively involved in the provision of care, as assigned.

Senior residents or fellows shall serve in a supervisory role of junior residents in recognition of their progress toward independence based on the needs of each patient and the skills of the individual.

Program Responsibilities:
Each residency program will establish schedules which assign qualified faculty physicians, residents, or fellows (or appropriate other licensed independent practitioners as permitted by the RRC) to supervise at all times and in all settings in which residents of the residencyprogram provide any type of patient care. The type of supervision to be provided will be delineated in the curriculum’s rotation description.

The program will update annually a listing of procedures pertinent to that specialty with an indication of the requirements for performing an activity with or without direct supervision.

The program director will ensure that attending physicians are educated regarding appropriate supervision standard requirements, including physical presence requirements and documentation ones.

Each program will develop program-specific policy based on respective ACGME common and specialty-specific requirements, consistent with the institutional WSU GME policy. Programs will set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members, such as the transfer of a patient to the intensive care unit or end-of-life decisions.

Monitoring

Compliance with the individual program’s Supervision policy will be monitored by the GMEC via:

  • Annual Program Evaluations
  • Special Review of the program
  • Annual GME resident evaluation of the program
  • Annual GME faculty evaluation of the program
  • Annual ACGME Faculty Survey
  • Annual ACGME Resident Survey
  • Resident Council
  • Anonymous contact via hotline and/or online complaint form.

Acceptable Use of Technology Resources Policy

GMEC approved: March 2015

Purpose

IT refers to the use of information technology services and connections during the residents’ regular work and on-call hours. This policy is designed to guide residents in the acceptable use of computer systems, networks, and other information technology resources at Wayne State University (WSU), WSU School of Medicine and all affiliated entities. This policy is that of WSU which the WSUSOM is required to follow and is reprinted here for your convenience.

Policy

Guiding principles
The University community is encouraged to make innovative and creative use of information technologies in support of educational, scholarly, and administrative purposes. Wayne State University supports access to information representing a multitude of views for the interest, information and enlightenment of students, faculty and staff. Consistent with this policy, Wayne State University supports the use of information technology resources in a manner that recognizes both the rights and the obligations of academic freedom.

Wayne State University recognizes the importance of copyright and other protections afforded to the creators of intellectual property. Users are responsible for making use of software and other information technology resources in accordance with copyright and licensing restrictions and applicable University policies. Using information technology resources in a manner violating these protections, or furthering the unauthorized use or sale of protected intellectual property, is prohibited.

Wayne State University cannot protect individuals against the receipt of potentially offensive material. Those who use electronic communications occasionally may receive material that they might find offensive. Those who make personal information available about themselves through the Internet or other electronic media may expose themselves to potential invasions of privacy.

Information technology resources are provided to support the University’s scholarly, educational, and administrative activities. Information technology resources are limited, and should be used wisely and with consideration for the rights and needs of others.

User responsibilities
Users are expected to use computer and network resources in a responsible manner. Users should take appropriate precautions to ensure the security of their passwords and prevent others from obtaining access to their computer resources. Convenience of file or printer sharing is not a sufficient reason for sharing computer accounts. Users may not encroach on others’ use of computer resources. Such actions include, but are not limited to, tying up computer resources with trivial applications or excessive game playing, sending frivolous or excessive messages, including chain letters, junk mail, and other similar types of broadcast messages, or using excessive amounts of storage.

The following behaviors are prohibited while using University information technology resources, including computers and networks owned or operated by Wayne State University, or to which Wayne State University is connected:

  • Modifying system or network facilities, or attempting to crash systems or networks;
  • Using, duplicating or transmitting copyrighted material without first obtaining the owner’s permission, in any way that may reasonably be expected to constitute an infringement, or that exceeds the scope of a license, or violates other contracts;
  • Tampering with software protections or restrictions placed on computer applications or files;
  • Using University information technology resources for personal for-profit purposes;
  • Sending messages that are malicious or that a reasonable person would find to be harassing;
  • Subverting restrictions associated with computer accounts;
  • Using information technology resources to obtain unauthorized access to records, data, and other forms of information owned, used, possessed by, or pertaining to the University or individuals;
  • Accessing another person’s computer account without permission. Users may not supply false or misleading data, or improperly obtain another’s password to gain access to computers or network systems, data or information. Obtaining access to an account name or password through the negligence or naiveté of another is considered to be a specifically prohibited use;
  • Intentionally introducing computer viruses, worms, Trojan Horses, or other rogue programs into information technology resources that belong to, are licensed to, or are leased by Wayne State University or others;
  • Physically damaging information technology resources;
  • Using, or encouraging others to use, information technology resources in any manner that would violate this or other University policies or any applicable state or federal law; and
  • Falsely reporting or accusing another of conduct that violates this policy, without a good faith basis for such an accusation.

Users should remember that information distributed through the University’s information technology resources may be considered a form of publication. Although Wayne State University does not take responsibility for material issued by individuals, users must recognize that third parties may perceive anything generated at Wayne State University as in some manner having been produced under Wayne State University auspices. Accordingly, users are reminded to exercise appropriate language, behavior, and style in their use of information technology resources.

Policy administration
The University encourages all members of its community to use electronic resources in a manner that is respectful of others. While respecting users’ privacy to the fullest extent possible, the University reserves the right to examine any computer files. The University reserves this right for bona fide purposes, including, but not limited to:

  • Enforcing polices against harassment and threats to the safety of individuals;
  • Protecting against or limiting damage to University information technology resources;
  • Complying with a court order, subpoena or other legally enforceable discovery request;
  • Investigating and preventing the posting of proprietary software or electronic copies of texts, data, media or images in disregard of copyright, licenses, or other contractual or legal obligations or in violation of law;
  • Safeguarding the integrity of computers, networks, software and data;
  • Preserving information and data;
  • Upgrading or maintaining information technology resources;
  • Protecting the University or its employees and representatives against liability or otherpotentially adverse consequences.
  • No action under this section may be taken by university officers without the approval of the President or his/her designee.
  • The University may restrict the use of its computers and network systems when presented with evidence of violation of University policies, or federal or state laws, or when it is necessary to do so to protect the University against potential legal liability. The University reserves the right to limit access to its information technology resources, and to remove or limit access to material stored on University information technology resources.
  • All users are expected to conduct themselves consistent with these responsibilities. Abuse of computing privileges may subject the user to disciplinary action as established by applicable University policies.
  • Students who violate this policy may be subject to discipline pursuant to the Student Due Process Policy, Wayne State University Code Annotated.
  • Represented employees may be subject to discipline in accordance with the applicable collective bargaining agreement.
  • Non-represented employees may be subject to discipline in accordance with the Handbook for Non-represented Employees.

The University and users must recognize that all members of the University community are bound by federal and state laws pertaining to civil rights, harassment, copyright, security and other statutes governing use of electronic media. This policy does not preclude enforcement under such laws.

This policy is for all units of the University. Schools, colleges, and divisions may adopt policies governing the Acceptable Use of Information Technology Resources that incorporate the University Policy. School, college and division policies must be approved by the Vice President for Information Technology.

Reporting violations
Allegations of conduct that is believed to violate this Acceptable Use policy should be reported in writing to the Computing and Information Technology Information Security Office. To ensure the fairness of any proceedings that may follow a reported violation, the individual filing the report should not discuss or provide copies of the allegations to others.

Nothing in the section shall be interpreted to prohibit an individual from pursuing such other administrative or legal rights as he or she may have. While the University’s primary responsibility to investigate violations of this policy rests with Computing and Information Technology. Exceptional cases should be reported to the President or his/her designee.

Additional IT requirements for WSUSOM GME Residents
Access to protected patient information is covered by the Health Insurance Portability and Affordability Act (HIPAA). Residents are expected to comply with all HIPAA policies as set forth by WSU SOM and all its hospital partners. Particular care should be taken to avoid copying sensitiveinformation onto removable devices such as flash drives; PDAs, etc.

Residents utilizing IT services at teaching sites may have to meet additional requirements established by the host institution. This policy should be presented at the site-specific orientation. If not, the resident should notify the program director.

Monitoring

Compliance with this policy will be monitored by the GMEC via:

  • ACGME Annual Resident Survey
  • Annual GME resident evaluation of the program
  • Resident Quality Council
  • Anonymous contact via hotline and/or online complaint form

Resources

WSUPG Social Media Policy https://upgdocs.ellucid.com/documents/view/434 (secure site)
WSUSOM Technology Guidelines: http://www.med.wayne.edu/elab/orientation/guidelines.html
WSU Acceptable Use of Information Technology Resources: https://wayne.edu/policies/acceptableuse/

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