ࡱ>    _ .+bjbjuu eq0b0b"?,>>,,Z-Z-Z-$~.~.~.N0"7~.=&?@AAAEHI<======$<@B%=Z-tJ:E|E"tJtJ%=,,AA&:=]]]tJ6,8A -8A:]tJ<]] ',B--AP1PNG"9P=0=" CJU<Cl-,-CZ-.X tJtJ]tJtJtJtJtJ%=%=YtJtJtJ=tJtJtJtJCtJtJtJtJtJtJtJtJtJ>B +:  INTERNAL MEDICINE RESIDENCY PROGRAM RESIDENCY MANUAL 2018-2019 http://www.im.msu.edu Last Updated 09/18/18 Table of Contents PAGE Foreword 5 Section 1 Personnel. 6 Program Leadership and Staff Program Director Responsibilities Resident Physicians Section 2 Code of Conduct 9 Section 3 Program Overview. 11 Yearly Rotation Schedule Curricula Core Competencies Conferences Section 4 Ambulatory Medicine 20 General Clinic Policies and Resident Responsibilities Language Interpretation Continuity Clinic Assignments Electronic Medical Record -Athena Section 5 Inpatient General Medicine Rotations. 29 Teaching and Learning Policies and Procedures for Firm Responsibilities of residents (by training level) Night Float Section 6 Intensive Care Rotations. 37 Medical ICU and Coronary Care Unit Section 7 Evaluation 40 Resident Evaluation Procedures In Training Examinations Performance Criteria Due Process Remediation Evaluation of the Program Section 8 Residency Policies....47 Related to Primarily Clinical Activities Supervision Policy Service Policy Duty Hours and Fatigue Mitigation Medical Records Procedures Chaperones for Sensitive Examinations Needle Sticks, Universal Precautions, and Blood Borne Pathogens Pagers Hospital Mobile Phones Laptops and Tablets for Firm Moonlighting Related to Primarily Educational Activities Out-of-Residency Rotations Creating New Curricula Clinical Investigation Rotations Membership in Professional Organizations Mentoring Mandatory Counseling or Assessment Human Resources Personal Leave: Duration, Rotation Requirements, and Length of Training Requesting Personal and Educational Leave Unexpected Absences due to Illness or Emergency and Back Up Call Professional Attitudes and Behaviors Resident Counseling and Support Services Physician Impairment Sexual Harassment MSU Diversity Resources Maintaining Contact Information E-mail Section 9 Benefits69 Compensation Other Benefits Leaves of Absence Section 10 Legal Policies 73 DEA Numbers Medical Licenses Compliance Liability Section 11 Member Institutions. 76 Michigan State University E. W. Sparrow Hospital and Sparrow Health System Section 12 Residents as Teachers78 Student Performance Expectations R1 Resident Teaching Expectations R2 and R3 Resident Teaching Expectations Section 13 Information Technology..83 Program Website Electronic Health Records Electronic Evaluation System: New Innovations Web-based Schedules Additional Information Technology Resources Section 14 Information for Attendings. 85 Teaching Attending Billing Documentation Attending Responsibilities Foreword Welcome to the Michigan State University Internal Medicine Residency Program at Sparrow Hospital! We are a dynamic, learner-centered program focusing on our residents individual needs and goals to produce excellent physicians. Thats our mission, and we work hard to live up to it every day. Residency training is an exciting, rewarding and busy time in your life; it will be one of your most formative experiences as you develop a personal practice style. We believe that the MSU Internal Medicine Residency will offer you the experiences you need to grow as a professional. We are committed to training residents who will constantly pursue excellence. We strive to provide a challenging yet supportive atmosphere, where autonomy and supervision are in dynamic balance. MSU is a truly energizing training site, fueled by a proactive team spirit. The energy, enthusiasm and aptitude you yourself bring to our program will help our program continue to grow and flourish. Together, we can create the highest quality experience possible, while forming friendships that will last a lifetime. This manual was created to serve both as an introduction to and also as a reference for the program. Keep it handy and refer to it as you embark on new rotations or have questions. It will be periodically updated and posted in electronic format on our web site. The written copy provided to you during R1 orientation is for initial introduction; updated policies will be posted electronically with new version dates noted; therefore they will supersede the written version once posted. If you need any further information, do not hesitate to contact us. Welcome to our program and our community! Supratik Rayamajhi, MD, Allopathic Program Director Peter Gulick, DO, FACOI, FACP, Osteopathic Program Director Nazia Khan, MD, MPH, Associate Program Director April Wojewoda, Program Administrator Dalia Harris, Program Coordinator SECTION 1 PERSONNEL Program Leadership and Staff Program Director Responsibilities Resident Physicians Program Leadership and Staff PROGRAM DIRECTORS Supratik Rayamajhi, MD FACP Peter Gulick, D.O., FACOI, FACP ASSOCIATE PROGRAM DIRECTOR Nazia Khan, MD, MPH Director, Evidence Based Medicine, Journal Club Research Director CORE FACULTY Shilpa Kavuturu, MD Site Director, Inpatient Medicine Director, Morbidity and Mortality, Board Review Laura Freilich, MD Site Director, Resident Continuity Clinic Robert Smith, MD, MS, FACP Psychosocial Medicine director Heather Laird-Fick, MD MPH FACP HA site-director Mukta Sharma, MD Discharge clinic director CHIEF MEDICAL RESIDENTS (PGY3) Ahmad Alratroot, MD Om Diwani, MD Mahmoud Elsayed, MD Divyesh Nemakayala, MD PROGRAM ADMINISTRATOR April Wojewoda, M.Ed PROGRAM COORDINATOR Dalia Harris Program Director Responsibilities The program directors will comply with all ACGME and AOA requirements, including but not limited to the following: Updating the appropriate regulatory bodies of any change in program director or core faculty appointments. Maintain current board certification, medical licensure and medical staff appointment. Oversee all aspects of the program to ensure high quality didactic and clinical experiences, including appropriate supervision of resident physicians. Completing appropriate reports at the local and national level for ongoing accreditation. Ensure compliance with program level, institutional, and national policies and procedures. Monitor stress, duty hours and mitigate excessive service demands or fatigue. Supervise ACGME-accredited subspecialty training programs linked to the core program. Additional responsibilities are detailed within the ACGME and AOA documents. Current Resident Physicians Allopathic ABDELGADIR, Ayat (PGY1) ABRO, Calvin (PGY2) ABU ROUS, Fawzi (PGY2) AL-ABCHA, Abdullah (PGY1) ALMALKI, Thamer (PGY1) ALRATROOT, Ahmad (PGY3) ALUKO, Atinuke (PGY2) ATTI, Varunsiri (PGY2) BASNET, Nishraj (PGY1) BOUMEGOUAS, Manel (PGY1) CHERIAN, John (PGY1) DAWANI, Om (PGY3) DUDLEY, Morgan (PGY3) ELKINANY, Sherif (PGY2) ELSAYED, Mahmoud (PGY3) ENOFE, Ikponmwosa (PGY2) FENANDO, Ardy (PGY1) GHAURI, Asfar (PGY2) GRIGORYAN, Seda (PGY1) HASSANEIN, Mohamed (PGY3) HERZALLAH, Khader (PGY2) IFTIKAR, Mian (Harris) (PGY3) KANDOLA, Samanjit (PGY2) KARAPETYAN, Lilit (PGY3) LING, Xiao (Mark) (PGY3) LUNDIN, Michael (PGY3) MUJER, Mark (PGY2) NEMAKAYALA, Divyesh (PGY3) NICHOLS, Aaron (PGY1) NORGAIS, Konchok (PGY3) PANTHI, Sagar (PGY3) RAI, Manoj (PGY3) RAO, Sowmika (PGY2) RAZIQ, Fazal (PGY1) SALEH, Yehia (PGY2) SHAH, Syed (PGY3) SHROTRIYA, Shiva (PGY2) TATINENI, Shilpa (PGY1) Osteopathic PRINSEN, Joseph* (PGY3) SILEVANY, Farashin (PGY3) *Eligible for AOA and ABIM certification SECTION 2 Code of Conduct Code of Conduct As physicians, we have unique and important professional responsibilities to our patients, our colleagues, and society. Our code of conduct incorporates the ideals of our member institutions: From the College of Human Medicines The Virtuous Professional: A System of Professional Development for Students, Residents and Faculty. We will aspire to the three virtues of Courage, Humility, and Mercy. We accept our professional responsibilities of Competence, Honesty, Compassion, Respect for Others, Professional Responsibility, and Social Responsibility. We will continue to grow as professionals through dialogue, reflection, and practice. From the Sparrow Values, ICARE: We will find new ways to improve the quality of health services. We will provide radical loving care for everyone. We accept responsibility for our actions. We value diversity, inclusion, and working well together. We will achieve the best results in all we do. Relevant policies and procedures within the residency program and its member institutions (Michigan State University College of Human Medicine, Sparrow Hospital, and Graduate Medical Education Inc.) include but are not limited to: Confidentiality Conflicts of interest Duty hours Expectations for professional appearance, attitudes and behaviors Harassment and discrimination Physician impairment Research ethics, policies and procedures (per institutional review boards) Social media Supervision and teaching of medical students Please refer to Section 7 and 9 of this document, the Sparrow house staff manual (provided electronically at your orientation), http://www.gme.chm.msu.edu/administration.aspx,  HYPERLINK "http://www.gmei.msu.edu" http://www.gmei.msu.edu for specific policies. SECTION 3 PROGRAM OVERVIEW Yearly Rotation Schedule Curricula Core Competencies Conferences The Yearly Rotation Schedule The rotation schedule is prepared each year after receiving resident schedule preferences. The schedule (including the call and continuity clinic schedule) is posted at:  XE "Schedule:Amion online scheduling"  XE "Amion"  HYPERLINK "http://www.amion.com" http://www.amion.com. Accessing the schedule requires a login password. The current login/password is available from the residency office (432-2404). After the schedule is distributed, no rotation changes can be made unless the resident submits a complete change of rotation form at least 8 weeks prior to the rotation start date, and receives approval from the residency office. The change of rotation form is posted on our website,  HYPERLINK "http://www.im.msu.edu" http://www.im.msu.edu , under the resident resources section. Rotation changes impact other medical residents, other Lansing area residencies, community volunteer faculty, community faculty office support staff, MSU faculty, and residency staff; therefore, changes will not be approved without a pressing and specific educational reason. An average resident schedule:  MD 3-year requirementsDO 3-year requirementsR1 - 13 four-week blocks 5 blocks General Medicine Inpatient 1 block Night Float 2 blocks Critical Care 1 block Womens Health 1 block Psychosocial 3 ElectivesR1 - 13 four-week blocks 5 blocks General Medicine Inpatient (incl perioperative care) 1 block Night Float 2 blocks Critical Care 1 block Womens Health 1 block Psychosocial 1 block Cardiology 1 block Emergency Medicine 1 electiveR2 - 13 four-week blocks 3 blocks General Medicine Inpatient 1 block Night Float 1 -2 blocks Critical Care 1 block Cardiology 1 block Neurology 1 block Emergency Medicine 4-5 ElectivesR2 - 13 four-week blocks 3 blocks General Medicine Inpatient 1 block Night Float 1 -2 blocks Critical Care 1 block Cardiology 1 block Neurology 6 ElectivesR3 - 13 four-week blocks 2 blocks General Medicine Inpatient 1 block Night Float 2 blocks Critical Care 1 block Hematology/Oncology 1 block Geriatrics 1 block Ambulatory Medicine 5 Electives R3 - 13 four-week blocks 2 blocks General Medicine Inpatient 1 block Night Float 2 blocks Critical Care 1 block Hematology/Oncology 1 block Geriatrics 1 block Ambulatory Medicine 5 Electives Ambulatory Selectives (5.5 needed over 3 years) Allergy and Immunology (1) Additional Ambulatory GIM (0.5-1) Advanced Nephrology (1) Dermatology (0.5) Endocrinology (1) Hand surgery (0.5) HIV/Viral Hepatitis (0.5-1) Hospice (1) Noninvasive Cardiology (0.5-1) Occupational Medicine (1) Phlebology (0.5-1) Ophthalmology (0.5) Outpatient Cardiology (0.5-1) Physical Medicine and Rehab (0.5) Rheumatology (1) Sports Medicine (0.5-1)Required rotations for R2 & R3 DOs Pulmonary Endocrinology Gastroenterology Infectious Disease Nephrology Rheumatology Resident schedule limits: Per ABIM eligibility rules, residents must have at least 30 months of training in general internal medicine, subspecialty internal medicine, and emergency medicine. Up to four of the 30 months may include training in areas related to primary care, such as neurology, dermatology, office gynecology, or office orthopedics. Three months vacation is assumed. The remaining 3 months of training may include other electives approved by the program director. Therefore, residents requesting non-internal medicine electives will be allowed a maximum of 3 such rotations during their total training. Curricula The curricula for rotations are available through New Innovations and upon request to the residency faculty and staff. Residents and faculty members are expected to review the curricula by the beginning of each rotation. Curricula describe the educational objectives, learning venues, supervision, methods of evaluation, and milestones on which residents are evaluated. Core Competencies Our goal is to train residents possessing the diverse skills required of an internist in our ever-changing health care system. The Accreditation Council for Graduate Medical Education (ACGME) and the American College of Osteopathic Internists (ACOI) Core Competencies form the foundation for our longitudinal curriculum and evaluation system. Detailed Competency Curricula for longitudinal training with learning objectives for each training year are posted on the residency website,  HYPERLINK "http://www.im.msu.edu" www.im.msu.edu, and are also distributed to each resident. Every resident is expected to fully review the current edition of the residencys Competency Curricula and Learning Objectives. The following descriptions quote the full language ACGME text of the Competencies, as endorsed by the ACGME July 2009. This text is publicly posted at: http://acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/140_internal_medicine_07012013.pdf Patient Care and Procedural Skills Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents: are expected to demonstrate the ability to manage patients: in a variety of roles within a health system with progressive responsibility to include serving as the direct provider, the leader or member of a multi-disciplinary team of providers, a consultant to other physicians, and a teacher to the patient and other physicians; in the prevention, counseling, detection, and diagnosis and treatment of gender-specific diseases; in a variety of health care settings to include the inpatient ward, the critical care units, the emergency setting and the ambulatory setting; across the spectrum of clinical disorders seen in the practice of general internal medicine including the subspecialties of internal medicine and non-internal medicine specialties in both inpatient and ambulatory settings; using clinical skills of interviewing and physical examination; and, by caring for a sufficient number of undifferentiated acutely and severely ill patients. Residents must be able to competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice. Residents: are expected to demonstrate the ability to manage patients: using the laboratory and imaging techniques appropriately; and, by demonstrating competence in the performance of procedures mandated by the ABIM. must treat their patients conditions with practices that are safe, scientifically based, effective, efficient, timely, and cost effective. Medical Knowledge Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents: are expected to demonstrate a level of expertise in the knowledge of those areas appropriate for an internal medicine specialist, specifically: knowledge of the broad spectrum of clinical disorders seen in the practice of general internal medicine; and, knowledge of the core content of general internal medicine which includes the internal medicine subspecialties, non-internal medicine specialties, and relevant non-clinical topics at a level sufficient to practice internal medicine. are expected to demonstrate sufficient knowledge to evaluate patients with an undiagnosed and undifferentiated presentation; treat medical conditions commonly managed by internists; provide basic preventive care; interpret basic clinical tests and images; recognize and provide initial management of emergency medical problems; use common pharmacotherapy; and, (Outcome) appropriately use and perform diagnostic and therapeutic procedures. Practice-based Learning and Improvement Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to develop skills and habits to be able to meet the following goals: identify strengths, deficiencies, and limits in ones knowledge and expertise; set learning and improvement goals; identify and perform appropriate learning activities; systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement; incorporate formative evaluation feedback into daily Internal Medicine practice; locate, appraise, and assimilate evidence from scientific studies related to their patients health problems; use information technology to optimize learning; and, participate in the education of patients, families, students, residents and other health professionals. Interpersonal and Communication Skills Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to: communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds; communicate effectively with physicians, other health professionals, and health related agencies; work effectively as a member or leader of a health care team or other professional group; act in a consultative role to other physicians and health professionals; and, maintain comprehensive, timely, and legible medical records, if applicable. Professionalism 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. Systems-based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to: work effectively in various health care delivery settings and systems relevant to their clinical specialty; coordinate patient care within the health care system relevant to their clinical specialty; incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate; advocate for quality patient care and optimal patient care systems; work in interprofessional teams to enhance patient safety and improve patient care quality; and, participate in identifying system errors and implementing potential systems solutions. work in teams and effectively transmit necessary clinical information to ensure safe and proper care of patients including the transition of care between settings; and recognize and function effectively in high-quality care systems. The following descriptions quote the full language ACOI text of the Competencies, as endorsed by the American Osteopathic Association and the American College of Osteopathic Internists August 2012. This text is publicly posted at:  HYPERLINK "http://www.acoi.org/ResidentIMStds2.html" http://www.acoi.org/ResidentIMStds2.html (accessed 11/21/13) The specialty of internal medicine consists of the prevention, diagnosis and treatment of diseases with emphasis on internal organs of the body in the adolescent and adult patient. The goals of the osteopathic internal medicine program are to achieve mastery of the following core competencies: Osteopathic Philosophy & Manipulative Medicine 5.9 Training in osteopathic principles and practice must be provided in both structured educational activities and clinical formats. 5.10 Residents must complete an OPP/OMM curriculum. Medical Knowledge 5.11 The formal structure of educational activities must include monthly journal clubs. 5.12 The formal structure of educational activities must include twice-weekly case conferences. 5.13 The formal structure of educational activities must include four hours per week of structured faculty didactic participation. 5.14 Attendance at required educational activities must be documented. 5.15 Residents must participate in the internal medicine structured educational activities throughout their training program, including during the OGME-1 Year and while doing base-site selectives or non-internal medicine months. 5.16 Each resident must participate in internal medicine board review, either in the form of an ongoing program, or by the program sponsoring the resident's attendance at an internal medicine board review course. Patient Care 5.17 The resident must have training and experience in comprehensive histories and physicals, including structural examinations, pelvic exams, rectal exams, breast exams and male genital exams. 5.18 The resident must have training and experience in central venous line placement, arterial puncture for arterial blood gases, osteopathic manipulative treatment and endotracheal intubation to include, at minimum: indications; contraindications; complications; limitations and evidence of competent performance. 5.19 The resident must have training and experience in arthrocentesis, peripheral blood smears, exercise stress tests, ambulatory ECG monitors, lumbar puncture, spirometry, sputum gram stain, urine microscopy, vaginal wet mounts and thoracentesis to include, at minimum: indications; contraindications; complications; limitations and interpretation. 5.20 The resident must have training and experience in the interpretation of electrocardiograms, chest x-rays, and flat and upright abdominal films. Interpersonal and Communication Skills 5.21 The resident must have training in communication skills with patients, patient families and other members of the health care team, including patients with communication barriers, such as sensory impairments, dementia and language differences. Professionalism 5.22 The resident must have training in health care disparities. 5.23 The resident must have training in ethical conduct in interactions with patients, patient families and other members of the health care team. 5.24 The resident must have training in health information protection policies. Practice-Based Learning and Improvement 5.25 The resident must have training in teaching skills. 5.26 The resident must participate in the training of students and/or other residents. 5.27 The resident must have training in the use of electronic health records. 5.28 The resident must have learning activities and participation in quality improvement processes. 5.29 The resident must have learning activities in medical research throughout the program including, at minimum: research types and methodology; biostatistics; health services research and interpretation of medical literature. Systems-Based Practice 5.30 The resident must have training in practice management. 5.31 The resident must have training in health policy and administration. This quoted text is publicly posted at:  HYPERLINK "http://www.acoi.org/ResidentIMStds2.html" http://www.acoi.org/ResidentIMStds2.html  XE "Conferences" Conferences  XE "Conferences:Attendance Policy" Conference Attendance Policy: Residents are expected to attend a minimum of 60% of all conferences designated as mandatory by the program director. Residents must sign in to receive credit for attendance. Residents are excused from conferences during vacation, educational leave, out of town rotations, and night float. Dually accredited residents receive credit for Statewide Campus system and Sparrow Hospital osteopathic teaching sessions; 70% attendance at these events is required. A conference calendar is available on the residency web site:  HYPERLINK "http://im.msu.edu/Website/housestaff/calendar/2013-14%20Master%20Conference%20Schedule.pdf" http://im.msu.edu/Website/housestaff/calendar/2013-14%20Master%20Conference%20Schedule.pdf To facilitate protected time for conferences, most required conferences are clustered into a single weekly Teaching Afternoon each Thursday.  XE "Medical Emergencies" \t "See Conferences"  XE "Conferences:Medical Emergencies" Emergencies in Medicine MANDATORY Tuesdays 12-1 PM (July and August) This series repeats yearly and reviews management of urgent complaints frequently encountered in the care of hospitalized patients. Medical Emergencies lectures may also be scheduled during the Thursday teaching afternoon, in place of other mandatory conferences during July and August, at the Program Directors discretion.  XE "Grand Rounds" \t "See Conferences"  XE "Conferences:Medical Grand Rounds" Medicine Grand Rounds - MANDATORY Tuesdays 12-1 PM (September June) 3.  XE "Conferences:Journal Club"  XE "Journal Club" \t "See Conferences" Journal Club/Critical Analysis of the Medical Literature - MANDATORY Monthly Residents engage in discussion of a recent significant article. Principles of evidence-based medicine and critical appraisal of the medical literature are reviewed. Faculty will supervise the selection of articles, and guide the scientific discussion. 4.  XE "Conferences:Morbidity and Mortality"  XE "Morbidity and Mortality" \t "See Conferences" Morbidity and Mortality Conference - MANDATORY Monthly Residents present all deaths and important cases of morbidity, including health care quality or patient safety issues, to facilitate identification of systems improvement opportunities and to address issues leading to medical error. 5.  XE "Conferences:Core Curriculum"  XE "Core Curriculum Conference" \t "See Conferences" Core Curriculum Conference - MANDATORY This series includes didactic sessions and group educational formats. It covers fundamental clinical and scientific topics, as well as special topics addressing the Core Competency curriculum. 6.  XE "Conferences:Clinical Pharmacology"  XE "Clinical Pharmacology" \t "See Conferences" Clinical Pharmacology Conference - MANDATORY Monthly Gary Stein, Pharm.D, leads this conference covering important topics in clinical therapeutics to coincide with board review. 7. ECG Conference MANDATORY The Chief Medical Resident and Dr. Robert Smith lead this didactic series on ECG, exercise stress test and cardiac monitor interpretation. 8.  XE "Conferences:Primary Care Block Curriculum" Ambulatory Curriculum MANDATORY Ambulatory Curriculum sessions occur on Thursday teaching sessions on a periodic basis. Clinic conference also occurs each assigned clinic day from 1:30-2 PM. These sessions utilize the Yale Ambulatory Medicine Curriculum, and are precepted by continuity clinic attendings. Ethics Conference MANDATORY Ethics sessions occur quarterly as part of the Thursday teaching sessions. Multidisciplinary Conferences with Psychiatry and Family Medicine MANDATORY The three residency programs will have a two hour combined conference every two months on average.  XE "Town Meeting" Resident Town Meeting This monthly forum provides an opportunity for residents to communicate around issues that affect them in the residency program. The Chief Resident leads the meeting. The residents and chief resident generally set the agenda, with additional items from the residency office. These sessions are intended to discuss new residency initiatives and what is going well in the residency program, as well as problems, challenges, and potential solutions. The spirit of the discussions should be constructive and conducive to team building and a culture of excellence. Osteopathic Journal Club MANDATORY R1 osteopathic residents Mondays 12-1 R1 osteopathic residents will participate in the Sparrow Hospital-wide osteopathic journal clubs which cover a broad range of OPP/OMM content. Base Campus Osteopathic Workshops MANDATORY R1 osteopathic residents R1 osteopathic residents will participate in the Sparrow Hospital-wide osteopathic workshops which include skills training and precepted OMM experiences. Statewide Campus Didactic Sessions MANDATORY osteopathic residents All osteopathic residents will attend resident level-specific programming, including a week long board review for R3s, as scheduled. SECTION 4 AMBULATORY MEDICINE General Clinic Policies and Resident Responsibilities Language Interpretation Continuity Clinic Assignments Electronic Medical Record - Athena General Clinic Policies  XE "Clinic:Policies" Introduction: You will spend 130 half-day sessions in an assigned ambulatory care continuity clinic, in MSU A225 Clinical Center. The purpose of clinic is to improve your knowledge and skills of caring for a panel of patients in an outpatient setting, including acute care, chronic disease management, health maintenance, and counseling. Refer to the continuity clinic curriculum for detailed educational objectives. The clinic is an important and busy experience. Other clinical responsibilities must be delayed or transferred during this weekly session. You must sign out to the resident covering your inpatients until you return. The Residency Office will only cancel your clinic when you are post-night shift, on vacation/leave, on Night Float, ICU or in other special circumstances as determined by the Program Administrator, Program Coordinator and Chief Resident. Residents may NOT independently cancel a clinic. Each resident continuity clinic session begins with clinic teaching from 1:30-2 PM. Patient visits are scheduled 2-5pm. Residents should arrive at clinic at 1 PM whenever possible to review paperwork. An attending physician is assigned to be your preceptor during the continuity clinic. The Clinic Attending will be available for on-the-spot consultation and to see patients with you as needed, as well as to assume ultimate responsibility for all patient care. For this reason, the attending must include a teaching-attending note at the bottom of your documentation and sign each note electronically.  XE "Primary Care Exception"  XE "HCFA Exception Billing" HCFA Primary Care Exception: Department policy permits use of the HCFA Primary Care Exception, which allows residents with more than 6 months of training to see certain patients without the direct physical presence of the attending in the exam room. The rules are as follows (check with your attending in any situations where there is doubt about how to proceed): Residents furnishing a service without the presence of a teaching physician will have completed more than six months of an approved residency program. The teaching physician billing Medicare Part B will not supervise more than four residents at any given time and will direct the care from such proximity as to constitute immediate availability. The teaching physician billing Medicare Part B will: Have no other responsibilities at the time of the service for which payment is sought, Assume management responsibilities for Medicare beneficiaries treated by residents, Assure that services furnished are appropriate, Review with each resident during or immediately after the patient visit the beneficiarys medical history, physical examination, diagnosis, and record of tests and treatment therapies, and Document participation in the review and supervision of services provided. The patients seen are an identifiable group who consider the facility to be a continuing source of their health care. Residents under the medical direction of teaching physicians furnish services. The residents generally follow the same group of patients throughout the course of their residency program. The range of services furnished by residents includes all of the following: Acute care for undifferentiated problems or chronic care for ongoing conditions including chronic mental illness, Coordination of care furnished by other physicians and providers; and Comprehensive care not limited by organ system or diagnosis. The primary care exception only applies to low- and mid-level services (e.g., 99211, 99212, and 99213) for new and established patients. Attending physicians must physically see and confirm the essential components of the history, examination and decision making for patients billed at higher-levels (e.g., 99214, 99215), for health maintenance visits (preventive care, yearly pap and pelvic, etc.), and for procedures such as skin biopsy, etc. The primary care exception will be applied to all patients, regardless of insurance status. Patients seen with the attending physician should have the modifier GC circled on the billing sheet, while patient billed under the exception rule should have GE (E for Exception) added. Since the primary care exception only allows 4 residents to be present in any half-day session, no more than 4 residents will be scheduled at a time in any one preceptors clinic. Be sure to check your clinic schedule ( HYPERLINK "http://www.amion.com" http://www.amion.com) regularly to determine your schedule, and the clinic white boards as you may work with a different preceptor on the opposite side of the clinic for some sessions.  XE "Clinic:Resident Responsibilities" Universal Resident Responsibilities in the Ambulatory Clinics: Residents must obtain and document a complete history and physical examination (H&P) on all patients. A recent (< 1 year) hospital-generated H&P is a satisfactory substitute. Residents must document progress notes in S-O-A-P format (Subjective data, Objective data, Assessment, Plan) using one of the approved electronic health record templates. Osteopathic residents must document structural exams and osteopathic treatments in patient notes. Residents must track health maintenance in the EHR by appropriately recording health maintenance interventions and counseling in the flow sheets. Residents must maintain an up-to-date medication list. Residents must maintain an up-to-date problem list. Residents are responsible for typing in the EHR follow-up letters for referral physicians and agencies as required. Residents must respond in a timely fashion to all pages, flags and routed documents in the EHR. (Notes must be completed within 48 hours. Residents are responsible for checking desktops daily.) Residents who will be out of the office for more than half a day must designate a covering resident, notify the chief medical resident and change their pager messages to reflect availability. Residents must review and clear their clinic file folder at each clinic. These should not be allowed to accumulate a large number of papers, as doing so may impede the delivery of care to patients and decrease support staff efficiency. Residents must ensure that their patients understand the after-hours call system. (See additional information in the following pages.) Residents must ensure that their patients have been given a personalized resident business card listing the telephone numbers for appointments and after-hours emergency care. Residents must be available until the end of the clinic session for walk-in or add-on patients, even if they are otherwise done seeing their scheduled patients. Residents may need to schedule make up clinic sessions for clinics canceled for reasons other than vacation and ICU/NF rotations to complete at least 130 clinics prior to graduation. R 1 Resident Special Responsibilities in the Ambulatory Clinic: First-year residents must arrange coverage for hospitalized patients before leaving the hospital to attend clinic. The covering resident will be responsible for all patient calls and admissions during the clinic resident's absence. First-year residents must present all patients to the clinic attending. During the first 6 months of training, the clinic attending must see all patients. After 6 months of training the resident is eligible to operate under the HCFA Primary Care Exception. All patients must be discussed with the clinic attending before a billing level is determined. Assume the attending must see, examine and write a teaching note on all patients until you are instructed otherwise. See HCFA Primary Care Exception details above. R1 residents are expected to see 3 patients per session, on average. All breast exams, pelvic exams, rectal exams, and procedures performed by the first-year resident must be directly supervised (in the same room) by the clinic attending until the clinic attending authorizes you to perform them without direct supervision. R2 and R3 Special Responsibilities in the Ambulatory Clinic: Senior residents must arrange coverage with another senior resident prior to leaving the hospital for clinic. The covering resident is responsible for supervising the inpatient service first-year residents and all other senior resident inpatient duties. The senior resident will present all patients to the clinic attending for discussion. All patients must be discussed with the clinic attending before a billing level is determined. Assume the attending must see, examine and write a teaching note on all patients until you are instructed otherwise. R-2 and R-3 residents are expected to see 4-6 patients per clinic session on average.  XE "Clinic:appointment scheduling" Appointment scheduling policies: The standard length of a scheduled patient appointment will be: Length (min) Criteria 60 New patient Any patient who does not have a complete H&P in chart Any patient not seen by a general internist or resident from our clinic in the past 3 years 45-60 Established Patient Interval H&P High complexity care (see E&M guidelines) Procedure planned (e.g., skin biopsy, suturing, arthrocentesis, I&D, etc.) Hospital follow up visit R1 resident within first 6 months of training 30 Established patient Routine or urgent care not requiring full H&P New patient work-in appointment prior to appointment for H&P The nursing staff has the authority to fill resident appointment slots that remain empty 24 hours prior to a scheduled clinic. This allows the clinic to accommodate ill patients, and increases the diversity of patients seen by residents. To accommodate their primary care patients, residents may double-book a clinic appointment slot with one of their own clinic patients. Only residents may double-book their schedule, and they may do so a maximum of once per clinic session. Residents are urged not to double-book unless a primary care patient requires urgent evaluation. Controlled Substances Residents do not have independent DEA numbers to be used in ambulatory settings. Attending physicians must be the prescriber for all Schedule II and III medications (signature and electronic prescribing information). Hospital Follow-up New to Clinic XE "Clinic:late patients" : When possible, patients new to the clinic should be scheduled for 1 hour for hospital follow-up. If tight schedules preclude a 1 hour follow-up visit for the hospital follow-up for a patient new to the clinic, that patient should be scheduled for 30 minutes. In this case, the resident should do a focused visit only. He/she should not do a complete H & P when the visit is scheduled for 30 minutes. Implicit in the 30 minute scheduling is the expectation that the resident will deal only with the major issue at hand post hospitalization. The H & P should be scheduled for a later date following that focused 30 minute appointment. This is part of the training for residents to learn to do focused assessments when scheduling does not allow for extended assessments.  XE "Clinic:late patients" Late-arriving Patients: Spending even a minute or two with a patient when he/she arrives late to clinic enhances patient care and mutual satisfaction of providers and patients. A late-arriving patient may be seen for the time remaining of the original appointment, focusing only on the most pressing issue. If a patient arrives after the end of their originally scheduled appointment, give the option of waiting in case there is an opening between patients, or waiting until the end of the clinic for a brief visit regarding their most important concern.  XE "Clinic:after-hours coverage" After-Hours Coverage: After-hours telephone care for resident clinic patients is provided by the Firm Senior Resident on-call at Sparrow Hospital. If a clinic patient needs to be seen between 5 PM and 8 AM, the on-call resident should instruct the patient to go to the nearest Emergency Department or another appropriate urgent care site (e.g., Redi-Care, Delta Medical Center). Residents call the general medicine faculty attending on-call for the clinic for any questions. Residents providing telephone care to patients are expected to document telephone encounters using the EMR phone note feature. It is our clinic policy to not prescribe controlled substances or habit-forming medications (e.g. narcotics, sedatives) over the phone after hours. Patients should be aware of this policy. Primary Resident Unavailable: Clinic staff may contact residents directly regarding questions relating to resident patients. You must change your pager message post-call or at any other time that you are not available by pager to indicate this. If the primary resident physician cannot be reached, the nurse will contact the pre-specified covering physician. The covering resident may defer answering questions immediately in order to further research the patients history or appropriate management strategies. S/he may also contact the Clinic Attending designated for that patient. The chain of command is as follows: Covering Resident Sick Call resident Residents clinic attending Any available attending physician in clinic. Gen Med attending-on-call Residency Clinic Site Director Residency Program Director Some response to the nurse is required before the end of that business day. Hospitalization of clinic patients: The resident making the decision to admit a patient must notify the on-call inpatient senior resident and hand-off the patient. If the resident who is making the decision to admit is not the primary physician for that patient, s/he must also notify the primary physician. Patients should be admitted to Sparrow Hospital. The inpatient resident and primary resident should have ongoing communication about the patient during the course of the hospitalization to ensure optimal transitions of care.  XE "Clinic:Off-service notes"  XE "Off-service Notes:Clinic" Graduating Residents Starting February 1 of their final year of training, residents clinics will be closed to new patient visits except under extenuating circumstances. During these months residents must ensure their patients problem, medication, and health maintenance flow sheets are updated. The EHR contains well-organized data and changes the concept of an off-service note. Clinic Cancellation Policy Clinics can only be cancelled by the residency office. Clinics shall be cancelled in the following circumstances: Residents assigned to prohibitive rotations (i.e.: ICU/ Night Float rotations) Residents on vacation or other leave Instances when the number of residents per clinic attending exceeds 4. Post-call or duty hours limitation. Residents might have their clinics reinstated even in the above circumstances if: Their clinics would be cancelled more than 4 consecutive times (ACGME violation) The said residents clinic was cancelled because of the 4 resident rule and a second resident from that clinic is unable to attend due to an unforeseen event. In this case, the original resident will see the second residents patients. Residents whose clinics have been cancelled due to the 4 resident rule must be prepared at all times to attend their respective clinic on emergency basis. Clinic Staff will be notified >2 months in advance of regularly cancelled clinics due to prohibitive rotations and ASAP when vacation requests are submitted 8 weeks in advance. It shall be the responsibility of program coordinator to communicate this to the clinic staff and s/he shall be the sole person to cancel the clinics on the  HYPERLINK "http://www.amion.com" www.amion.com web site. Please refer to the policy for leave for additional information. The inpatient general medicine call schedules are created with clinic schedules in mind. Since rotations and call switches may occur during the residency year, please be sure to double-check the call schedule before each call rotation and let us know if you have been assigned short call the day of your clinic. Also remember that you must not change your call with another person without permission from the program office. Language Interpretation A subset of the continuity clinic patients do not speak English or have limited proficiency. Residents may work with interpreters who accompany patients; utilize colleagues or staff members who speak the language of the patient; or arrange for other interpretation services by coordinating with the clinic nursing staff. 2017-18 Internal Medicine Resident Clinic Clinical Assignments GREENMondayTuesdayWednesdayFridayFreilichTikariaBouknightKaVUTURULilit Karapetyan, MD (R3)Mahmoud Elsayed, MD (R3)Xiao (Mark) Ling, MD (R3) Manoj Rai, MD (R3)Atinuke Aluko, MD (R2)Sagar Panthi, MD (R3)Mohamed Hassanein, MD (R3) Syed Shah, MD (R3)Khader Herzallah, MD (R2) Calvin Abro, MD (R2) Ikponmwosa Enofe, MD (R2) Farashin Silevany, DO (R3)Aaron Nichols, MD (R1) Ayat Abdelgadir, MD (R1) Varunsiri Atti, MD (R1) Thamer Almalki, MD (R1)Seda Grigoryan, MD (R1)Ardy Fenando, MD (R1)Yehia Saleh, MD (R2) Fazal Raziq, MD (R1)WHITEMondayTuesdayWednesdayFridaySmITHTIMMER OlomuLaird-FICKAhmad Alratroot, MD (R3)Morgan Dudley, MD (R3)Divyesh Nemakayala, MD (R3)Mian (Harris) Iftikhar, MD (R3) Om Dawani, MD (R3)Joseph Prinsen, DO (R3)Konchok Norgais, MD (R2) Michael Lundin, MD (R3)Sherif Elkinani, MD (R2)Asfar Ghauri, MD (R2)Fawzi Abu Rous, MD (R2)Samanjit Kandola, MD (R2)Shiva Shrotriya, MD (R2)Manel Boumegouas, MD (R1)Mark Mujer, MD (R1)Sowmika Rao, MD (R2)Nishraj Basnet, MD (R1)John Cherian, MD (R1)Abdullah Al-Abcha, MD (R1)Shilpa Tatineni, MD, (R1)  XE "EMR:Logician, clinic"  XE "Logician" Electronic Health Record The MSU HealthTeam uses the Athena electronic health record (EHR). You will be trained to use the EHR during your orientation, and will learn further details of EHR function throughout your ambulatory training Office Visit Notes by Residents: Holding and Signing Instructions Resident tasks (Part A): 1. Enter note into Centricity, and soft sign by entering .sign at the end. 2. Click on End Update. 3. Click on New, select attending name, and click OK 4. Select Hold document to keep the note open until the attending can review it, suggests changes and corrections, and add his/her teaching note. (NOTE: DO NOT click SIGN DOCUMENT yet because you will not be able to fulfill an attendings request to make corrections, and the attending will not be able to add his/her teaching note at the end of your note). Attending Physician tasks (Part A): The attending will add his/her teaching note, and determine what, if any, changes in the residents documentation are necessary. After adding a teaching note, the attending should select Hold document to send it back to the resident per usual protocol. Routing it back to the resident who originally routed the note should be easy, as that residents name will be checked by default in the routing dialog box. If not, select New, select the residents name, etc. (If the resident note is acceptable, permanently sign the record by selecting Sign Document. Click no when asked if you wish to become the physician of record for the encounter.) Attendings should not directly change a residents documentation. S/he should instead make suggestions to the resident. Resident tasks (Part B): The resident should open the document and make any appropriate changes. After making any necessary changes, the resident should click Hold document The resident should send the document back to attending for his/her final signature. The resident will click SIGN DOCUMENT to make the changes permanent. The document will then go to the attending for his/her final signature. Attending Physician tasks (Part B): The attending physician should open the document, inspect the residents changes and then click End Update and click SIGN DOCUMENT to add his or her permanent signature. If additional comments are desired, the attending physician should use the append option. Requirements for Office Note Completion for Residents and Attending Physicians The resident must complete the office note on the day of the clinic visit and prior to leaving the clinic. The resident will route the office note to the Attending Physician prior to leaving the clinic. The Attending Physician will add a teaching note to the residents note and soft sign the note on the day of the clinic visit. The Attending Physician will review the residents clinic note within one business day of the visit and either hard sign the note or return the note to the resident with recommended changes. Within one business day, the resident will incorporate any changes suggested by the Attending Physician. The Attending Physician will review the residents modified note and hard sign the note within 2 business days of the office visit. The Attending Physician will again route the final note to the resident for his/her permanent signature (hard sign). In order to give additional time for in-clinic completion of notes, the first patient appointment will be at 1:30 pm and the last 30 minute appointment will be at 4:00 pm. The clinic staff will keep a record of resident and attending notes which are not compliant and provide reports for the Resident Clinic Site Director (Dr. Meerschaert). Attending and covering physicians are responsible for monitoring their clinic residents desktops to ensure resident note compliance. The resident clinic site director will report non compliant residents to their attending physician. The resident clinic site director will report non compliant attending physicians to the Chief of General Internal Medicine. SECTION 5 INPATIENT GENERAL MEDICINE ROTATIONS Teaching and Learning Policies and Procedures for Firm Responsibilities of Residents (by Training Level) Night Float MSU organizes general medicine inpatient services into Firms or teams. There are four Firm teams: White, Green, Sparty, and State. Each team consists of a senior resident (R2 or R3) and two R1s, with the exception of State team, which consists of two senior residents (R2 and R3) and occasionally one R1. Each team is supervised by an attending physician, who makes daily teaching rounds with the team. Assigned senior and junior residents (night floats) provide cross-coverage at night. Each Firm junior will also complete a night shift, in compliance with duty hour requirements. While continuity contributes to quality patient care, some variety in patient exposures, peer interaction, and faculty exposure is also desirable to optimize education. This occurs through assignment of various combinations of senior and junior residents on Firm rotations, and by two-week teaching assignments for faculty. Teaching and Learning FIRM and Night Float residents will participate in three distinct morning activities - Hand Offs, Teaching Morning Report, and Multidisciplinary Report as described below. These will occur in the designated room. Hand offs: Hand offs will occur from 7:00-7:30 AM each day, in compliance with duty hour restrictions.Each team will have new patients on their list assigned to them by the Night Float resident. Each team will keep these patients and will take face to face (intern to intern and senior to senior) sign out on each of these new patients from the NF resident. Residents will also communicate any changes in status of patients signed out overnight. While one team is getting the sign out, the remaining team can look up their new patients and can ask pertinent questions. The chief resident or his/her designee will ensure that the process goes on smoothly and all the patients are assigned. (Please see the additional procedure for patient assignments in the next session.) Teaching Morning Report: Residents on FIRM; the chief resident or his/her designee; and attendings rounding on the FIRM service including the assigned teaching attending (typically a general internist) will participate in the activity Monday, Wednesday and Friday from 11:30 am till 12:15 pm. One resident will be assigned to present each day; a schedule will be distributed at the beginning of each rotation. Every internal medicine resident must present at least once per two week period. The cases on every 2nd Wednesday includes a biopsychosocial discussion, moderated by a faculty member with expertise in this area. For each case presentation: The assigned resident will present a patient admitted during that rotation. The presentation of the case should follow the format of an initial History and Physical examination document, including specific pertinent historical information (e.g., sexual, occupational, substance use, etc.) , and highlighting pertinent examination findings. All radiographic studies, ECGs, and other pertinent data should be available for review Residents should then discuss the differential diagnosis, appropriate diagnostic work up, and management plan for the patient. The last 10-15 min can be spent discussing the particular medical condition, depending on their specific learning objective and training level. The teaching attending will serve as facilitator and content expert for the sessions. All residents are expected to attend the morning report, unless assigned to be off duty or responding to a Code Blue. The resident who misses the morning report for any reason is expected to explain to the teaching attending the reason. Multidisciplinary Report: On Tuesdays from 8:00-8:30 AM, the residents and chief medical resident will meet for Multidisciplinary Report. (This is an encouraged but not required activity for the teaching attending.) Multidisciplinary team members including nurses, case managers, and pharmacists may also participate based on their availability. The schedule of activities will vary from block to block, but will include: Pharmacology rounds: The purpose of pharmacology rounds is to provide real-time case-based teaching in pharmacology. The teams will meet with Dr. Stein for two sessions per block. The chief medical resident will elicit 2-4 case-based questions from the residents and relay them to Dr. Stein Wednesday morning preceding the session. Academic Case Management: Residents will meet with the academic case manager on the first Tuesday of the rotation to learn more about the systems issues pertinent to hospital admission, discharge planning and coordination of care. S/he will also provide the residents with feedback on their performance over the rotation on a variety of systems issues. Attending Management Rounds Managing attendings round every day, including weekends and holidays. Additional clinical teaching is incorporated into team rounds. Policies and Procedures for FIRM  XE "Work Hours" Duty Hours: The usual inpatient day is 7:00am-5:00pm, but may be extended until patients are stabilized and the daily assigned tasks are satisfactorily completed. Firm juniors each complete one night shift during the block, scheduled to be in compliance with duty hour requirements. Please refer to the separate policy on Duty Hours and Fatigue Mitigation. Residents will sometimes be required to complete a night shift prior to starting a new rotation. When this occurs, the resident should report for orientation for the new block, but will then be excused. Limits on Admissions and Patient Load (Caps): There are two types of limitations on the number of patients a resident physician may assume care for an admission maximum or cap, and a census cap. See table below. When the on-call senior resident caps, s/he should notify the chief medical resident, who in turn will notify the Hospitalist attending and ER. Any additional patients will go to the Hospitalist Service. Resident Training LevelAdmissions in 24 hours Admissions in 48 hours Short Call capCensusR15858R2/3 supervising a single R1 team10161012*R2/3 supervising a two R1 team10161016* *This doesnt mean that on a given day when an intern has a day-off, senior will off-load patients to bring the census to 12. If you are supervising 2 intern team senior census cap remains 16 and doesnt change day-to-day. Census cap for a 2-senior and 2-junior team is 18. NF senior works with the hospitalist teaching service if the FIRM total census has capped and may admit up to 5 patients under hospitalist service depending upon Firm admission done during the night shift.  XE "Admitting Patients:general policies"  XE "Admitting Patients:limits on admissions" General Expectations for Performing Admissions: Senior residents triage all patients for admission to the Firm teams. Most patients will come through the emergency department; that work flow is described below. New patients may also be admitted from clinic directly to the hospital; transferred from the ICU or another specialty service to the Firm; transferred from another hospital; or referred to the Firm for consultation. R1 residents should be assigned to patients as early as feasible in the course of the admission process, and complete admissions under the supervision of the senior resident. For  XE "Emergency Department:Admitting patients"  XE "Admitting Patients:Emergency Department" Admissions from the Emergency Department (ED): An ED physician contacts the on-call senior resident when it is likely that the patient require inpatient admission or observation within the main hospital. The resident verifies that the patient "belongs" to the Firm (e.g., "no-doc" patient, a specific referral to the teaching service by a physician, an MSU clinic patient of an attending or resident, or a recent patient of the teaching service). The resident and ED physician discuss the case. Ideally, the resident should review the electronic record simultaneously or prior to the case presentation. Appropriateness for admission to Firm and level of care required (e.g. step down, general medical bed) should be part of the discussion. Appropriate for Firm and Stable: The resident gives bridging orders to allow the patient to be transferred to the floor within 1 hour or less. The resident may then fully evaluate the patient on the floor. Appropriate for Firm and (Potentially) Unstable: The resident proceeds immediately to the ED to determine whether a higher level of care is needed. Uncertain if Appropriate for Firm: The resident should go to the ED to evaluate immediately. If the resident still disagrees with the request to admit the patient, s/he should confer with the medicine attending on call. If s/he thinks a higher level of care (critical care) or admission to another service would be more medically appropriate, this should also be discussed immediately with the ED physician. Never refuse to admit a patient against the advice of an ED physician without evaluating the patient. A decision regarding disposition of the patient should occur within 30 minutes of the initial call. The admission process must not be delayed for additional test results when the clinical information indicates that the patient needs to be admitted and is appropriate for the level of care requested.  XE "Admitting Patients:Expediting admissions" The assigned resident(s) complete the History and Physical on the floor, with full admission evaluation and completed within 2 hours. R1 residents should be involved as early as possible; the senior directly supervises the R1 and adds a brief supervisory note. If no R1 is available, the senior resident completes the entire admission process. Readmission of recently discharged patients (Bounce Back): Any no-doc patient readmitted to Sparrow Hospital <30 days of the original hospital stay needs to return to the team that performed the prior admission, assuming that the team specialty remains appropriate to the cause of admission. This is irrespective of any rotation changes that may have occurred in the interim.  XE "Orders"  XE "Writing Orders" Order Writing: Residents should write all non-emergent orders for patients under their care. Attending physicians must refrain from writing orders except in emergencies or if no resident is on-duty. Consulting physicians and their residents may write orders on the charts of patients on internal medicine teaching services at the discretion of the referring resident(s), who should clarify this issue during the consultation request. Infractions of this policy must be brought to the attention of the program Site Director (see Core Faculty list) or the Program Director. Translator Services: Interpreter services are available at Sparrow for more than 200 languages 24/7 using special phone services. Process for Requesting Consultative Services: Directly contact the consulting physician (phone or face to face). Communicate the urgency of (emergent, urgent, routine) and reason for the consult (e.g. clinical question, procedure, management). If you would like to do a procedure with the consultant's supervision, make your request clear when you discuss the case with the consultant. Advise patient of the consultation and what to expect. Process for Providing Consultations: In general, consults should be performed in a manner similar to that for admissions. There are several key differences, as described below. The senior resident performs the consultation without an R1 resident or student. The resident should talk directly with the referring physician when possible to clarify the request. Documentation is focused on the question asked. Answers to the referring physicians questions are presented succinctly at the close of the note. Orders should not be written on teaching patients of other residents unless specifically instructed otherwise. Transfers to the Critical Care Units: When a patient requires transfer to the ICU, the transferring resident should orally hand-off the patient to the on-call ICU senior resident and the on-call critical care attending, then write a note summarizing the patients significant problems and events. The patient should be transferred back to the original teaching service, once stabilized, for the remainder of their hospitalization. Transfers of Patients from Non-teaching Services:  XE "Transfer patients:from non-teaching services" Transferring a patient from a non-teaching to a teaching service is sometimes appropriate, for purposes of continuity (e.g. clinic patient) or educational value. Transfer must not result in exceeding census limits. Process for Assigning Patients to Teams and Individual Residents: The admitting team senior/NF will add the new patients to the New admissions list (under the Shared list) as soon as the patient is accepted on the service. (Residents should not remove patients from the Admission list). During the day, the on call call residents will keep the first three patients evaluated. The senior resident will keep one patient, and the R1 will keep two patients for his/her team. At the end of the call, unassigned patients are hand over to the night float resident. By 6 am, the Night float resident is expected to distribute the remaining new patients among the teams, adding the patients to the respective team lists. After identifying teams with one or more residents scheduled off or in clinic for that day, the resident determines the number of patients to be given to each team. Teams with one or more residents absent should receive 1-2 fewer patients. When more than 3 admissions were done by the day team, the NF resident will try to give the additional patients to the physicians who performed their admissions. Bounce backs return to the same team. Residents preferentially receive their own clinic patients when on service. The team gets 20 % more patients when it has two senior residents. If there are any issues regarding patient assignment, the night float resident will contact the chief resident at 7 am. The chief resident or designee will remove patients from the New Admissions list after making sure that all have been assigned to teams. Residents are responsible for updating team and resident assignment information in the treatment team sticky notes section of the chart. This section is visible on the first page when opening a patients chart in EPIC. The senior resident should make sure the rounding attending has been added to the treatment team as the attending physician of record in EPIC. Hand Offs: Residents caring for patients on Firm must hand over their patients in writing and orally at the end of every duty period (including nights, weekends and holidays) to the on-call resident before leaving the hospital. This should be completed using the sign-out tool in EPIC. Residents who fail to sign-out to covering residents may be required to return to the hospital to complete this task. Repeated failure to complete this required task reflects poorly on resident professional behavior and may be sufficient grounds to justify a failing evaluation for the rotation, or administrative disciplinary action. Residents coming on-duty the next day should get patient lists back from the on-call resident at hand-off report (intern-to-intern AND senior-to-senior), again with oral discussion of patient care needs. Off Service Notes: At the time of service change, off service notes must be written on all patients by the departing resident primarily responsible for the patient (this will generally be the first-year resident). Senior residents supervising first-year residents must ensure that off-service notes are completed. Responsibilities of Residents on Firm First year residents: Supervise and educate M3 students. Work collaboratively with M4 sub-intern students. Are fully supervised by and report to senior residents and attending physicians. Completely evaluate all assigned patients, formulate an assessment for all major problems, and outline management plans. Lead patient presentations (unless a student has been assigned assigned) and bedside interactions with patients. Document progress notes in SOAP format daily on all assigned patients, with additional documentation of significant events or conversations as needed. Document all procedures personally performed. Complete  XE "discharge summary:inpatient" \i discharge summaries within 24 hours of discharges (see exceptions under R2/3 responsibilities). Write  XE "Off-service notes:inpatient" off service notes on any patients under his/her care that will be transferred to an oncoming resident. Notify supervising senior resident immediately of any changes in the condition of patients. Remain in the hospital when on-call. Sign out to covering residents when leaving for clinic. Present at hand off rounds all patients admitted in the previous 24 hours. Senior residents: Supervise M3, M4, and R1 trainees, with direct oversight of all patient care Orient them to the rotation and review responsibilities. Ensure that at least one senior resident is available on-site at all times (unless similar coverage is provided by a subspecialty fellow or attending) to back up R1 residents. Provide active, educational back up that is equally vigorous at night as during the day. Triage all admission/transfers before assignment to an R1 or medical student Review all admissions/transfers soon after the R1 has completed the evaluation Write brief supervision notes for all patients newly admitted Maintain awareness of all medical issues and management decisions for assigned patients Check the R1 resident's work-ups, problem lists, orders, and progress notes at least daily. Provide constructive feedback to R1 residents and medical students Rapidly notify the Clerkship Coordinator or attending physician of problems (clinical, behavioral, and other) with students or R1 residents When on call, contacts the attending regarding all admissions at the time of admission when possible, and no later than a few hours later, even if the patient is stable. Complete all consultations to the Firm (these should not be assigned to R1s) and proactively communicates with referring physician at time of consult, time of discharge, and as needed in between. Contact referring primary care and/or other continuity physicians regarding all patient admissions and discharges. Notify the attending physicians promptly about all admissions, discharges, consultations, and status changes in any patient at an interval that is appropriate and agreed upon in advance. If a patient is in danger of death, the resident should immediately notify the attending physician and the appropriate nurse supervisor, so that family can be notified. The resident should notify the attending promptly in the event of a death on the teaching service. Make daily morning work rounds Complete a  XE "discharge summary:inpatient" \i discharge summary within 24 hours of each patient discharge in cases when the R1 is unavailable (post call, days off, clinic, etc.). Report all deaths occurring on the service to the residency office. Assure timely attendance at required teaching events and clinic for all team members Communicate difficulties with team function or attending physician (e.g. failure to appear at morning report at assigned times, concerns regarding supervision) to the program director, a core faculty member, or chief resident in a timely fashion. Model appropriate attitudes and behaviors for others. In addition, R3 residents: Assist R2 residents with leadership responsibilities, including negotiating communication and teaching challenges. Serve as the lead senior resident for all matters requiring technical, administrative, or educational supervision. NIGHT FLOAT The night float residents work as an integral part of the Firm system. They participate in morning teaching activities and follow the same policies and procedures related to duty hours, caps, admission, etc. as the Firm residents. The chief resident is responsible for creating all night float schedules, and must approve any changes. The night float resident is responsible for assuring the timely arrival of post-call interns and census print outs to Hand Off Rounds, and ensuring that all patients are accounted for during evening and morning hand offs. SECTION 6 MEDICAL INTENSIVE CARE AND CORONARY CARE UNITS Intensive Care Units The internal medicine residency staffs the Sparrow critical care rotation for eight blocks per year; emergency medicine staffs it for the other five. Rotating R1 residents from other disciplines (neurology, OB/Gyn, family medicine, urology, etc) are assigned throughout the year. Patients requiring medical management in the Intensive Care Unit and Cardiac Care Unit will be admitted to the ICU teaching service if they are under the care of designated ICU teaching faculty. Please refer to the Critical Care Curriculum and the Sparrow Hospital resident ICU guide: Survivor Tools for New Residents. This guide, distributed at the beginning of each rotation, contains critical curricular documents, safety information, orientation details, and clinical care guidelines. ICU Chart Cards: Residents are expected to properly identify each patient on the ICU Teaching Service by updating the Treatment Team Sticky Note section of the electronic health record. This facilitates patient care, maximizes resident participation in patient care questions or orders, and helps consultants know which residents to communicate with. Compliance with this is an element of Professionalism as well as Communication. ICU Caps and Patient Types Given the complexity of the patients within the critical care units, the team caps are lower than for general medicine patients. Team caps are based upon the number of R1 residents assigned to the team, since R1s must always have direct supervision by a senior resident or attending physician immediately available. Any admissions to the units above the cap will be covered by attendings only. 24 hour capCensus capR166R2/R310- Census capTeam with 2 R1s14Team with 3 R1s20 ICU Transfers Transfers into the ICU: Residents on call for the ICU service should not agree to evaluate patients on non-ICU floors to determine appropriateness of ICU transfer. Only in the case of an emergency (pre-code/code) where a floor patient will definitely require ICU transfer may an ICU on-call resident go to the floor to initiate ICU care/workup before a decision to transfer has been made. Otherwise, if any attending physician would like an ICU resident to workup a patient for transfer, the transferring physician must talk to the ICU attending, who must have agreed to accept the patient in ICU transfer prior to resident involvement in the case. Transfers out of the ICU: If a new service will assume care of a patient transferred out of the ICU, the ICU resident team must complete a transfer summary. The summary may be completed as a more detailed progress note on the day of transfer or may be a separate formal transfer summary. Components of the transfer summary should be the same as a standard discharge summary. The resident team must also contact the accepting floor team to provide a verbal hand-off on the patient. The ICU team in these cases relinquishes patient care responsibilities as soon as the patient leaves the ICU. Responsibilities of R1 Residents on Intensive Care Medicine Rotations: R 1 responsibilities in the ICU are as noted in Section 4 general inpatient duties with the following exceptions: If a patient is transferred from a general hospital floor to the Intensive Care Unit, the accepting R1 resident will complete a critical care H&P. If a patient is discharged directly from the Intensive Care unit to home, or expires in the Intensive Care unit, the R1 resident will dictate the discharge summary/death note. If the patient is transferred from the Intensive Care unit to the medical wards, the R1 resident will write a transfer note and transfer orders Responsibilities of R2 and R3 Residents on Intensive Care Medicine Rotations: A senior resident will be available at all times (unless similar coverage is provided by a subspecialty fellow, house physician or the attending) to back up first-year residents. This should be active, educational back up and should occur equally vigorously at night as during the day. Admissions must be seen and reviewed soon after admission. The responsibilities of senior residents in the ICU are as noted in Section 4 describing general inpatient rotation duties with the following additions: Unless qualified by experience and given permission by the attending physician, senior residents will perform procedures only under the direct supervision of the attending physician, teaching attending, or other qualified physician. The senior Critical Care resident will be responsible for evaluating patients for admission to the critical care units from the emergency department. SECTION 7 EVALUATION Resident Evaluation Procedures In Training Examinations Performance Criteria Due Process Remediation Evaluation of the Program Resident Evaluation Procedures Resident evaluation focuses on the ACGME and AOA Milestones and Competencies. For descriptions of the competencies, see Section 2. We will abbreviate them for ease of reference as: Patient Care PC, Medical Knowledge MK, Practice-Based Learning and Improvement PBLI, Interpersonal and Communication Skills IPCS, Professionalism P, Systems-Based Practice SBP. Satisfactory completion of three years of internal medicine residency training is not sufficient to be eligible to sit for the American Board of Internal Medicine (ABIM) or the American College of Osteopathic Internists (ACOI) certification exams. Both organizations require programs to evaluate each resident's competence by conducting longitudinal evaluations and reviews by a clinical competency committee and/or program director. Consistent demonstration of and progress in the competencies are important to this determination. The ABIM has noted that residents perceived as having little chance of passing the ABIM certifying examination should not be allowed to sit for the examination (i.e., should not be declared Board Eligible). Our goal is to ensure that residents demonstrated knowledge, skills, attitudes and behaviors meet criteria for Board eligibility. Evaluation Procedures: For each rotation, faculty will complete competency evaluations of the resident. The evaluations use specific criteria based upon the year of training of the resident, with the following designations for performance: unable to assess, significant deficits, minor deficits, competent, and exceptional/exceeds expectations. The designations represent the level of skills, knowledge and attitudes expected for a resident at the end of the training year. The resident should demonstrate progression toward competency in each core area during the year, with attainment of competency required to progress to the next training level. Most evaluations are recorded in the web-based evaluation system, New Innovations. Evaluations should be constructive, collegial and formative. They should advance the medical knowledge, clinical skills, and professional behaviors of residents during training. Residents are expected to have areas of significant deficiency early in the training year, based upon the graded expectations; it is our intent to support the growth and development of the resident by identifying and correcting these deficiencies constructively and early. Competence must be attained by the end of the training year in order to advance. Resident evaluations include, but are not limited to the following [Competencies addressed in brackets]: R1 resident OSCE [all] Chart review of randomly selected H & Ps (Chart Audits) [PC, IPCS] On-going review of sample documents generated by residents during inpatient and outpatient assignments throughout residency training (Chart Audits) [PC] Mini-CEX assessments [all] Evaluation of resident competencies in rotation evaluations [all] Semiannual evaluation of ambulatory continuity clinic performance by the faculty preceptor [all] Procedural skills cognitive examinations [PC, MK] ACLS certification exam [PC, MK] USMLE or COMLEX Step III exam [MK] Annual in-training examinations [MK] Performance on Board Review exams [MK, PBL] Resident peer evaluations [all] Patient satisfaction surveys [PC, IPCS, P] Praise and concern notes from faculty, staff and peers [all] Procedure logs and evaluations [PC, P] Evaluations by the dedicated inpatient Firm case manager [PC, IPCS, P, SBP] Clinic staff evaluations [IPCS, P, SBP] Semiannual performance reviews including review of resident portfolios [all] Quarterly performance evaluations for allopathic-osteopathic residents [all] Evaluations of scholarly/didactic presentations [MK, IPCS, P] Summative competency evaluation at completion of training [all] Global evaluations per rotation [all] PICO literature search exercise [PBLI] ECG examination [MK] Patient logs for allopathic-osteopathic residents [PC] Chart stimulated reviews [all] Semi Annual Resident Evaluations: Twice yearly, residents discuss their overall performance with the Program Director or a designated Core Faculty member. During this semi annual evaluation, multisource evaluations (from nurses, patients etc) are discussed, with a review of all performance information available to the evaluator. Residents are required to bring their professional portfolio to this evaluation. Portfolios are maintained in the residency office, and residents should submit all evidence of their academic progress for retention in their formal portfolio. Portfolios should contain: a HIPAA de-identified sample of a recent H&P, copies of any recent publications or scholarly products, documentation of required exercises such as Night Float literature search, and a recent CV including information on scholarly activities, performance awards, and community service. Residents must also complete a semi annual self-evaluation and reflection to bring to the semi-annual review. The designated faculty will provide the resident with guidance on their progress in the achievement of competency objectives for their stage of training, and will also provide general professional guidance. The purpose of the meeting is to identify academic strengths and weaknesses, plan and individualize curriculum, develop study plans, and plan for the post-residency period. Residents who are not satisfactorily progressing in achievement of the Milestones may be reviewed by the TEC for appropriateness of promotion. See Promotion Criteria for performance guidelines. Osteopathic residents seeking dual accreditation will meet quarterly with the Osteopathic Program Director or a designated Core Faculty member. Review of the Resident Evaluation File: A resident may review his/her formal portfolio and administrative file during usual office hours. Web-based confidential evaluation data are continuously available in real-time at:  HYPERLINK "https://www.new-innov.com/login/" https://www.new-innov.com/login/ Twice annually the resident will review his/her file with the Program Director or one of the Program Core Faculty, as part of the semi-annual review. In-Training Examinations: The In-Training Examination (ITE) is offered yearly by the American College of Physicians; dually-accredited residents also take the annual In-Training Exam from the American College of Osteopathic Internists. These exams are external measures of medical knowledge to assess resident progress toward certification. All residents must take the ACP ITE during each year of residency training. The results of the exam will not be used to determine status in the program. Results will be used to make informed decisions regarding rotation assignments, directed study programs, other educational interventions, and program improvements. Individual ITE results are confidential and are only shared with the residency administrative leadership (Department Chairman, Program Director, and Core Faculty), unless the resident grants specific permission. Residents who perform poorly as judged by the Program Director may be required to participate in remediation activities. Board Review Modules: Residents are required to pass post tests for ten modules per year in the Challenger program. Individual subscriptions with usernames and passwords are provided by the residency office. USMLE and COMLEX Step 3 Examinations: The Step 3 examinations are intended to verify an adequate knowledge base for the independent practice of medicine as a general practitioner (after one year of residency training) and are required for permanent medical licensure. Our program requires that residents must: pass the USMLE and/or COMLEX Step 3 exam to be promoted to R3 status. Performance Criteria Performance Review: The Clinical Competence Committee reviews all resident evaluation files, including attendance at mandatory conferences and completion of academic and administrative assignments, at least biannually. The committee will decide when additional action is necessary. Such action may include a requirement for resident appearance before the Training and Evaluation Committee (TEC), a specific required remediation program for the resident, or a possible delay or denial of promotion or renewal of contract. Performance Requiring Resident Appearance Before the TEC: A resident shall have his/her evaluation file reviewed and is required to appear before the TEC when faculty evaluations reflect one or more of the following during a single year of training: During the first half of the academic year (i.e., July through December): Two (2) or more performance evaluations of significant deficits for the same single competency. During the second half of the academic year (i.e., January through June): One (1) performance evaluation of significant deficits for a single competency. An overall performance evaluation of minor deficits in the end-of-year semiannual evaluation. Other triggers: Concern Cards or critical incident reports which the Program Director/CCC determines are appropriate for programmatic review. The TEC shall deliberate and decide whether further action is necessary. Such action may include a specific required remediation program for the resident, formal probation, possible delay or denial of promotion or renewal of contract, a denial of recommendation to sit for the American Board of Internal Medicine or ACOI Certifying Examinations. If the TEC determines the resident is not appropriate for remediation, probation, or training delay, the TEC may consider resident dismissal. Performance Scores Requiring Resident Appearance Before the TEC with Possible Immediate Dismissal: A resident shall have his/her evaluation file reviewed and is required to appear before the TEC for immediate dismissal consideration when faculty evaluations reflect one or more of the following during a single training year: Three (3) evaluations of significant deficits on the same single competency by more than one observer. One (1) overall performance evaluation of significant deficits on a semiannual-evaluation. Failure to pass USMLE or COMLEX Step 3 by the end of the R2 training year. Concern Cards or critical incident reports which the Program Director determines raise the necessity of considering resident dismissal. Other action may include, at the TEC's discretion, a specific continued remediation program or a possible delay or denial of promotion of that resident, non-renewal of the resident's contract, or a denial for the resident to sit for the American Board of Internal Medicine or ACOI Certifying Examinations. Review of Descriptive Reports: Reports of interactions with patients, other professionals, peers, and students are collected for resident feedback. These various reports are kept within the resident portfolios, and are available for resident review during normal business hours. Persistently negative reports from peers, student, patients, or staff that are perceived to be severe by the Program Director may be shared with the TEC. At the discretion of the TEC, the resident may be required to appear before the TEC to respond to the content of the reports, and the TEC may choose to take an action up to and including consideration of dismissal. As in all other circumstances, the resident has an opportunity to rebut this information in writing. Failure to do so by the time of a required appearance before the TEC will be assumed by the Committee to imply agreement. Resident Rebuttal of Marginal and Unsatisfactory Faculty Performance Score Ratings: Any resident who disagrees with or wishes to comment on any overall evaluation of minor deficits or significant deficits, OR an evaluation of significant deficits on any single competency is invited to submit a Resident Rebuttal for TEC review. Failure to provide such a letter by the time of a required appearance before the TEC will be presumed to imply agreement with the evaluation. The comments of the TEC about resident rebuttals will be entered in the resident's file in addition to the rebuttal. The opinion of the TEC at such time shall take precedence. Furthermore, a resident may request to appear before the TEC to review any aspect of his/her training or evaluation. Any resident who appears before the TEC, regardless of the circumstance, is encouraged to identify and bring a faculty and/or resident advocate of their choice to the TEC meeting. Incident Reports: Any incident report that is received by the Program Director will be shared with the resident and possibly with the CCC/TEC. Depending upon the nature of the problem, the resident may be asked to appear before the TEC to explain his/her behavior. A large number of unfavorable behavioral reports or any report that is of severe enough consequence, in the opinion of the TEC, may prompt action from the TEC. This action may include a specific required remediation program, probation, delay or denial of promotion, or dismissal from the residency program. Due Process The MSU Graduate Medical Education Committee (GMEC) oversees the MSU Internal Medicine Residency Program along with all other MSU College of Human Medicine residencies. This oversight committee assists all MSU residencies by setting uniform legal and procedural policies. The GMEC operates under the aegis of the Dean, or the Associate Dean for GME as delegated, and governs by authority granted from the Dean. GMEC membership includes the Associate Dean for GME, each sponsored residency Program Director, department Chairs, Directors for Medical Education for participating institutions, and resident representatives. The GMEC serves as the representative body within CHM that sets forth the process and procedures related to the hearing and resolution of resident grievances. Resident Dismissal and/or Corrective Action: The GMEC manual with dismissal policy is online at:  HYPERLINK "http://www.gme.chm.msu.edu/administration.aspx" http://www.gme.chm.msu.edu/administration.aspx Select Table of Contents link and look for Resident Dismissal Procedures Resident Grievance Procedures: The GMEC manual with resident grievance procedure is online at:  HYPERLINK "http://www.gme.chm.msu.edu/administration.aspx" http://www.gme.chm.msu.edu/administration.aspx Select Table of Contents link and look for Resident Grievance Procedures . Resident Remediation or Performance Improvement Plan (PIP) The Program director or CCC or TEC may recommend resident remediation programs whenever a resident is failing to meet performance expectations as detailed above. Remediation programs are not punitive and non-reportable these are performance improvement plans designed to help struggling learners in specific competencies. Remediation plans are specified by the Program director or CCC or TEC and individualized to the learner and his/her needs, but may include reading schedules, additional assessments of knowledge, direct observation with feedback from another physician, regular meetings with an academic advisor, reflective essays, repeating specific educational or clinical experiences. This list is not exhaustive. The time period may vary, but could be several months long. Progress on the remediation/PIP is reported back to the Program director or CCC or TEC. Based on performance review, outcome could be the end of remediation due to successful completion; extension of remediation/PIP; or extension of training at the same training level. Successful remediation/PIP activities that do not require extension of training are not reflected within the residents permanent educational record, and will not be reported on subsequent credentialing forms or performance reviews. Evaluation of the Program The residency performs continual and systematic program evaluation during TEC meetings at least 4 times per year. The following elements are a partial listing of formal evaluation content that is maintained in the TEC minutes. Resident and Faculty Evaluations of Teaching Services: Residents are required to submit confidential evaluations regarding their faculty at the conclusion of each rotation. They also evaluate their continuity clinic experiences. Residents evaluate the entire teaching sites, rotations and faculty once a year in residents retreat. These evaluations are reviewed annually by the Training and Evaluation Committee to enhance curricular structure and attending physician performance. Residents are required to complete 80% of the evaluations assigned to them. Evaluations completed by residents, including any descriptive comments, are not released to involved faculty until a sufficient number of evaluations have been submitted to ensure resident confidentiality. Results of resident evaluations of faculty teaching performance are reviewed by the Program Director and are considered by the Division Chief/Chair of the Department of Medicine during annual faculty performance evaluations. Faculty members are surveyed annually for their opinions on strengths, weaknesses, and training improvement opportunities. All data are reviewed by the Training and Evaluation Committee. Curriculum Revisions: All curricula are fully reviewed and revised at least every 3 years. As a part of this process, a resident to ensure that it accurately describes the educational process and to enhance the total description reviews each curriculum. Each curriculum is assessed for strengths and weaknesses, and weaknesses are targeted for improvement during the continuing curriculum revision process. In-Training Examination Results: The Program Director reviews the results of the annual ITE to consider opportunities for program improvement. Whenever possible, the Board Review conference is organized to address significant deficiencies revealed in the ITE. The Training Evaluation Committee reviews the overall program performance on the ITE. Annual Resident Surveys and Retreat Feedback: Residents complete a confidential, comprehensive annual survey provided by the MSU Graduate Medical Education Committee (GMEC). Results are compiled by the GMEC and aggregate results are shared with the program leadership and TEC for evaluation of improvement opportunities. Residents provide annual feedback at the programs annual resident retreat. They complete a questionnaire to address strengths and weaknesses. At the retreat, residents discuss the program and present constructive feedback to program leadership. The Chief Resident provides a written summary; suggestions are then reviewed by the Core Faculty and presented as appropriate to the TEC. ABIM and ACOI Certification Exam Pass Rate: Annual graduate performance on the ABIM and ACOI certification exam in Internal Medicine is closely reviewed by the Program Director and reported to the Training Evaluation Committee. Subsection performance is reviewed for curriculum revision. Post-Residency Graduate Employer Evaluation Results: Annual graduate competency-based performance as rated by subsequent employers and fellowship directors is closely reviewed by the Program Director and reported to the Training Evaluation Committee. SECTION 8 RESIDENCY POLICIES Related to Primarily Clinical Activities Supervision Policy Service Policy Duty Hours and Fatigue Mitigation Medical Records Procedures Chaperones for Sensitive Examinations Needle Sticks, Universal Precautions, and Blood Borne Pathogens Pagers Hospital Mobile Phones Laptops and Tablets for Firm Moonlighting Related to Primarily Educational Activities Out-of-Residency Rotations Creating New Curricula Clinical Investigation Rotations Membership in Professional Organizations Mentoring Mandatory Counseling or Assessment Human Resources Personal Leave: Duration, Rotation Requirements, and Length of Training Requesting Personal and Educational Leave Unexpected Absences due to Illness or Emergency and Back Up Call Professional Attitudes and Behaviors Resident Counseling and Support Services Physician Impairment Sexual Harassment MSU Diversity Resources Maintaining Contact Information E-mail Related to Primarily Clinical Activities Supervision Policy Resident physicians will perform their clinical duties under the supervision of identifiable, appropriately-credentialed and privileged attending physician who is ultimately responsible for the patients care. Residents will be granted progressive responsibility and autonomy based upon their performance. First year residents will perform their clinical duties either under direct supervision by a senior resident, fellow, or attending physician, or with indirect supervision with direct supervision immediately available. Senior residents may work with direct supervision, indirect supervision with direct supervision immediately available, or with indirect supervision with direct supervision available (e.g. by phone). Attending physicians of record are required to make management rounds on their patients either with the resident or independently; if the latter occurs, the attending must effectively communicate with the resident(s) regarding ongoing patient management. In the resident continuity clinic, the physicians may operate under the Primary Care Exception Rule. Service Policy In accordance with ACGME regulations, residents patient care responsibility will be limited to teaching service patients only. This includes patients established with the MSU Firm (inpatient) teams, MSU general medicine and subspecialty clinics, and patients seen under the supervision of residency faculty members in other settings (such as the emergency department on the emergency medicine rotation, private patients seen under the supervision of a subspecialist during an elective rotation, etc). Emergent or urgent care: As internal medicine residents are members of the Code Blue team at Sparrow Hospital when on critical care and Firm rotations, they are expected to care for non-Firm patients within the context of Code Blues. The Sparrow Hospitalists provide Rapid Response Team coverage for all patients admitted to Sparrow Hospital, independent of resident coverage. Therefore, residents should not be involved in the care of these patients. Limits on the number of patients cared for by residents: Caps (for admissions and census) are discussed separately under the Inpatient General Medicine and Critical Care sections. Duty Hours and Fatigue Mitigation The residency program complies with both ACGME and AOA regulations regarding duty hour limits for resident physicians. These include: Type of RequirementApplied toRuleHours per weekAll residents<80 hrs/week averaged over a 4 week period (including all in-house call and moonlighting)Days free of dutyAll residents1 day off per week, averaged over a 2 week periodMaximum Duty Length PeriodR116 hours*R2-324 hours*, with alertness management strategies encouraged Additional 4 hours maximum for transition of careMinimum Time Off between Scheduled Duty PeriodsR1Must have 8 hours Should have 10 hoursR2-3Should have 8 hours*Maximum Night Float FrequencyAll6 consecutive nightsMaximum In-House On-Call FrequencyAllEvery third night*According to the ACGME, In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. Under those circumstances, the resident must: appropriately hand over the care of all other patients to the team responsible for their continuing care; and, document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director. The program director must review each submission of additional service, and track both individual resident and program-wide episodes of additional duty. Residents and faculty must complete assigned training in fatigue recognition and mitigation. Residents who are too fatigues to safely return home may utilize the assigned call room or be reimbursed for taxi service under the Sparrow Hospital policy. Medical Records Documentation Requirements: Admission and discharge medications must be updated on the institutional medication reconciliation forms. Notes and H&Ps must be completed in timely fashion (eg, within 4 hours of evaluation). All telephone orders must be authenticated: the order must be entered by the accepting provider, read back to the physician, and documented by the accepting provider as read back; the order must then be electronically signed within 24 hours of origination. HIPAA rules apply to any release of information. Refer to the complete HIPAA orientation information from the applicable training site. Copies of dictated summaries should be directed to your clinic or to involved physicians offices without further specific permission from the patient, as necessary for usual patient care. Medical abbreviations can be a source of confusion and medical error. Due to risk for errors, note the following abbreviations are no longer acceptable; please use the noted alternatives in all orders: Abbreviation NOT ACCEPTEDMisinterpretationCorrection - AcceptedU or uMisread as a 0 (4U read as 40)unitIUMisread as IVunitsZero after a decimal (1.0 mg)Decimal not seen (1.0 read as 10)Never use a terminal zero. Write 1 mg.No zero before a decimal (.1 mg)Decimal not seen (.1 read as 1)Always use a zero before a fraction unitQ.D or Q.O.D.Decimals and D read as I or OWrite daily or every other dayMS, MSO4, MgSO4Confused for each otherMorphine Sulfate or Magnesium SulfateCC or ccMisread as umLgMisread as mgmcgB.I.W. or T.I.W.Mistaken for BID or TIDWrite for specific days of the week  History and Physical Examinations There is no definitive complete history and physical examination. At minimum, the following elements should be included: Chief Complaint, History of Present Illness, Past Medical and Surgical History, Social History, Allergies, Medications, Review of Systems, Physical Exam (including an osteopathic structural exam), Diagnostic Test Results, Assessment and Plan. Within the hospital electronic medical record, PMH and Sopcial History are entered into flowsheets that are supplemental to the notewriter form. Progress notes Daily notes should be in SOAP format using one of the hospital templates; the Internal Medicine Progress Note is preferred. Periodic chart audits will be done to evaluate quality of records. Discharge Summary The discharge summary is the responsibility of the resident who discharges the patient, and should be completed within 24 hours. Delinquent Medical Records Policy: Timeliness and quality of completion of medical records are important indicators of professionalism. Concerns will be forwarded from faculty to the residency staff (chief resident, site director or program director) as they arise. If incomplete documentation is not completed within 24 hours of the resident being notified (unless post-call), the resident will be suspended without pay from the residency program until all delinquent records are complete. Residents suspended from clinical duty because of delinquent records will not be available for call duty. Uncovered call nights will be covered according to the "illness" policy outlined in the resident manual, and residents must make up their missed calls. Residents are exempt from the delinquent records policy if, during the time a record becomes delinquent, the resident has an excused absence from the residency program. The resident will be notified of delinquent records on their return to the residency program and the delinquent record policy will be activated. The chief resident will notify medical records of the residents absence. Any resident suspended more than once in an academic year may be asked to appear before the Training Evaluation Committee and may be subject to disciplinary action. Procedures Regardless of the level of training, each resident must satisfy the following requirements prior to performing any procedure (see below for exceptions pertaining to life-threatening emergencies). The resident must: Be knowledgeable in the performance of the procedure, including: Indications Contraindications Anatomic considerations Patient evaluation and preparation Personnel and equipment Technique Specimen examinations and interpretation Post-procedure care Complications Obtain permission from the supervising attending physician Clarify with the attending physician the nature of the supervision the attending will provide (e.g., direct physical presence or indirect supervision without physical presence). While an attending physician may determine on the basis of a resident's knowledge, experience, and demonstrated ability that the resident no longer requires direct supervision to perform a given procedure, this applies only to the specified procedure and attending. As such, a resident must still obtain clarification on the nature of the supervision for other procedures or other attending physicians. Fully inform and obtain verbal and written consent from the patient (or legal guardian if the patient cannot provide informed consent) Have a chaperone of the same sex as the patient physically present in the room with the patient if the procedure involves the female breast (e.g., needle aspiration, skin biopsy), genitals (e.g., culposcopy, treatment of genital condylomata), anorectal area (e.g., anoscopy, flexible sigmoidoscopy). See below for the policy on chaperones for procedures or exams involving these organs. Perform and document a procedural Time Out whenever performing a procedure for which you have obtained informed consent. The Time Out includes confirmation and documentation of: Right patient Right procedure Site marking and confirmation of laterality Patients body position is correct for the procedure All necessary equipment is available Performing Procedures in Life-Threatening Emergencies: In the event of a life-threatening emergency, there may not be enough time to complete procedural requirements 2-6 above. Further, an unresponsive patient whose representative is not immediately available may require a life-saving procedure before consent can be given. Even under such conditions, the resident must be knowledgeable in the performance of the procedure and have a chaperone present when applicable. The resident should inform the attending physician as soon as possible following completion of the procedure, as well as the patient representative when applicable. Procedure Logs: Residents must record procedures in their ABIM Logbook. No procedures may be performed without direct supervision (by a credentialed physician) until the resident has been certified as competent by the residency office. Residents should document all procedures beyond the certification minimum, as they will reflect competence for Board-eligibility and will support competency documentation for future employment privileges. Procedure logs are reviewed during semiannual evaluations. The program will not certify residents for future employment procedure credentialing in the absence of procedure documentation. It is the residents responsibility to document performed procedures; failure to document procedural competence jeopardizes a residents Board Eligibility and will severely restrict future professional credentials. Sample of proper completed ABIM procedures book page  The MSU internal medicine residency requires the following minimum numbers for procedure competency documentation, in addition to evaluations of satisfactory performance: Required Knowledge and Performance of:Minimum number for competenceACLSContinuous certificationArterial puncture5Central venous line placement5Endotracheal intubation5 (osteopathic-allopathic only)OMMPer OMM (osteopathic-allopathic only)Pap and endocervical culture5Peripheral intravenous line placement3Venipuncture (drawing venous blood)3Required knowledge:As documented in Procedures Consult or if performs minimum number of procedures as belowArterial line placement5Arthrocentesis5I&D of abscess3Lumbar puncture5Nasogastric intubation3Paracentesis5Pulmonary artery catheter placement5Thoracentesis5Required knowledge and interpretation of:Minimum number for competence or other criteria:ECG interpretationPass ECG examExercise stress tests5 (osteopathic-allopathic only)Holter monitors5 (osteopathic-allopathic only) Chaperone Policy for Sensitive Examinations Please review policy  HYPERLINK "https://www.healthteam.msu.edu/intranet/Policies/PatientPrivacyDuringProcedures_v14_FINAL_Oct2017.pdf" CP-15 Patient Privacy, Chaperones and Informed Consent for Examinations, Treatments, or Procedures Chaperones: Patients or legal representatives are entitled to have a chaperone (informal or formal) present for any consultation, examination, treatment, or procedure where the patient considers it necessary. All providers are entitled to have a formal chaperone present at their discretion. Chaperones are required for sensitive exams, sensitive treatments or sensitive procedures unless a waiver is signed. For all sensitive exams, the clinic staff will either be present or the patient will sign a waiver. The HCA or staff member rooming the patient is responsible to make sure that the chaperone documentation is accurate and complete. There will be circumstances where the provider will be the responsible party completing the steps below. Providers will look at the P/E section of MSUHealth prior to beginning their encounter with the patient, to become aware of the Chaperone Status.  For all encounters where a chaperone is present, the chaperones name will be documented in the Chaperone Name section. For informal chaperones, documenting mother, father, etc. is acceptable and may be done by the rooming staff, if known, or by the provider. Formal chaperones will document their name.  Changes in chaperone status during an encounter can be completed by the HCA or the provider. Change from Non-Sensitive exam no chaperone required > Sensitive exam formal chaperone required requires the provider to stop and bring in a chaperone before the exam can proceed. Change from Non-Sensitive exam no chaperone required > Sensitive exam with informal chaperone can be changed by the provider, with the provider documenting the informal chaperone name. Change from Non-Sensitive exam no chaperone > Sensitive exam, patient declines a chaperone; waiver signed requires the provider to have a waiver signed before proceeding with the exam. Chaperone waiver signatures can be obtained by an HCA or the provider. Status change to Non-Sensitive exam patient/provider requests chaperone, requires the provider to stop and bring in a chaperone before the provider can proceed. The provider can always add additional information in the Notes field when necessary. Needle Sticks, Universal Precautions, And Blood Borne Pathogens All residents are required to maintain current training certification through the MSU HealthTeams online training programs in universal precautions and bloodborne pathogens. The training program is maintained by the MSU Office of Radiation, Chemical, and Biological Safety. All residents must obtain a passing score on the quiz at the completion of the online tutorial. Residents are notified when annual refresher recertification is required, and residents must respond promptly to notices for retraining. All portions of training, both the online modules and the worksite orientation and checklist, must be completed as assigned annually. During simulation training experiences at the MSU Learning and Assessment Center, universal precautions safety processes are emphasized and appropriate feedback is provided to all learners. At all times residents should use the risk reduction strategies and materials available both in the Clinical Center and Sparrow Hospital. If at any time any person, no matter their specific role, detects a resident or other provider engaging in practices that do not meet safety standards, that person must bring their concerns immediately to the Clinic supervisor, the nurse manager, the supervising attending, or the Program Director. At minimum, remediation of safe practices will be required. Needle Stick or High Risk Exposure Policy: Any person potentially exposed to a blood borne pathogen (through cut/puncture injury, open wound exposure, mucus membrane exposure, prolonged skin contact, or any other exposure of concern to the affected person) should first attempt to wash/flush the area for 15 minutes (with soap and water for skin contact, water or normal saline for mucous membrane exposure), then immediately report the incident to your supervisor. Procedures are location specific: At Sparrow Hospital, call the nursing supervisor on call. He/She will bring information/instructions to you. If the nursing supervisor is not available, go to Sparrow ER. At Michigan State, go to the Olin Urgent Care Clinic during business hours only; or the Sparrow ER after hours. At the urgent care facility you will have medical evaluation and laboratory follow up. If at any time you have concerns or questions, promptly notify your supervising attending, your chief resident, the program office, or all of the above. The program and the resources of the occupational health centers at each training center are designed to serve your health needs. YOU MUST NOTIFY GMEI Central office immediately after treatment (517) 432-4421 Updated information regarding HIV occupational exposure guidelines can be accessed through  HYPERLINK "http://www.cdc.gov/hiv/treatment.htm" www.cdc.gov/hiv/treatment.htm or  HYPERLINK "http://aidsinfo.nih.gov" http://aidsinfo.nih.gov. MICHIGAN STATE UNIVERSITY MSU HEALTHTEAM POLICIES AND PROCEDURES Subject: Patient Privacy, Chaperones, and Informed Consent for Examinations, Treatments, or ProceduresNo: CP- 15 eScope: All HealthTeam clinicsPage: 1 of 2Effective Date: 04/15/2017Last Review/Revise Date: 05/25/2017 10/2017 1/2018Responsible Department: Operations Policy MSU HealthTeam is committed to providing a safe environment for patients and staff. All patients are entitled to hav e t h e i r medical interactions conducted with appropriate privacy and confidentiality protections. Informed consent will be obtained for all treatments and sensitive examinations performed. Patients are entitled to have a chaperone ( i n f o r m a l o r f o r m a l ) present for any consultation, examination, t r e a t m e n t , o r procedure where the patient considers i t n e c e s s a r y . All p roviders are entitled to have a formal chaperone present at their discretion. Chaperones may be formal or informal, as identified in the Process. Chaperones are required for sensitive exams, treatments or procedures. Whenever possible, clinical staff members should serve as chaperones rather than f r o n t office staff or family members. Providers who are contracted to work in non- HealthTeam organizations must follow the policies of that organization. Purpose All medical interactions have the potential to be uncomfortable or difficult for patients. Sensitive examinations, treatments, or procedures may predispose patients to feelings of vulnerability and emotional discomfort. Patient r esponse to those feelings will vary based on individual beliefs, religion, culture and experience. Attention to privacy offers important benefits to both patients and providers. Definitions Chaperone: a parent, guardian, other caretaker, or a staff member. It may not be a student. Formal chaperone is a HealthTeam staff person or provider. Informal chaperone is a parent, guardian, adult significant other, or other caregiver consented to by the patient, as appropriate. Informed consent: An explanation of an exam, treatment, or procedure; reasonable alternatives; indications and contraindications; as applicable, and patient verbalized understanding of the discussion. Provider: Any person employed in the HealthTeam who provide consultation, examination, care, treatment, or procedures Sensitive examinations, treatments, or procedures: those that occur with the patient, whether disrobed, partially disrobed or in street clothing, involving the breasts, genitalia, or rectum Examples include: breast exams, procedures of the pelvic floor or urogenital diaphragm, vaginal or rectal exams. Universal Precautions: An approach to infection control. All human blood and certain body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens. Body fluids include: semen; vaginal secretions; cerebrospinal, synovial, pleural, pericardial, and amniotic fluid. Process Always employ appropriate disrobing and draping practices to respect the patients privacy. Do not allow medical students or other parties to observe sensitive examinations, treatment, or procedures without the patients informed consent. Universal Precautions should be followed for examinations, treatments, or procedures involving the genital, rectal or direct digital contact with oral mucosal areas. Notification to patients of availability of chaperones will be included in a clinics 'welcome letter' and posted in examination rooms. A clear explanation of the nature of any examination or treatment must be given to the patient. This explanation must also be provided to an informal chaperone when appropriate (e.g., pediatric patient or impaired patient who may be unable to understand or comprehend the explanation.) Informed consent will be obtained for sensitive examinations or treatments. Chaperones are required for all sensitive examinations, treatments or procedures For any physical examinations of a minor (including sensitive under age 11 years), the parent, guardian, or approved alternate should always be present and may serve as the chaperone. If they are unavailable or the provider has concerns with their ability to appropriately serve as a chaperone, a formal chaperone is required. Sensitive examinations of patients 11 years of age or greater require a formal chaperone. A formal chaperone will be made available to any patient upon the request of the patient. If one is requested and none is available at that time, the patient must be given the opportunity to reschedule their appointment within a reasonable timeframe. If a patient declines/refuses a chaperone for an examination where one is required the provider must document in the record that an offer was made and declined. The provider retains the final decision whether to proceed without a chaperone. If the provider proceeds with the examination, the patient or guardian must first sign a waiver. In the event a patient requires successive visits for the same sensitive examination, treatment or procedure, a single waiver documentation may be used, given that the duration of the waiver does not exceed twelve months. In the event a provider or clinic medical director believes there exists a compelling reason to waive components of this policy for specific types of patients, approval for that waiver must be requested and granted by the MSU HealthTeam Board, before such a waiver may take effect. References: AAP: Policy Statement Use of Chaperones During the Physical Examination of the Pediatric Patient Federation of State Medical Boards: Addressing Sexual Boundaries: Guidelines Centers for Disease Control and Prevention:MMWR 1988/37(24);377 Pager Policy Your pager should be on at all times during assigned duties. You are responsible for responding to pages within 15 minutes of receipt. Your pager receives both numeric and text pages). Be sure to check for messages on a regular basis and make sure your battery life is adequate. Above all, it is the resident's responsibility to insure that he/she or the covering resident - can be reached during on-duty hours. If you leave your beeper at home, immediately notify your clinic, the hospital operators and the residency office, and change your pager message. If you are not available by pager during inpatient/call rotations, you must sign out to a covering resident and change your pager message to reflect this. If you are not available by pager at other times (due to leave, presence in a shielded site such as radiology where pages dont go through), you must change your pager message to reflect this. (See below for instructions.) If your pager is not functioning, please contact hospital information technology/ telecommunications office to receive a new one. The same resident should never carry the 294 (firm senior) and 606 (ICU senior) pagers, which are also Code Blue pagers. To re-program your pager: Dial your pager number When you start to hear your greeting message, press 0 Enter your access code (4-digit number) Press 30 to change your greeting message When you hear the beep, enter a new message, such as: You have reached the pager of Dr (Self). Please enter your call back number after the beep and I will get back to you as soon as possible. Please stop. This pager is off until (Date/Time). All daytime calls for Dr. (Self) should be referred to Dr. (Covering) at (pager number), evening calls to (On-call resident for Internal Medicine) at (pager number). Press 1 to save your message Press 40 to listen to your newly recorded message Hang up Remember to restore you usual greeting message by the start of the next workday. Hospital Mobile Phones Each resident will provided with a portable phone (ASCOM or similar) to use while on ICU and FIRM. These phones are provided to help improve the rounding experience by allowing residents to receive callbacks anywhere within the hospital without the need to wait at the station. Each resident will be assigned a phone by the Chief at the beginning of the rotation, please note that rotators also receive a phone. A record of phone assignments will be maintained by the chief each block. In the event that a phone is lost or found to be damaged the person responsible will be assessed a nominal fee of $100.00. There are phones specifically for the on-call Firm and ICU residents, in addition ot the personal phones. These phones also receive calls for Code Blues. Charging bricks are available in resident call rooms and at nursing stations. Laptop Computers and Tablets for Firm Service The program provides a limited number of laptops and/or tablet devices to expedite patient care for residents on the Firm service. The chief resident supervises distribution of the devices. Residents must sign a contract to obtain one, and return the device at the end of the assigned block. There is a fee to replace lost or damaged devices, which is specified in the contract. Moonlighting Residency is a full time endeavor. Moonlighting must not interfere with residents achievement of the goals and objectives of their educational program. Moonlighting requires program director approval and is closely monitored. If at any time resident educational performance, professional performance, physical wellbeing, or emotional wellbeing becomes impaired, the program director may withdraw moonlighting privileges. Any work for pay that is not a standard part of the residency educational program is considered moonlighting. Types of moonlighting: Moonlighting may occur internally within the institutions that host the residency program. These are known as Supervised Extra Work Shifts, where residents work dependently, supervised by the attending physician of record, in activities that fall within the scope and practice of residency training. GMEI professional liability insurance will cover these experiences. A permanent medical license is not required for this type of work. These extra shifts are available only to R2 and 3 residents. The MSU Internal Medicine residency program does not require residents to moonlight internally, such that any internal moonlighting is an entirely voluntary experience of work for pay. Moonlighting may occur externally, defined as work outside the institutions that host the residency program OR work within the hosting institutions where residents are working independently OR supervised, dependent work within the hosting institution that does not fall within the scope and practice of internal medicine residency training. Scope and Practice determination for internal activities is at the discretion of the program director. GMEI professional liability insurance WILL NOT COVER any of these activities. A permanent MI medical license and written documentation of liability insurance coverage are required before any external moonlighting can begin. Residents are eligible for permanent licenses only after they have successfully completed two years of residency training. Moonlighting as a non-physician is defined as work that does not require possession of a physician license. All moonlighting, whether internal, external, physician, or non-physician, requires approval of the program director. This is an ACGME Program Requirement. Such permission must be provided by the Program Director in writing before a resident can engage in any outside work for pay activities. Moonlighting cannot begin until formal Program Director approval is obtained in writing. Completion of this process cannot be guaranteed faster than 2 business weeks; therefore residents should submit a request to moonlight at least 2 weeks prior to their desired moonlighting start date. Required before the program director will consider authorizing ANY moonlighting: The resident must be performing in a satisfactory manner in the residency program as defined by the Program Director, including conference attendance, completion of evaluations, completion of medical records, academic performance, and professional performance. Although results of the in training exam cannot be used to make advancement decisions, residents whose score is below the 25th percentile standardized for their training year will not be approved to moonlight. The resident will document moonlighting hours using a moonlighting hours documentation form, available under forms on the program website, and ensure that they are in compliance with the 80 hour rule at all times. In addition, the following are required before the program director will consider authorizing any external moonlighting as a physician: A permanent Michigan license on file in the residency office Documentation that the employer will provide malpractice insurance that is satisfactory to the Program Director Moonlighting is prohibited while residents are on core medicine rotations. These rotations include ICU, Firm, Hospitalist Medicine, and Night Float. These rotations include frequent calls and have significant patient care duties that could be compromised by any moonlighting activity. Furthermore, during ER blocks residents should restrict any moonlighting activity to their non-call days. All moonlighting residents must present documentation of scheduled moonlighting hours and total weekly work hours to the residency office for each block rotation within one week of the end of the rotation. This should be accomplished by submitting a block rotation moonlighting shift report to the residency office. This form is available via the residency program web site. Failure to document moonlighting and total work hours in a timely fashion will lead to revocation of approval. The program reserves the right to verify work hours by contacting moonlighting employers. Residents who violate this policy threaten the accreditation of the residency program and may also be in violation of Michigan and/or Federal law. As such, residents found to be in violation of this policy may be subject to harsh disciplinary action, including dismissal from the residency program. Related to Primarily Educational Activities Out-of-Residency Rotations Under special circumstances, a maximum of one out-of-town clinical rotation and one out-of-town clinical investigation rotation may be approved per resident during 36 months of training. For the 2nd out-of-town, its encouraged to be done within 90 mile radius so that more outpatients continuity clinics arent missed to meet the required 130 in 3 years. Final approval for OOT comes from the Sparrow med-ed office. The rotation will need to be either an experience that is not available locally, an opportunity to explore potential future practice site or fellowship training site, or other training criteria acceptable to the reviewers. Please note that because training opportunities through MSU are extensive, residents need to clearly express in writing why they are seeking to pursue a training experience out of town. Residents should consult with the residency office for advice prior to attempting to arrange such a rotation. Any resident requesting an out-of-town clinical rotation must provide the following information to the residency office: 1. A letter from the attending at the host-training site stating they have agreed to supervise the resident for this rotation with the involved dates. 2. A copy of the written curriculum and learning objectives for the rotation. 3. A written statement from the rotation host that a formal electronic evaluation of the resident will be performed at the completion of the rotation; the e-mail address of the evaluator must be included. After complete information is provided to the residency office, the inter-institutional financial and administrative agreements must be formalized by the program administrator, in conjunction with the hospital GME office, and the host-training site. Sparrow Hospital and the host institution must agree upon the provision of adequate general liability insurance, in keeping with the standards in the hospital industry, before a rotation can be approved. All papers must be presented to the program for review at least 16 weeks prior to any requested rotation. Creating New Curricula Residents may wish to pursue areas of particular interest. The MSU Internal Medicine Residency must ensure that newly developed training experiences satisfy educational expectations and requirements. Any request for a new elective experience requires a draft of a competency-based curriculum and a letter of support from the attending physician responsible for supervision and evaluation of the involved resident(s). These items are required for preliminary Program Director approval. Interested persons should contact the residency program office for more information regarding competency-based curricular development, and to obtain a checklist for the complete requirements for new curricula. If preliminary approval is granted by the Program Director, the involved resident(s) are then allowed to schedule and complete the training experience. During this preliminary rotation experience, the resident is required to make final edits to the new curriculum, including adding a statement on strengths and weaknesses, for final TEC submission and approval. This TEC review must occur before the end of that academic year in order to receive training credit toward completion of the year. Because final TEC approval must await a scheduled meeting of the TEC, and because final approval must be obtained in order to receive credit and therefore to advance or graduate, residents may not develop new curricula with the intention of performing the rotation in the final 2 blocks of their training year. Clinical Investigation Rotations Residents are allowed to perform up to 2 blocks of clinical investigation during their residencies. A resident requesting a block experience of clinical investigation must request, complete, and submit to the residency office all paperwork no later than 10 weeks (16 weeks for out of town experiences) prior to scheduled date of rotation for submission to the research director for approval. Refer to the website for the Clinical Investigation Request Form. Failure to complete or submit all required paperwork may result in your request not being granted. You are reminded that a change in rotation may result in a change in participation with training hospitals, so please contact the residency office for verbal approval to proceed before attempting to get signatures from attending physicians. The following papers are required for the request: Rotation Change Request Form (if you are not already scheduled for Clinical Investigation) and follow all rotation change policies regarding signatures. You are expected to continue your continuity clinic while performing clinical investigation in the Metro Lansing area. A letter from the resident stating his/her desire to do a clinical investigation rotation or continuity experience. In the letter he/she must identify: Name of clinical investigation mentor The clinical investigation topic The clinical investigation plan (that clearly delineates the residents role and should include): Background/Introduction Clinical investigation question Proposed methods including analysis The plan for documented daily patient contact. (for metro Lansing rotations only) Expected product of clinical investigation experience (e.g. paper or poster) A letter from the clinical investigation mentor, stating that the mentor has agreed to work with the resident and specifying: a) Clinical investigation topic Clinical investigation plan Plan for patient contact during the rotation. (for metro Lansing rotations only) Agreement to evaluate you at the end of the rotation on our evaluation for Please refer to forms that are available on the website at  HYPERLINK "http://www.im.msu.edu" www.im.msu.edu. Membership in Professional Organizations Residents are expected to become associate members of their core professional organization (American College of Physicians for all residents, and American College of Osteopathic Internists for osteopathic residents). Applications are sent to incoming residents with the contract and other entry materials. Membership allows residents to participate in regional and national meetings, present original research, access online resources (as for career guidance, practice management), and receive discounts on organizational products such as the MKSAP. Mentoring and Academic Advising Each R1 resident is assigned a faculty mentor on entry to the residency program. Residents may continue to work with their assigned mentor, or they may independently select a new mentor. Residents who choose to change mentors must notify the residency program office. The resident may also opt to have more than one mentor. Mentors serve as role models and advisors. Mentors help residents with issues of professionalism, scholarship, patient needs, meeting responsibilities, and continuous improvement. Mentors can also help residents with problems in or away from the hospital as well as future plans and scholarly activities. Residents are required to meet with their mentors at the beginning (within 90 days) of each academic year, and at least once more before the end of the academic year. Each R1 resident is also assigned a senior resident mentor at the beginning of the academic year. This individual is intended to help them navigate the system through judicious and practical advice and provision of moral support. Residents discuss issues of academic advising (career plans, study strategies, research opportunities, elective selection) during semi annual reviews with the program director and/or her designee. In addition, residents may discuss any or all of these issues with the assigned mentor, a core faculty member, or other faculty members. Residents are encouraged to schedule additional meeting with the program director as needed as well. Mandatory Counseling or Assessment The Training Evaluation Committee may mandate confidential counseling and/or neuro-psychiatric assessment for residents when resident performance indicates possible undue stress or neuro-psychiatric barriers to effective learning. Such assessment is intended to support the health and education of the resident learner, and will be specifically targeted to address the residents professional learning needs. Specifics findings of the health-related evaluations are not routinely available to TEC. Human Resources- also see the Sparrow Contract Personal Leave: Duration, Rotation Requirements, and Length of Training Each residents assigned vacation time, paid holidays, and educational leave are specified in the yearly contract. A resident may in rare circumstances be granted increased educational leave days, but not increased vacation time, at the discretion of the program director or his/her designee. Such leave dates would be approved only for attendance at special conferences that arise occasionally and are deemed in the best interests of the program (e.g. ACP meetings for presentations or competitions, APDIM for rising chief.) Unless specific permission is granted by the program director, personal leave cannot be taken on inpatient general medicine, ICU, Night Float, or 2 week rotations other than Ambulatory Medicine. Up to 1 week of leave may be taken from other 4-week rotations. Two week blocks of leave are possible only with special permission or by coordinating 1 week periods at the beginning and end of two consecutive 4-week rotations, or in combination with a 2 week rotation in a single block. Senior residents may elect to take a four-week block vacation in which 3 weeks of vacation can be combined with 1 week of educational leave or leave of absence with approval of the program director. The American Board of Internal Medicine stipulates that board-eligibility requires that a resident's training program must be extended beyond 36 months if the total time away from the residency program for any reason (vacation, sickness, leave of absence, parental leave, etc.), exceeds 3 months out of the 36 month total, or an average of one month per year. It is important for you to be aware of this rule as it may delay your graduation from the residency program and impact your availability to begin practice or fellowship training on July 1 of a given year. Requesting Personal or Educational Leave The resident must complete and submit the on-line absence form (available at  HYPERLINK "http://im.msu.edu/staff/resources/index.asp" http://im.msu.edu/staff/resources/index.asp ) for processing at the earliest time feasible. The program coordinator or her designee processes the request as follows: Received 3 blocks out or more: approved if leave time available and in compliance with rotation requirements (see below). Received 8-12 weeks out: reviewed with chief resident, approval not guaranteed. Received <8 weeks out: reviewed with chief resident; approval only considered in extreme circumstances. The resident may be asked to provide additional information to justify the leave. An e-mail will be sent to the residents HealthTeam e-mail account notifying the approval or denial of the request. The resident may appeal decisions by contacting the program director in writing. Absences due to Emergencies or Illness and Back Up Call In case of any unexpected absences, you MUST notify: the chief resident (by phone or page) your attending/senior resident (by phone or page) program coordinator (by email or phone). Notification should occur as soon as possible, preferably prior to the beginning of your daily duty period. Failure to notify the office of an absence prior to departure will result in time-off without pay that may affect your training schedule, and may also result in disciplinary action. The chief resident and/or residency staff will arrange back up coverage as needed for the absent resident. Abuse of the back-up call system is a serious violation of professionalism and will be reviewed by the Program Director for possible TEC evaluation. If the resident misses more than 3 days of duties due to illness or injury, s/he should be examined by a physician for a recommendation regarding duration of sick leave. Time missed from assigned duties due to emergencies or illness are deducted from personal leave time unless otherwise designated (see Benefits) At all times, at least one senior resident is designated to be on beeper call for back up call in case of an emergency or illness. (Junior residents may also be assigned as sick resident back up but may not substitute for a senior resident on inpatient services.) The Chief Resident assigns this responsibility. The sick call resident needs to be available to report for duty within 1 hour upon notice and must always be accessible by pager while on sick call. Professional Appearance, Attitudes and Behaviors In keeping with the programs Code of Conduct, resident physicians and faculty members are expected to maintain a professional appearance during assigned duties, while demonstrating professional attitudes and behaviors. Expectations for appearance include but are not limited to: wearing clean white lab coats during patient care activities displaying institutional picture ID badges above waist level avoiding visible body piercing jewelry (other than earrings) avoiding exposure of ones abdomen or breasts/chest maintaining neat, controlled hair keeping nails clipped short, without nail polish wearing closed toe shoes or boots conforming to minimum local standards for hygiene (deodorant, dental hygiene, etc) avoiding wearing scents (perfume, cologne, scented lotions) when involved in direct patient care wearing business casual or business clothing except when on-call or post call (e.g. no scrubs, tennis shoes or jeans in clinic or on non-call days) avoiding wearing clothing with logos or slogans. Professional attitudes and behaviors include but are not limited to: acting with courage, humility, and mercy being honest demonstrating compassion and respect for others accepting responsibility for our actions working well with others striving to achieve the best possible outcomes(from the viewpoint of patients, team members, and society) in any situation engaging in continuous learning and improvement through dialogue, reflection, and practice Angry resident outbursts, abuse or disciplining of other health professionals, and avoidance of responsibilities are unprofessional behaviors and will lead to adverse consequences. Similarly, hostile or abusive behavior by a supervisor is unprofessional; such occurrences should be reported immediately to allow for intervention. Accrediting and certifying bodies such as the ABIM and AOA require that the program director make a judgment about the professional behaviors of residents and to certify that their behaviors reflect the organizations high standards. Resident Counseling and Support Services Counseling is available to residents through the following systems: Sparrow CARES Employee Assistance Program (364-2626) Sparrow Hospital Human Resources Department (364-5858) Residents may also contact: Program Director: Dr. Rayamajhi or Dr. Gulick Associate Program Director: Dr. Nazia Khan Program Core Faculty: Drs. Smith, Freilich, Sharma, Nabeel, or Kavuturu Faculty mentors Other faculty Sparrow VPME : Dr. Ted Glynn MSU Assistant Dean for GME: Dr. Randy Pearson NB: Contact numbers are available on the pager card or through the Sparrow Operator. Physician Impairment In conjunction with the hospital, our program offers educational conferences to address physician impairment and substance abuse. Reporting a fellow health professional is an uncomfortable task, but it is necessary to protect public safety and is required by law. Keep alert for the following signs of potential impairment in a colleague who: Has become more irritable, defensive, moody, easily angered and defensive during normal working routines Is frequently tardy or misses work because of illness or oversleeping Starts missing appointments, submits work late or with unacceptable errors on an increasing basis Seems to be withdrawing more, both personally and professionally Has become depressed or has expressed guilt about drinking or drugs Smells of alcohol or has personal hygiene problems To protect the public and to facilitate the identification and rehabilitation of an impaired physician colleague, residents are instructed to use the following process if they encounter a physician (attending or resident) or other health professional whose behavior is suspicious of substance or alcohol use. The resident is obligated to: Immediately notify the following people to protect the patients and staff: The nursing supervisor on duty The supervising Department Chair Write a detailed report of the incident and provide copies to the department chair as well as to his/her own residency director. Individuals who suspect impairment in a fellow health professional should report their significant concerns even if they are not certain that the behaviors they have observed reflect true impairment. The program director and other administrative officials will assist in determining the likelihood of impairment and whether additional action is required. The confidentiality of all parties will be respected and protected according to standard procedures in such matters. The MSU GMEC institutional policy is available online. The hospital has policies regarding concerns of possible physician impairment. Detecting and immediately reporting these concerns helps protect patients and coworkers, and ultimately will lead to helpful intervention for the individual suspected of impairment. In addition, the State of Michigan Department of Consumer and Industry Services (CIS) developed the Health Professional Recovery Program (HPRP) to assist in the identification and rehabilitation of impaired health professionals. More information is available by calling 1-800-453-3784. The training program has a responsibility to society, the community, patients and residents. If it appears to be in the best interest of the resident and the program, a remediation and rehabilitation program will be designed for the resident suffering from a substance abuse problem. However, for the resident to re-enroll in the training program, he/she must agree to and sign an Impaired Resident Re-entry Agreement. An example of that agreement follows: IMPAIRED RESIDENT RE-ENTRY AGREEMENT Xe "Impaired Resident Re-Entry Agreement"  PREAMBLE Recognizing its responsibilities to its residents and to society, Michigan State University's Internal Medicine training program will make every effort to assure that the rights and well being of both are maintained. This is especially difficult to accomplish in the case of an impaired resident seeking re-entry to the Internal Medicine training program since on the one hand support and rehabilitation for the resident are vital, and on the other hand patients and society must be protected from potential harm. It is imperative that an agreement is formed between the Internal Medicine training program and the impaired resident to clarify requirements for re-entry and continued enrollment, and to protect the rights and privileges of all parties involved. AGREEMENT I, __________________________________________ understand that my re-entry and continued status as a resident in the Internal Medicine training program at Michigan State University is based upon my agreement to accept and comply with the following statements. 1. I hereby waive my rights of confidentiality as they relate to issues of alcohol or drug abuse. I understand that this waiver applies to any person or institution that may be involved in my medical education as long as I am enrolled as a resident in the Internal Medicine training program at Michigan State University. This waiver will extend to any future recommendations made by the Internal Medicine training program to residency programs, hospitals, potential employers, etc., as such future recommendations relate to my status and performance as a resident in the Internal Medicine training program at Michigan State University. 2. I agree to participate in a surveillance system that may include monitors in the hospital, in the home, in the Lansing Assistant Dean's Office and from Alcoholics Anonymous. 3. Regular attendance (two or more times a week) to Alcoholics Anonymous meetings is mandatory. 4. Total abstinence from all mood-altering substances (unless as a patient in the hospital under medical supervision) is mandatory. 5. I accept immediate suspension from all clinical activities upon any suspicion of relapse. A procedure of confirmation will take place shortly thereafter (e.g., a laboratory test) and if a relapse is confirmed I accept dismissal XE Dismissal"  from the Internal Medicine Residency training program. If relapse is not confirmed, my clinical activities will be immediately re-instituted. 6. Random, unannounced urine checks for alcohol and drug screening may be required. 7. The ultimate responsibility for the cost of any laboratory test for alcohol or drug screening is mine. However, when possible, the Office of the Assistant Dean for Lansing will make every effort to assist in the payment of such laboratory tests. 8. Failure to comply with any of the above procedures will be grounds for my dismissal XE Dismissal"  from the Internal Medicine residency-training program. I have read and understand the above statements and fully accept each of them. RESIDENT ________________________________________ Date _____________ WITNESS __________________________, Program Director Date ______________ WITNESS __________________________, Department Chairman Date ______________ The most important factor in avoiding complaints of sexual harassment from others is to be able to see the world from their perspective and to be sensitive to what is comfortable and appropriate to them. What can be a welcome form of communication or contact in one culture or family can be unwelcome and inappropriate in a working relationship with teachers, patients, peers and students. The following guidelines are recommended: Ask if you think something you do or say is being perceived as unwelcome. If the answer is yes, apologize and stop it. Be aware that sexual remarks or physical conduct of a sexual nature can make some people uncomfortable even if you wouldn't feel this way yourself. People are different. Learn to: Respect these differences. Do not repeat the behavior if you have been told it is not wanted Do not take the risk of discovering that your behavior is, indeed, objectionable to another If you are in doubt, stop the behavior. Any resident who feels that s/he has been subjected to sexual harassment should immediately advise the Program Director so that the matter can be investigated and action taken. If the alleged offender is the Program Director, the resident shall advise the Chairperson of the relevant academic department at MSU so that the matter can be investigated. As a general principle, the resident should inform the next highest administrator above the alleged offender. The MSU Designated Institutional Official (Assistant Dean for GME) may also be notified directly by any resident; see the MSU GME policy statement. Any resident who makes a complaint of harassment or provides information related to such a complaint will be protected against retaliation. The confidentiality of the reporting individual will be maintained to the extent possible. All complaints will be reviewed with the relevant Human Resources staff regulating the site at which the complaint is relevant. Any incidents in which a resident is accused of sexual harassment will be thoroughly and impartially investigated by the Program Director in cooperation with the appropriate Employee Assistance officials at the relevant worksite, according to worksite and University sexual harassment policies. Residents whose behavior is considered consistent with sexual harassment will be subject to immediate corrective action, and may be subject to immediate dismissal at the judgment of the Program Director. The Dean of the College of Human Medicine is committed to the goal of creating a work environment in which students, residents, faculty, and staff can be communicative, supportive, and sensitive to each other. Sexual Harassment Sexual harassment is not tolerated. It is a violation of federal law. Sexual harassment as a behavior is defined as unwelcome (unwanted, uninvited) behavior of a sexual nature including unwanted touching, fondling, or hugging; behavior which has the purpose or effect of unreasonably interfering with an individuals work performance or which creates an intimidating, hostile, or offensive work environment; or direct or implied threats that submission to sexual advances is a condition for education/employment or educational/employment rewards or advancement. Any sexually harassing behavior including physical actions, offensive language, displays of offensive written material, and nonverbal offensive behaviors, will be fully investigated. MSU Diversity Resources The MSU Internal Medicine Residency supports diverse patient and physician interactions. Multicultural support groups and resources are available through the MSU Diversity office:  HYPERLINK "http://www.inclusion.msu.edu" http://www.inclusion.msu.edu. Maintaining Contact Information You must notify the office of any change in address or phone number in writing by filling out the Change of Occurrence form found on the residency website. Correct contact information is critical to Program administration. E-mail HealthTeam Account: A secure MSU HealthTeam e-mail account (hc.msu.edu and ht.msu.edu are interchangeable) is provided to all residents. The HealthTeam email is accessible over the Internet from remote sites at  HYPERLINK "http://www.hit.msu.edu" www.hit.msu.edu . This account cannot be forwarded. All residents are expected to check their e-mail at least daily unless on leave. You are responsible for the information in e-mail messages sent from the residency office; failure to respond to instructions in e-mail communications from the residency office staff may result in incident reports and/or negative evaluations for professionalism. MSU university account (aka MSU NetID): This email allows you to access university resources such as the electronic library, and is also called you . The address ends .msu.edu. Emails from this account may be forwarded to another account, such as the HealthTeam one. Sparrow Account: A secure Sparrow account (@sparrow.org) is also assigned to you. Hospital specific announcements and requirements may be sent to this account. Residents are responsible for all information sent to it. As a secure account, it cannot be forwarded. SECTION 9 BENEFITS also see Sparrow Contract Compensation Other Benefits Leaves of Absence Compensation Salary: Paychecks are issued every other Friday through the GMEI. We require direct deposit. Your check stub will be e-mailed to an email of your choice. Salaries are universal for the level of training, and residents receive an annual written contracted salary statement. Paid Personal Leave: First-year residents are eligible for 3 weeks (15 working days excluding weekends) of paid personal leave. Residents in years 2-4 are eligible for 4 weeks (20 working days excluding weekends) of paid personal leave. Residents may not forego personal leave time to make up a deficit in training time. Paid Holidays and Alternative Religious Holidays: follow Sparrow contract Paid Educational Leave: Educational leave, a maximum of 5 working days with pay, will be allowed per year when approved by the residency office. Educational leave is not considered vacation, and is approved for educational and professional opportunities. Education Fund: Residents annual allotted educational funds are stipulated in their Sparrow contracts. The funds may be used for books, journals, medical software, professional equipment, ABIM exam registration, or other professional and educational costs. These funds may also be used for attendance at educational meetings and conferences, including associated costs for transportation, housing, and registration Other Benefits Medical and Pharmacy Licenses: A temporary Michigan license and Michigan Board of Pharmacy license are required. The residency program covers the fees for these licenses. Liability insurance: The associated training sites provide resident malpractice insurance for patient care provided as part of the training experience. Liability for moonlighting external to the training sites is not covered and is the responsibility of the moonlighting resident. Health Insurance: Medical and Dental insurance are both provided for each resident, spouse, and dependent children. Hepatitis B vaccination will be reimbursed if necessary. Life Insurance: See the resident contract for details. White Coats: White coats are provided free. Food: On-call meals and some lunches are provided by the hospital when on duty. Sparrow Resident ID cards are loaded with funds at the beginning of the academic year only. Funds should be used only for residents personal consumption. Parking: Parking is provided free of charge at Sparrow Hospital. Residents must park on floors 4, 5 or 6 of the main ramp on the west side of the hospital. You will be issued a sticker and/or gate card by the security department. You must purchase a parking sticker to park on the MSU campus and register your vehicle at the Department of Public Safety. This requires a letter from the GMEI office confirming your employment on campus, and your automobile registration. Do not park in the patient/visitor lot in front of the MSU Clinical Center, in order to ensure patient access. Clinical Faculty Appointment at Michigan State University: As a University-based medical resident, you are appointed as a Michigan State University faculty member at the level of instructor. Faculty status provides numerous benefits for you and your family. The vast facilities at MSU are available to you at low or no cost. Your faculty/staff ID card can be used to obtain athletic tickets, lecture or concert series tickets, library privileges, and use of recreational facilities (pools, intramural sports buildings, golf, and tennis). The University library is available to you on campus, with its science component in the basement. This is a good source of medical literature, and a health services librarian is available. You may also access the electronic library using your MSU NetID. Moving Loans: Zero-interest loans to cover moving expenses at the beginning of the residency are available. (See Sparrow contract) Resident Clinical Investigation Support: Limited funds are available to support Clinical Investigation-related and scholarly activities, such as attendance at meetings for the purpose of presentation, research supplies, or publication fees. These funds are distributed to residents to reimburse meeting registration fees and other reasonable expenses. The total amount available per resident varies based on total resident meeting participation. Speak with the program director regarding the reimbursement policy. Leaves of Absence Family and Medical Leave Act (FMLA): Leave may be granted for the following reasons under FMLA: The birth of your child if the leave is completed within twelve (12) months of the date of birth of the child; The placement for adoption or foster care of a child with you if the leave is completed within 12 months of the date of placement of the child; To care for an Eligible Family Member if that individual has a Serious Health Condition; For your own Serious Health Condition that renders you unable to perform the essential functions of your job; Qualifying Exigency Leave this leave is taken because of a Qualifying Exigency arising out of the fact that a Military Member in your family is on Covered Active Duty Status (or has been notified of an impending call or order to such covered Active Duty) in the Armed Forces; or Military Caregiver Leave this leave is taken because a Covered Service member in your family has a Serious Illness or Injury and needs your care. Paid Leave will be considered for employees that have a Serious Health Condition, including the birth of your child, while under a doctors care. Please see the GMEI Policy and Procedure on Family and Medical Leave Act at:  HYPERLINK "http://gmei.msu.edu/images/FMLA_PP_10-31-14.pdf" http://gmei.msu.edu/images/FMLA_PP_10-31-14.pdf. FMLA paperwork should be completed with the GMEI staff. Vacation time cannot be forfeited to meet training requirements. Leave may require extension of the training program. Paid Bereavement Leave: In the unfortunate event of the death of an immediate family member, a resident is eligible for up to three days of paid bereavement leave. The bereavement leave must be requested and taken within two weeks of the death of an immediate family member. If a resident wishes to take time off due to the death of an immediate family member, the resident should notify the Residency Program Administrator. Approval of bereavement leave will occur in the absence of unusual departmental requirements. A resident may, with Program Administrator approval, use accrued paid time off benefits for additional time off as necessary. Immediate family members are defined as follows: Spouse or person occupying the place of a spouse in the household Resident's and/or spouse's child Resident's and/or spouse's parent Resident's and/or spouse's grandparent Resident's and/or spouse's brother or sister A miscarriage will be covered under this policy according to the following criteria: The pregnancy was previously confirmed by a physician, and there is a subsequent and involuntary termination of the pregnancy (as verified by a physician);. Bereavement pay will be granted to the parent(s) only, and will not apply to other family members. Leaves of Absence without Pay: A leave of absence without pay may be granted with approval of the program director, and may be subject to restrictions under FMLA. A leave of absence will generally delay advancement to the next training level and/or completion of the residency training. Time off without pay is only available with the Program Directors approval after all accrued paid time off benefits have been exhausted. Residents who are determined to be absent from assigned duty without prior permission may be determined to be absent without pay, and their payroll will be appropriately reduced. Other administrative actions up to and including dismissal will be taken as determined appropriate by the Program Director and/or TEC. SECTION 10 LEGAL POLICIES DEA Numbers Medical Licenses Compliance Requirements Liability DEA Numbers All physicians who prescribe controlled substances in Michigan are required to register with the State Board of Pharmacy and use an appropriate controlled substance number on all prescriptions for such substances. The appropriate controlled substance number to use depends on the practice site from which the prescription is generated. You will be provided with your unique number for the hospital a Sparrow "AS number. This can only be used for patients receiving care from you at Sparrow Hospital. Controlled substances must be prescribed under your attending physicians license in non-hospital settings. Residents (in R3 or later) who choose to get a permanent license will also need to apply for a permanent DEA license that can be used at any institution. Drugs are classified into 5 schedules depending on the potential of that substance to produce dependency. Schedule I: Investigational drugs (heroin, marijuana, LSD, peyote, mescaline) Schedule II: Narcotic analgesics, local anesthetics, sympathomimetics, stimulants Schedule III, IV, V: Sedatives, anticonvulsants, cough and cold preparations, antidiarrheal agents Please note that schedule II drugs may be written for a maximum of 30 days supply, and may not include refills. These medications require a paper prescription that meets State of Michigan legal requirements. Medical Licenses A temporary Michigan license and Michigan Board of Pharmacy license are required. Hese are valid only for patient care you provide under supervision of a fully licensed physician. The residency program will apply for your renewals of temporary medical and pharmacy licenses, and will assume the cost for these temporary licenses. You may apply for a permanent license following satisfactory completion of two years of residency training. You cannot be involved in patient care without a valid medical license. Documenting resident licensing: All newly appointed Internal Medicine residents will be sent a package of licensing materials including an application for a temporary educational license and Michigan Board of Pharmacy license. Fill out the application forms immediately and return to the residency office for processing. Before the new residents are allowed to begin clinical rotations, the Board of Medicine must approve their medical and pharmacy licenses. The residency office will track the progress of the application and notify the resident when the licenses are approved. Each year the residency office will receive renewal forms for medical and pharmacy licenses for current residents (R2 and R 3). The residency office will complete and submit for July 1st renewal. Residents who acquire a permanent medical license must obtain their own unique DEA number and supply this information to the office. Residents who fail to supply the required information will be subject to certain sanctions of increasing severity including dismissal from the residency program. Compliance Requirements Training: Resident physicians must complete training on Hazards in the Work Place, Universal Precautions, and HIPAA Compliance. The residency office will provide the resident with information necessary to complete the training, either online or at a face to face session. Hepatitis B Vaccination: Hepatitis B vaccination is strongly recommended for all residents and will be provided at the expense of the residency program. Initial vaccination is given at the time of your physical examination and it is the responsibility of the resident to keep track of and complete the vaccination series. Present vaccination documentation to the residency office, where it will be kept in your file. If you had hepatitis B vaccination prior to entering the residency, you must provide written proof. Those wishing to decline this vaccine will need to sign a waiver. BCLS/ACLS Certification: Certification in BCLS and ACLS must be maintained at all times. The residency office must have a copy of your current certification cards. You cannot be involved in patient care in the hospital without current BCLS and ACLS certification. The residency program has contact information for recertification training and testing. Liability Because residents are limited-licensed physicians, attending physicians are ultimately responsible for the care you render. If you become aware of a situation in which a patient becomes angry, or in which a patient has been or feels to have been injured or not adequately cared for, report this immediately to your attending physician. No student or resident should give solicited statements or testimony to anyone (attorneys, insurance companies, the press, TV, radio). Report requests for such statements to your attending and the Program Director, who will arrange appropriate legal counsel. The following reflect prior legal opinion regarding resident testimony in legal proceedings: Any doctor of medicine may testify at legal proceedings. Licensure is not a prerequisite. A resident can serve as an expert witness if it can be established that he/she has special knowledge or expertise. A resident may testify as to his/her own acts and observations. If the attending is also legally involved, he/she can and should witness the resident's testimony as well as review transcripts prior to his/her own testimony. All patients are legally the responsibility of the attending physician, but can concurrently be the legal responsibility of a resident physician. The key factor in determining negligence is the degree to which the attending controls the resident's work: if that work is "controlled" the attending is responsible for the resident's negligence; if not, the responsibility is shared (unfortunately there is no explication of control). Our member institutions provide professional liability insurance for program residents. To comply with the liability policy, any "away" elective must have prior program approval. The Program Director must sign an official form for this purpose at least two months prior to the onset of the elective. Failure to meet this requirement will mean that the resident will not be insured for that period of time. Residents must contact the Program Director when a risk is perceived or legal counsel is felt to be needed for activities performed in the scope of resident activities. The Program Director (or Director of Medical Education) will arrange appropriate follow up. SECTION 11 CONTRACTED INSTITUTIONS Michigan State University E. W. Sparrow Hospital and Sparrow Health System MICHIGAN STATE UNIVERSITY: The MSU Clinical Center contains a modularized 80-room ambulatory care center with supporting radiology and laboratory facilities. Additional MSU practice sites include The MSU Breslin Cancer Center and offices within the Eyde Building and Sparrow Professional Building. Clinical faculty members maintain privately-owned offices across the Greater Lansing area. The residency program office is in B-301 Clinical Center. Extensive MSU information is online at  HYPERLINK "http://www.msu.edu" www.msu.edu. SPARROW HOSPITAL: President and CEO: Dennis Swan Vice President of Medical Education: Ted Glynn, MD Medical Education Office: (517) 483-2580 Facilities Physician Communication Center/Attending Lounge, Medical Records - Lower Level ED 1st floor -west wing ICU, CCU 3 West Neuro Care Unit (NCU) 10 West Cafeteria/basement: open 24 hours a day Caf/hospital lobby Call Rooms/Resident Lounge - 3 Foster and ICU senior on 3 West Laundry - deposit and pick up in call rooms Library Sparrow Professional Building 1st floor ; 24 hour ID card pass system entry Parking Use the labeled spots on the West Parking Deck. Residents on elective may use the Sparrow Professional Building Parking Deck for Grand Rounds only. Phone - dial "0" to get operator; dial 9 for an outside line  SECTION 12 RESIDENTS AS TEACHERS Student Performance Expectations R1 Resident Teaching Expectations R2 and R3 Resident Teaching Expectations Residents as Teachers Striving for excellence in the teaching and mentoring of medical students is a powerful way to improve your own skills, as well as assisting the program in the recruitment of qualified students into our residency program. Remember, in all of your attitudes and actions, you are representing the residency program. Every interaction you have with medical students teaches them something: about you and how you see the world, including the field of internal medicine and this program. If you feel good overall about your career choice of internal medicine and being in this program, make sure your words and behaviors reflect that reality, even when you are tired and stressed. If you dont feel good about your current life situation, speak with the Program Director to explore ways to improve your job satisfaction rather than venting frustrations at medical students, who are an important and vulnerable point in their own career planning. Our goal in interacting with medical students is to provide them with: A stimulating learning environment Outstanding examples of role models A positive relationship with an internal medicine physician in-training A feeling that their potential is recognized and supported A sense that they are valued colleagues in our program, rather than inconvenient additions to our workload A sense of the strengths of our program A sense that we would be happy to have them join our residency when they graduate All residents attend PEERS Day, an MSU-wide residency teaching development workshop, as R1s. We encourage you to utilize the skills acquired during all teaching interactions. Be a kind, supportive, and courteous host. Treat those you supervise like they are your best customers. Remember that many of these students are new to the inpatient environment and will need your support to deal with the stress of acute illness, death, and difficult medical or psychosocial issues. Student performance expectations: The clerkship directors will review the expectations for students performance at the beginning of the year. Additional questions or concerns may be forwarded directly to them or to the clerkship administrator. R1 resident teaching expectations: Orient the students to the teaching service. Work and attending rounds: time and purpose How to interact with unit clerk and other staff Show the student the various sources of patient information that need to be reviewed. Patient orders and progress notes Nursing notes Medication sheet and vital signs Computers (lab, x-rays) Show the student how to organize data and how to incorporate into a progress note. Show the student a systematic way to write orders. Allow students to write orders on their patients (or your patients) with your review, feedback, and co signature. Explain rationale behind orders that are written on their patients, and your patients Review daily progress notes written by the student with the student. Concentrate on proper organization, completeness, and assessment and plan. Student notes do not replace resident documentation. Watch the student examine patients. The proper exam sequence (inspection, palpation, percussion, and auscultation) and the use of appropriate branching steps characterize a "complete" exam. Allow the student to respond to calls regarding their patients. Ask the student to evaluate the patient, formulate a diagnostic and therapeutic plan, and orders to implement the plan. Pending your approval, allow the student to implement the plan. Give the student meaningful patient management responsibility. Avoid assigning the student unrewarding, non-educational, service driven tasks. Give the student face-to-face feedback on a weekly basis. At every opportunity, offer the student encouragement, support and constructive feedback. R2 and 3 medical student teaching expectations: Assign student to a first-year resident for immediate supervision if relevant. Assign at least two new patient evaluations per week per student. Read and give person-to-person feedback on history and physical examinations. Assign readings to students regarding their patients, preferably from standard textbooks. Review reading assignment the following day with the student. Review each ECG ordered on any patient on the teaching service with the medical students. By the end of the rotation, expect the student to read the ECG unassisted. Review each chest x-ray ordered on any patient on the teaching service with the medical students. By the end of the rotation expect the student to read the chest x-ray. Review oral case presentations performed by the student. Concentrate on organization and conciseness. Prepare the student for attending rounds presentations. Allow the student the opportunity to present to the attending. Protect the student form unrewarding, non-educational, service driven tasks. Give the student face-to-face feedback on a weekly basis. At every opportunity, offer the student encouragement, support and constructive feedback. R3 special teaching expectations: R3 residents are considered senior scholars for their resident peers. R3 residents should also assist R2 residents in their growth as leaders and educators. See section 4 regarding special R3 responsibilities, and refer to the Core Curriculum graded learning objectives. Michigan State University Internal Medicine Clerkship Sample evaluation form (completed by students about residents) Subject: Evaluator: Site: Period: Dates of Activity: Activity: Lansing - CPE & Preceptor Evaluations (MED 608) Evaluation Type: Clinical Educator Evaluation information entered here will be made available to the evaluated person in anonymous and aggregated form only.Faculty Preceptor Evaluation Your honest and constructive feedback is essential for helping our faculty and residents improve their teaching. Critical and Constructive Comments (Question 1 of 14 - Mandatory) Did the preceptor review your H & P and provide critical and constructive comments? NA Never Sometimes Always 0 1 2 3 4 5 Physical Findings (Question 2 of 14 - Mandatory) Did the preceptor confirm your physical findings? NA Never Sometimes Always 0 1 2 3 4 5 Progress Notes (Question 3 of 14 - Mandatory) Did the preceptor review and critique your progress notes? NA Never Sometimes Always 0 1 2 3 4 5 Expectations (Question 4 of 14 - Mandatory) Did the preceptor orient you to their expectations? NA Never Sometimes Always 0 1 2 3 4 5 Discussion/Guidance (Question 5 of 14 - Mandatory) Did the preceptor make him/herself available to you for discussion/guidance? NA Never Sometimes Always 0 1 2 3 4 5 Interested and Supportive (Question 6 of 14 - Mandatory) Did the preceptor seem interested and supportive of your efforts on medicine? NA Never Sometimes Always 0 1 2 3 4 5 Role Model (Question 7 of 14 - Mandatory) Did the preceptor facilitate your opportunity to learn on the medicine clerkship through discussions, lectures, and role modeling? NA Never Sometimes Always 0 1 2 3 4 5 Responsibilities (Question 8 of 14 - Mandatory) Did the precetor allow you to become part of the health care team by entrusting you with important and meaningful responsibilities? NA Never Sometimes Always 0 1 2 3 4 5 Performance Feedback (Question 9 of 14 - Mandatory) Did the preceptor provide feedback on your performance? NA Never Sometimes Always 0 1 2 3 4 5 Diagnostic Impression (Question 10 of 14 - Mandatory) Did the preceptor encourage you to commit to a diagnostic impression when discussing a patient? NA Never Sometimes Always 0 1 2 3 4 5 Case Presentation (Question 11 of 14 - Mandatory) Did the preceptor encourage you to discuss your rationale during case presentations? NA Never Sometimes Always 0 1 2 3 4 5 Adequate Feedback (Question 12 of 14 - Mandatory) Did the preceptor provide adequate feedback concerning your ability to accurately and reliably identify important clinical data? NA Never Sometimes Always 0 1 2 3 4 5 Positive Characteristics (Question 13 of 14 - Mandatory) Did the preceptor exhibit characteristics you want to emulate as a physician? NA Never Sometimes Always 0 1 2 3 4 5 Comments (Question 14 of 14)  SECTION 13 INFORMATION TECHNOLOGY Program Website Electronic Health Records Electronic Evaluation System: New Innovations Web-based Schedules Additional Information Technology Resources Residency Program Website The MSU Internal Medicine Residency Webpage,  HYPERLINK "http://www.im.msu.edu" www.im.msu.edu, is a source of diverse information including links to the numerous resources you will see noted below. Consider making this your homepage. Curricula, Basic Science Research information, the residency calendar, required forms, EMR access, the call schedule, and educational resources are all within easy reach from the programs home page. Electronic Health Records Residents will be trained in and become regular users of the Athena ambulatory Electronic Health Record (EHR) system. Athena is operational at the MSU Clinical Center. It is also available over the Internet remotely to residents using the  HYPERLINK "http://www.msuhealth.hc.msu.edu" www.msuhealth.hc.msu.edu under google chrome. During orientation, residents are introduced to the Sparrow Hospital Epic electronic health record (https://remote.sparrow.org/) and IMPAX for radiology viewing. Further information and training is available through the hospital as needed. Consult with the help desk for further information. Electronic Evaluation System: New Innovations Residents are trained in use of web-based evaluation systems. Link can be found at  HYPERLINK "http://www.im.msu.edu" www.im.msu.edu home page. Duty hours and conference attendance are tracked using New Innovations. Conference schedules and curricula are available through this system as well. Web-Based Schedules The master block, clinic, on-call and day off schedules are available at  HYPERLINK "http://www.amion.com" http://www.amion.com. Please contact the chief resident or residency office for log in information. Information Technology Resources Medical librarians skilled in computer-assisted information retrieval are available for personal guidance and literature search assistance at Sparrow Hospitals onsite library and at the MSU campus library. For the MSU online library resources go to:  HYPERLINK "http://er.lib.msu.edu/" http://er.lib.msu.edu/ SECTION 14 INFORMATION FOR ATTENDINGS Teaching Attending Billing Documentation Attending Responsibilities Teaching Attending Billing Documentation 2002 Medicare examples of minimally acceptable documentation for Evaluation and Management (E/M) Services of Teaching Physicians: Scenario 1 The teaching physician personally performs all the required elements of an E/M service without a resident. In this scenario the resident may or may not have performed the E/M service independently. In the absence of a note by a resident, the teaching physician must document as he or she would document an E/M service in a non-teaching setting. Where a resident has written notes, the teaching physicians note may reference the residents note. The teaching physician must document that he or she performed the critical or key portion(s) of the service and that he or she was directly involved in the management of the patient. For payment, the composite of the teaching physicians entry and the residents entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician. Scenario 2 The resident performs the elements required for an E/M service in the presence of, or jointly with, the teaching physician and the resident documents the service. In this case, the teaching physician must document that he or she was present during the performance of the critical or key portion(s) of the service and that he or she was directly involved in the management of the patient. The teaching physicians note should reference the residents note. For payment, the composite of the teaching physicians entry and the residents entry together must support the medical necessity and the level of the service billed by the teaching physician. Scenario 3 The resident performs some or all of the required elements of the service in the absence of the teaching physician and documents his/her service. The teaching physician independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident. In this instance, the teaching physician must document that he or she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient. The teaching physicians note should reference the residents note. For payment, the composite of the teaching physicians entry and the residents entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician. Following are examples of minimally acceptable documentation for each of these scenarios: Scenario 1 Admitting Note: "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care." Follow-up Visit: "Hospital Day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident's note." Follow-up Visit: "Hospital Day #5. I saw and examined the patient. I agree with the resident's note except the heart murmur is louder, so I will obtain an echo to evaluate." Scenario 2 Initial or Follow-up Visit: "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note." Follow-up Visit: "I saw the patient with the resident and agree with the resident's findings and plan." Scenario 3 Initial Visit: "I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs." Initial or Follow-up Visit: "I saw and evaluated the patient. Discussed with resident and agree with resident's findings and plan as documented in the resident's note." Follow-up Visit: "See resident's note for details. I saw and evaluated the patient and agree with the resident's finding and plans as written." Follow-up Visit: "I saw and evaluated the patient. Agree with resident's note but lower extremities are weaker, now 3/5; MRI of L/S Spine today." Following are examples of unacceptable documentation: "Agree with above" followed by legible countersignature or identity "Rounded, reviewed, agree." followed by legible countersignature or identity "Discussed with resident. Agree." followed by legible countersignature or identity "Seen and agree." followed by legible countersignature or identity "Patient seen and evaluated." followed by legible countersignature or identity A legible countersignature or identity alone. Such documentation is not acceptable, because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care. Billing Regulations for Residency Clinic Attendings: apply to all patients GE = exempt *Does not have to be seen by an attending, but must be discussed with attending at time of visit. Attending documentation must indicate this discussion use EHR quicktext: .tchpce. I have reviewed with the resident the patients medical history, the findings on physical examination, the patients diagnosis and treatment plan (including records of tests and therapies) and agree with the patients care as documented by the resident. I was immediately available to the resident and had no other responsibilities. Comments: *Only patients seen for an E&M level of 3 or less (that is, 99201, 99202, 99203, 99211, 99212, 99213). Levels of 4 or higher and health maintenance visits cannot be billed under the exemption. *Residents cannot bill based on time spent in counseling - to do so requires the physical presence of the attending in the room during the entire discussion. *Residents must have completed 6 months of training (i.e. - December of R-I year). Until then, you have to see every one of their patients, regardless of billing level, and document as a GC visit. GC = must be seen by attending * Applies to ANY patient who is billed for a level 4 or 5 visit, or for any health maintenance visit (including screening pap and pelvic). You need to be there for the pertinent part of the exam - for example, the pelvic exam if that is the only service being provided. *A patient who would qualify for a level 4 visit but was not seen by the attending must be down-coded to level 3 (with associated loss of revenue) and billed under the GE exception rule. No similar option exists for health maintenance visits. *You must document that you saw and examined the patient with the resident using one of the following Centricity EHR quicktexts: .tchpres I was present for the key/critical components of the service performed by the resident/fellow. I discussed the case with the resident/fellow and agree with the findings and plan as documented in the resident/fellows note and amended herein by me. See resident/fellows note for complete details of service. Comments: This note is to be used when the resident/fellow performs the elements required for an E/M service in the presence of the teaching physician and the resident/fellow documents the service.  .tchperf I have examined the patient and confirmed the essential components of the history, physical examination, diagnosis, and treatment plan. I agree with the patients care as documented by the resident/fellow and amended herein by me. See resident/fellows note for complete details of service. Comments: This note is to be used when the resident/fellow performs the elements required for an E/M service and documents it. The teaching physician performs an independent examination.  For Epic, use .tchper for a similar teaching statement. Attending Responsibilities The following topics are supplemental to the full Residency Manual. Significant information useful to faculty is integrated into the manual in the preceding sections. Please become familiar with sections relating to your teaching sites and rotations. For further questions or suggestions, please contact the residency office at 353-5100. Firm/Night Float Managing Attending Responsibilities: Attending responsibilities are assigned in 2-week blocks, and the Managing Attending is responsible for personally rounding each day. Should an unexpected absence be required, the attending must arrange a substitute. Any substitute attending must be able and willing to assume the same level of responsibility for patient care and teaching as the primary attending. The attending is ultimately responsible for each patient on the service. The level of involvement in patient care should reflect this responsibility while preserving the opportunity for primary care and decision making by residents. Attendings are responsible for supervision and back up of all clinical care provided by the residents until 5 PM, when the on-call Firm physician assumes the back-up and supervision role. Therefore, they should: Patient Care Be physically available in the hospital for at least 10 AM until 2 PM (including holidays and weekends), understanding that rounds completion may take longer. Reschedule clinics or other commitments to facilitate management rounds. Be willing and available to evaluate patients on the service at any time and to provide appropriate in-hospital backup to the residents commensurate with the needs of the patient and experience of the residents. Be available by pager from 8 AM until 5 PM daily (including holidays and weekends), or designate a covering physician. Staff daytime admissions with residents. Ensure that resident teams do not exceed admission or census caps (please see Section 4), including providing care of patients who exceed the maximum census. Write attending physician's notes within 24 hours of admission and daily thereafter on all patients admitted to the service and in compliance with Medicare coding and documentation requirements. Write orders for patients only in emergencies or if no residents are available (ie, days of resident retreats, etc.). Make sure that residents sign all verbal orders within 24 hours. Make sure that all team members practice hand hygiene every time before and after entering patient rooms. Teaching Ensure that the senior resident is providing adequate supervision and teaching for junior residents and medical students. Ensure that residents attend all required teaching sessions except in the case of patient care emergencies. Ensure residents are participating in a high quality hand off process. Make sure that their residents comply with duty hour restrictions to meet accreditation requirements, including: 10 hours off in between duty periods On average 1 day off in 7 over the course of the 4-week block No more than 16 hours of continuous duty Role model professional behavior and practice medicine in accordance with standards of practice for internists in the community including but not limited to medical judgment, use of procedures, tests and appropriate consultations. Conduct face-to-face evaluations of residents and students on their teams at the midpoint and conclusion of the assignment Complete assigned evaluations of residents and medical students, including: End of rotation evaluations Chart audits (H&P, discharge summary) Attending On-call Responsibilities After 5 PM on weekdays and on weekends and holidays, a designated MSU faculty member will assume resident supervision and patient care responsibilities. These physicians will be responsible for many of the same activities as the assigned daytime Firm attendings. More specifically, s/he will: Be responsible for supervision and back up of any clinical care provided by the residents from 5PM until 8 AM on all assigned weekdays, or 8AM-8AM on weekends and holidays. Ensure that resident teams do not exceed admission or census caps (please see Section 4). including providing care of patients who exceed the maximum census. Teaching Attending Responsibilities One Firm attending is assigned to teaching morning report per two weeks. The attending is responsible for participating in teaching morning report on Mondays, Wednesdays and Fridays, and is encouraged to participate in Multidisciplinary rounds on Thursdays. For morning report, the attending will co-facilitate discussions with the presenting resident, including performing bedside teaching. Please refer to Section 4 of this manual and the curricula for these rotations. Clinic Attending Responsibilities: Review the Continuity Clinic curriculum with your assigned residents. Arrive on time (1:30 PM) or send appropriate replacement. Remain until all patients are seen and have left the office. Comply with the HCFA primary care exception rule for all patients, regardless of insurance coverage. This includes: Supervising no more than four residents or other health professionals during any resident clinic. Personally examining and evaluating every patient for first-year residents with less than six months of training. Discussing all patients with the residents before the patients leave the clinic. Examining patients for whom a code other than 99201, 99202, 99203, 99211, 99212, or 99213 is billed. Documenting teaching notes for all patients. Become actively involved in patient care delivery by reading records, performing chart reviews for the presence of up-to-date databases, problem lists, medication lists, health maintenance flow sheets, and appropriate written history and physical examinations and progress notes. Establish an atmosphere that is open and warm yet focused on ambulatory care delivery. Remain open and readily available to residents. Avoid working on other projects while supervising resident clinic. Be ultimately responsible for patient flow and intervening when residents get behind. Assume ultimate responsibility for patient care. This includes, but is not limited to: Management of active problems Adequacy of follow up Health maintenance Involvement in practice improvement programs Perform formal mini-CEXs periodically for each resident, at least quarterly. Perform quarterly evaluations of clinic residents using the E*Value web-based evaluation system (https://www.e-value.net). Direct evaluative feedback to residents is expected and should be documented on the evaluation forms that the resident and attending complete on each other. Teach residents about the electronic health record and outpatient systems issues in addition to standard knowledge and patient care. Ensure that DO residents document osteopathic examinations. Become familiar with clinic teaching resources, patient education materials and supportive services available in the clinic. Notify the Dr. Bouknight (residency clinic local site director) if additional materials are needed. EMR Office Visit Notes by Residents: Routing and Signing Instructions: Resident tasks (Part A): 1. Resident enters office visit note data in Centricity 2. Upon completion of the note, the resident should use the .sign quick text tool to soft sign the document 3. The Resident will then click End Update and Route to attending per usual protocol: New, select attending name, etc. 4. The Resident will click Hold Document to keep the note from being hard signed until after the attending can review it, suggest changes and corrections, and add his/her teaching note. (NOTE: DO NOT click SIGN DOCUMENT yet because you will not be able to fulfill the attendings subsequent request to make changes or corrections, and the attending will not be able to add his/her teaching note information at the end of the note). Attending Physician tasks (Part A): The attending may use a .tchpce, .tchpres or.tchperf Quick Text tool to add his/her teaching note, and determine what, if any, changes in the residents documentation are necessary. After adding a teaching note, the attending should Route document to the resident per usual protocol. Routing it back to the resident who originally routed the note should be easy, as that residents name will be checked by default in the routing dialog box. If not, select New, select the residents name, etc. To avoid direct changes in the residents documentation that may otherwise end up in the permanent note without specific indication that the attending physician entered them separately, he/she should make these suggestions in a separate flag routed to the resident. The attending will click Hold Document to keep the note unsigned until after the resident can review the attendings comments and make any necessary changes. (NOTE: DO NOT click SIGN DOCUMENT yet because the resident will not be able to make any changes.) Resident tasks (Part B): The resident should open the document and make any required changes. After making any necessary changes, the resident should click End Update The resident should Route the document back to attending for his/her final signature by clicking Hold Document. Attending Physician tasks (Part B): 1. The attending physician should open the document and inspect the residents changes. 2. If the note is completed satisfactorily, the attending should End Update and click on SIGN DOCUMENT to add his/her permanent signature. The resident will hard sign the note after the attending has done so. 3. If additional comments are desired, the attending physician should repeat the steps under Part A. ICU Medicine Managing Attending Responsibilities: Rounding attending physicians conduct patient management rounds with at least one resident member of their rounding group daily. Management rounds should not interfere with other mandatory conferences or activities such as Morning Report, Teaching rounds, Critical Care Conference, Internal Medicine Teaching Afternoons (Thursdays, 12:00pm-4:00pm), Medical Grand Rounds and Medical Emergencies didactics (Tuesdays, 12:00pm-1:00pm). In addition, on days when rounding group residents are post-call, the rounding attending for that resident rounding group should plan to round early in the day, so post call residents can leave the hospital in compliance with duty hours restrictions. To enhance continuity of care, appropriate resident responsibility and autonomy, and minimize the need for attendings to write orders on teaching service patients, each assigned rounding attending physician is responsible for making management rounds with one of the residents on the critical care service on all weekend days and holidays during his/her assignment period. It is important to remember that all residents must have an average of 1 day (24 continuous hours) in 7 free of patient care duties. This translates to 4 days during the rotation when an individual resident must not work (an accreditation requirement). Given that there are 8 weekend days during a four-week rotation, this can be accomplished only if one resident rounds and the other has the day off on each of the 8 weekend days. We will make every attempt to avoid assigning both residents from a single rounding group to be on-call together on a weekend day. Otherwise, this will lead to one resident working more than 4 weekend days during the rotation. In the rare instance when this occurs, the rounding attending will need to arrange to grant a weekday off to the affected resident. This situation should occur only rarely if at all. Intensive Care Unit Attending Physicians: Will allow residents to write all patient orders except in emergencies when residents are not available. Failure to comply with this requirement may result in withdrawal of resident coverage for the patient. Will allow the senior resident to participate in the decision to admit patients from the emergency department to the critical care units. Will allow residents, under appropriate supervision, to perform indicated procedures. Will participate as a Critical Care Teaching Attending and in the educational activities at a frequency that is mutually agreed upon with the Critical Care director Must conduct a face-to-face evaluation of the residents in their rounding group at the conclusion of the assignment, as well as document this evaluation in the web-based evaluation system. Evaluations should identify strengths and areas for improvement regarding designated medical competencies. Failure to meet the above outlined requirements will result in withdrawal of resident service coverage by the Intensive Care Unit director or the appropriate training program directors.    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