Resident Policies and Procedures

Policy of East Tennessee State University, James H. Quillen College of Medicine

Accommodations for Disabilities Policy
Alertness and Fatigue Mitigation Policy
Authorship Policy
Clinical Experience and Education Policy
Delinquent Medical Record Policy
Disaster Policy
Discrimination & Harassment Policy
Dress Code Policy
Drug-Free Campus Policy
Eligibility and Selection Policy
Ethical Guidelines & Vendor Policy
Evaluation Policy
GMEC Committee Policy
GMEC Special Review Policy
Health Insurance Portability HIPAA
Hospital Suspension of a Resident Policy
Identification, Intervention, Assistance and Resolution of Unsatisfactory Performance by a Resident
Medical Licenses and Exemptions Policy
Moonlighting Policy
Non-Renewal of Resident Contract Policy
Observership Policy
Other Learners Policy
Periodic Review of GME Policies
Professional Liability Medical Malpractice Policy
Professionalism and Personal Responsibility Policy
Promotion Policy
Quality Improvement and Patient Safety
Reduction and Closure Policy
Resident Initiated Grievances Policy
Restrictive Covenant Policy
Security Background Check Policy
Sexual Harassment Policy
Social Networking Policy
Supervision Policy
Tobacco Free Campus Policy
Transfer Policy and Procedure
Transitions of Care Policy
Visas and Foreign Medical Graduates
Well Being Policy
Workers' Compensation Policy

ACCOMMODATION OF RESIDENTS WITH DISABILITIES POLICY

(Effective 7/12/2007, Revised/Approved 2/1/2018 by GMEC)
It is the policy of East Tennessee State University, James H. Quillen College of Medicine to provide reasonable accommodations as necessary for qualified individuals with disabilities who are accepted in to our post graduate training programs. We will adhere to all applicable federal and state laws, regulations and guidelines with respect to providing reasonable accommodations as required in accordance with the policies and procedures of the University.

University Policies and Procedures link:https://www.etsu.edu/human-resources/ppp/PPP-45.htm

The Graduate Medical Education Office will work with the University Office of Disability Services in determining if a resident has a disability and what accommodations may be reasonable and necessary for the College of Medicine to provide. Residents will still be required to meet all program educational requirements with or without accommodations as they must be able to demonstrate proficiency in all of the ACGME defined competencies and programs must certify that they are able to practice the specialty in which they have been trained competently and independently upon completion of training. This includes the ability to perform the required technical and procedural skills of the specialty. Patient safety must be assured as a top priority in these determinations.

Residents must request accommodations in writing to the Program Director. At that time the resident will be required to provide medical verification of a medical condition that he or she believes is a disability. The resident is responsible for the costs of obtaining verification. The Program Director must notify, within five (5) working days of the request, the Designated Institutional Official.

ALERTNESS/FATIGUE MITIGATION POLICY

(Effective 7/1/2017, Revised/Approved 2/1/2018 by GMEC)
East Tennessee State University, Quillen College of Medicine ensures that all residency/fellowship programs provide education for their faculty, residents and fellows to recognize the signs of fatigue and sleep deprivation, provide education in alertness management and fatigue mitigation processes, and must adopt and apply policies to prevent and counteract the potential negative effects on patient care and learning such as back-up call schedules and strategic napping. Education in recognizing sleep deprivation and fatigue mitigation is provided to all new incoming residents as part of annual new resident institutional orientation.

All residency and fellowship programs must provide an education program specifically addressing the signs of fatigue/sleep deprivation and the effects on patient care and clinician health. The program must specifically address fatigue mitigation techniques including but not limited to strategic napping and good sleep hygiene. Appropriate facilities must be available to permit sleeping while on in-house call and strategic napping as required.

The program director must monitor duty hours and adjust schedules as necessary to mitigate excessive service demands and/or fatigue. The program director must also monitor the need for and ensure the provision of backup support systems when patient care responsibilities are unusually difficult or prolonged. In accordance with duty hours and transition of care requirements, the programs must have a process in place to ensure continuity of care in the event that a resident may be unable to perform patient care duties due to fatigue, illness or other impairments.

Taxi services are available to all residents/fellows who feel that he/she cannot drive home safely due to fatigue or excessive sleepiness. Information on taxi service is available via our resident management system and disseminated by program administrators. This is at no cost to the resident/fellow.

AUTHORSHIP POLICY

(Effective 10/26/2017, Revised/Approved 10/24/2019 by GMEC)
Every manuscript and/or abstract that is sent out under the auspices of ETSU and/or Quillen College of Medicine must have a GME faculty member or ETSU QCOM faculty member in good standing as a co-author. This faculty need not be the corresponding or first author, however, the faculty author should have the credentials and be in a position to take responsibility for the scientific, procedural (e.g., IRB) methodological, etc. soundness of the submission.

It is the responsibility and duty of the program director to make this requirement known to residents/fellow and GME faculty alike.

This policy should be reviewed and documented at regular intervals along with other GME and program policies. The program director should monitor compliance with this policy during portfolio review at semi-annual evaluations. Any resident/fellow who fails to follow this policy shall be subject to the full range of disciplinary options available to the program director from verbal warning, letter of focused improvement, probation and termination for severe or repeated violations.

CLINICAL EXPERIENCE AND EDUCATION POLICY

(Effective 5/25/2017)
Clinical and educational work hours must be limited to no more than 80 hours per week 1 averaged over a 4-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting.

Residents must have eight hours off between scheduled clinical work and education periods.

There may be circumstances when residents choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education. This must occur within the context of the 80-hour and the one-day-off-in-seven requirements.

Residents must be scheduled for a minimum of one day in seven free of clinical work and required education (when averaged over four weeks). At-home call cannot be assigned on these free days.

Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments. Up to four hours of additional time may be used for activities related to patient safety such as providing effective transitions of care, and/or resident education. Additional patient care responsibilities must not be assigned to a resident during this time.

Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call. Residents must not be scheduled for more than six consecutive nights of night float.

Residents must be scheduled for in-house call no more frequently than every third night (averaged over a four-week period). Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum hour limit. The frequency of at- home call is not subject to the every-third-night limitation, but it must satisfy the requirements for one-day-in-seven free of duty, when averaged over 4 weeks. At-home call must not be frequent or taxing as to preclude rest or reasonable personal time for each resident.

Residents in the final years of education (as defined by the Review Committee) must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods (within the context of the 80 hour, maximum duty length and 1 day off in 7 standards).

Clinical and educational experiences are monitored by each residency/fellowship p program and by the GME office. Confirmed work hour violations are subject to review and possible action.
Moonlighting
1. Time spent by residents in external and internal moonlighting (as defined by ACGME) must be counted towards the 80-hour maximum weekly hour limit.
2. PGY-1 residents are not permitted to moonlight.
3. Residents on J-I visas are not permitted to moonlight.

CLOSURE/REDUCTION POLICY

(Effective 7/1/2007, Revised/Approved 2/1/2018 by GMEC)
In the event the College of Medicine has to reduce the number of positions or closes a residency training program, the College of Medicine will:

Notify the GMEC, DIO, and residents in training as soon as possible.

If possible, reductions will be made over a period of time to allow all residents to complete training.

In the event that an ACGME action or decreased financial or educational resources force the closure of a training program, the College of Medicine will allow the residents already in the program to complete their education or assist them in locating another ACGME accredited program in which they can continue their education.

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CONTINUATION OF GME SUPPORT IN THE EVENT OF A DISASTER

(Effective 7/12/2007, Revised/Approved 2/1/2018 by GMEC)

Purpose: ACGME requires the Sponsoring Institution maintain a policy consistent with ACGME Policies and Procedures that addresses administrative support for each of its ACGME-accredited Programs and resident/fellows in the event of a disaster or interruption in patient care. (Core) IV.M.

Definition Disaster: An event or set of events causing significant alteration to the residency experience at one or more residency programs. Extreme emergent situation: A local event (such as hospital-declared disaster for an epidemic) that affects resident education or the work environment but does not rise to level of an ACGME-declared disaster in the ACGME Policies and Procedures, 11.H.2.

Policy:The James H. Quillen College of Medicine, East Tennessee State University, acknowledges its ongoing support of graduate medical education in the face of any disaster (natural or otherwise) that interrupts the hospital/clinic based educational process. This ongoing support consists of the following commitments:

The Dean and College of Medicine administration, working with the graduate medical education affiliated hospitals, will strive to ensure financial and logistical support of residents until normal educational site(s) resume clinical activity.
The Office of Graduate Medical Education will maintain contact with all residents during any times of disruption, and provide assistance toward resuming the educational experience as soon as possible. To fulfill this commitment, resident demographic data will be collected and electronically secured off-site from the College of Medicine/University campus.
The Office of Graduate Medical Education, working with the various departments and training programs, will coordinate efforts to provide an alternate educational venue that is convenient and provides appropriate educational experience.

Specifically, programs will focus on strategies to utilize the existing Ballad Health System and the Veterans Affairs Health System to provide temporary clinical settings for the displaced residents. If these regional clinical sites are not available, the Program Director and Chair, along with the Graduate Medical Education Office, will strive to place residents in an educationally rewarding environment as close to this region as possible. The various programs will coordinate their efforts with the appropriate Residency Review Committee and the ACGME to ensure an approved experience for the displaced residents. In the aftermath of the disruption of graduate medical education, the College of Medicine will work to restore the clinical teaching environment as soon as possible so that residents may return to their pre-disaster hospital/clinic setting.

DELINQUENT MEDICAL RECORDS

Residents are expected to maintain all appropriate and reasonable medical records in a timely fashion. A resident who is identified as having delinquent medical records (any record considered delinquent by hospital bylaws) will be notified and given five (5) days to report to the hospital to complete the records. Any records not available to the resident at that time will become the responsibility of the attending physician of record. If the resident does not report within the five (5) day period, he/she will be subject to suspension. Each day of suspension will be counted as one day of annual leave; if there is no available annual leave, the resident will be placed on leave without pay. Extended lengths of suspension may require make-up duty, as outlined by the ACGME/RRC.

DISCRIMINATION & HARASSMENT - COMPLAINT & INVESTIGATION PROCEDURE

Effective 11/15/2012, Revised/Approved 3/24/2016 by GMEC)

Important: Other Available Complaint Procedures

An aggrieved individual may also have the ability to file complaints with external agencies such as the Equal Employment Opportunity (EEOC), the Tennessee Human Rights Commission (THRC), the Office of Civil rights (OCR), and the courts. Please note that the deadlines for filing with external agencies or courts may be shorter than the deadline established for filing a complaint under this Guideline. Examples of shorter deadlines include, but are not limited to 180 days to file a complaint under Title VI & Title IX, as well as 300 days to file a complaint under Title VII.

General Statement

It is the intent of the Tennessee Board of Regents that the Board and all of the institutions within the Tennessee Board of Regents System (including East Tennessee State University) shall fully comply with the applicable provisions of federal and state civil rights laws, including but not limited to, Executive Order 11246, as amended; the Rehabilitation Act of 1973, as amended; the Americans with Disabilities Act of 1990, as amended; the Vietnam Era Veterans Readjustment Act of 1974, as amended; the Equal Pay Act of 1963, as amended; titles VI and VII of the Civil Rights Act of 1964, as amended: Title IX of the Educational Amendments of 1972, as amended; the Age Discrimination in Employment Act of 1967; the Age Discrimination Act of 1975; the Pregnancy Discrimination Act; the Genetic Information Nondiscrimination Act of 2008; and regulations promulgated pursuant thereto. The Board of Regents and ETSU will promote equal opportunity for all persons without regard to race, color, religion, creed, ethnic or national origin, sex, sexual orientation, gender identity/expression, disability, age (as applicable), status as a covered veteran, genetic information, and any other category protected by federal or state civil rights law.

Campuses and the Central Office affirm that they will not tolerate discrimination against any employee or applicant for employment because of race, color, religion, creed, ethnic or national origin, sex, sexual orientation, gender identity/expression, disability, age (as applicable), status as a covered veteran, or genetic information, nor will they tolerate harassment on the basis of these protected categories or any other category protected by federal or state civil rights law.

Similarly, the campuses shall not subject any student to discrimination or harassment under any educational program and no student shall be discriminatorily excluded from participation nor denied the benefits of any educational program on the basis of race, color, religion, creed, ethnic or national origin, ex, sexual orientation, gender identify/expression, disability, age (as applicable), status as a covered veteran, genetic information, or any other category protected by federal or state civil rights law.

Please see the full TBR policy at: http://www.tbr.edu/policies/default.aspx?id=7907

Affirmative Action Officer for ETSU Office of the President, 206 Dossett Hall. (423) 439-4211.

DRESS CODE

(Effective 7/12/2007, Revised/Approved 11/15/2012;10/24/2019 by GMEC)
In order to address one aspect of the ACGME Professionalism Core competency, residents are expected to maintain professional appearance and demeanor at all times. Lab coats with QCOM departmental patches will be supplied for residents by their program with the expectation that residents wear a clean white lab coat when appropriate and always display an appropriate identification badge during rotation assignments.

In accordance with departmental policy, training program directors shall ensure that all residents are properly attired and appropriately groomed for their patient care roles. Access to, usage and proper maintenance of scrubs, lab coats and similar attire shall follow hospital and/or departmental regulations.

Special accommodations may be made for residents whose cultural and/or religious beliefs require certain types of attire.

DRUG-FREE CAMPUS POLICY

I. Policy
It is the policy of this university that the unlawful manufacture, distribution, possession, use of alcohol and illicit drugs on the ETSU campus in the workplace (on or off campus), on property owned or controlled by ETSU, or as part of any activity of ETSU is strictly prohibited. All employees and students are subject to applicable federal, state and local laws related to this matter. Additionally, any violation of this policy will result in disciplinary action

II. Legal Sanctions
Various federal, state and local statutes make it unlawful to manufacture, distribute, dispense, deliver, sell or possess with intent to manufacture, distribute, dispense, deliver or sell, controlled substances. The penalty imposed depends upon many factors which include the type and amount of controlled substance involved, the number of prior offenses, if any, whether death or serious bodily injury resulted from the use of such substance, and whether any other crimes were committed in connection with the use of the controlled substance. Possible maximum penalties for a first-time violation include imprisonment for any period of time up to a term of life imprisonment; a fine of up to $4,000,000 if an individual; supervised release; any combination of the above; or all three. These sanctions are doubled when the offense involves either: 1.) distribution or possession at or near a school or college campus or, 2.) distribution to persons under 21 years of age. Repeat offenders may be punished to a greater extent as provided by statute. Further, a civil penalty of up to $10,000 may be assessed for simple possession of personal use amounts of certain specified substances under federal law. Under state law, the offense of possession or casual exchange is punishable as a Class A misdemeanor; if there is an exchange between a minor and an adult at least two years the minors senior, and the adult knew that the person was a minor, the offense is classified a felony as provided in T.C.A. Section 39-17-417. ( 21 U.S.C. Section 801, et. seq.; T.C.A. Section 39-17-417)

It is unlawful for any person under the age of twenty-one (21) to buy, possess, transport (unless in the course of his employment), or consume alcoholic beverages, wine, or beer. Such offenses are classified as Class A misdemeanors punishable by imprisonment for not more than 11 months, 29 days, or a fine of not more than $2,500, or both. (T.C.A. Sections 1-3-113, 57-5-301) It is further an offense to provide alcoholic beverages to any person under the age of twenty-one (21), such offense being classified as a Class A misdemeanor (T.C.A. Section 39-15-404). The offense of public intoxication is a Class C misdemeanor punishable by imprisonment of not more than 30 days or a fine of not more than $50, or both (T.C.A. Section 39-17-310).III. Institutional/School Sanctions East Tennessee State University will impose the appropriate sanction(s) on any employee or student who fails to comply with the terms of this policy.

A. Employees
As a condition of employment, each employee, including student employees, must abide by the terms of this policy, and must notify the Office of Human Resources of any criminal drug statute conviction for a violation occurring in the workplace (on or off campus) no later than five days after such conviction. A conviction includes a finding of guilt, a plea of nolo contendere, or imposition of a sentence by any state or federal judicial body. Possible disciplinary sanctions for failure to comply with this policy, including failure to notify of conviction, may include one or more of the following depending on the severity of the offense:

termination
suspension
mandatory participation in and satisfactory completion of drug/alcohol abuse program, or rehabilitation program
recommendation for professional counseling
referral for prosecution
letter of warning
probation

Moreover, the following certification and notification requirements apply (responsibility of Research and Sponsored Programs in coordination with Human Resources):A certification statement will be placed in all federal grant requests that the institution is complying with the Drug-Free Workplace Act of 1988 and the Drug-Free Schools and Communities Act Amendments of 1989.
All employees involved in the performance of federal contracts and grants will be furnished a written copy of this policy statement. In addition, they must certify that they will abide by the terms of the policy.
Upon receiving notice of a drug conviction by an employee involved in the performance of a federal contract or grant, the appropriate federal agency will be notified (upon approval by the University President) within ten (10) days of the notice of conviction.

B. Students
Possible disciplinary sanctions for failure to comply with the terms of this policy may include one or more of the following depending on the severity of the offense:

expulsion
suspension
mandatory participation in, and satisfactory completion of a drug/alcohol abuse program, or
ehabilitation program
referral for prosecution
probation
restriction of privileges
educational project
assignment of volunteer work hours
referral to the University Counseling Center
written warning
reprimand

IV. Health Risks Associated With the Use of Illicit Drugs and the Abuse of Alcohol
There are many health risks associated with the use of illicit drugs and the abuse of alcohol including organic damage; impairment of brain activity, digestion, and blood circulation; impairment of physiological processes and mental functioning; and, physical and psychological dependence. Such use during pregnancy may cause spontaneous abortion, various birth defects or fetal alcohol syndrome. Additionally, the illicit use of drugs increases the risk of contracting hepatitis, AIDS and other infections. If used excessively, the use of alcohol or drugs singularly or in certain combinations may cause death.

V. Available Drug and Alcohol Counseling, Treatment, Rehabilitation Programs, and Employee Assistance Programs
The university and local community provide a variety of educational programs and services to respond to the problems associated with alcohol and drug abuse. The Campus Alcohol and Other Drug (AOD) Program at East Tennessee State University is designed to serve university students by providing information related to alcohol awareness and chemical dependency. The Office of the Vice President for Student Affairs offers several educational programs which seek to involve university student organizations.
Below is a list of campus and community agencies which also provide referral, information, and/or counseling to students and/or employees:

ETSU Counseling Center (students only) 423-439-3333
ETSU Department of Public Safety 423-439-4480
ETSU Employee Assistance Program 423-439-5825
State of Tennessee Employee Assistance Program 1 (877) 237-8574
Alcoholics Anonymous 423-928-0871
Comprehensive Community Services
(Alcohol & Drug Counseling & Prevention Center) 423-928-6581
Woodridge Hospital 423-928-7111
Watauga Mental Health Center 423-232-6200

ELIGIBILITY AND SELECTION POLICY

(Effective 7/12/2007, Revised/Approved 1/28/2016 by GMEC)
Residents and Fellows are selected on a fair and equal basis without regard to sex, race, age, religion, color, national origin, disability, veteran status, or any other applicable legally protected status.

The GME office will monitor programs for compliance with this policy on recruitment and appointment.

RESIDENT ELIGIBILITY:
Applicants with one of the following qualifications are eligible for appointment to programs, subject to additional qualifications as may be specified in specialty/subspecialty programs:

Graduates of medical schools in the United States or Canada accredited by the Liaison Committee on Medical Education (LCME).
Graduates of colleges of osteopathic medicine accredited by the American Osteopathic Association (AOA).
Graduates of medical schools outside of the United States or Canada must have a current certificate from the Educational Commission for Foreign Medical Graduates (ECFMG).
Individuals applying for Fellowship programs must have completed a residency in an ACGME accredited program, or in an RCPSC accredited or CFPC accredited residency program located in Canada.

Fellowship programs must receive verification of each entering fellow's level of competency in the Required field using ACGME or CanMEDS Milestones assessments from the core residency program.

A resident/fellow in our program must be a U.S. citizen, lawful permanent resident, or possess the appropriate documentation to legally train in the U.S.

RESIDENT SELECTION:
Resident applicants should apply through ERAS. All residency programs participate in the NRMP for entry level residents and will select residents according to NRMP policies and procedures. Each program will develop specialty specific criteria according to its own program's needs and those of the institution. These criteria may encompass preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity or other relevant personal, professional and educational characteristics of the candidate.

Applicants who are invited for an interview must be informed, in writing or by electronic means, of the terms, conditions, and benefits of appointment, either in effect at the time of the interview or that will be in effect at the time of their eventual appointment.

Beginning with the 2013 NRMP Main Residency Match, any program that participates in the NRMP Match must register and attempt to fill all of its positions through The Match or another national matching plan. This includes International Medical Graduates. Refer to the "All-In" Policy of the NRMP for the relatively limited situations in which exceptions can be made (Rural Scholars Program; Family Medicine Accelerated Programs; post-SOAP positions). One exception that may occur is that of off-cycle appointments. If training would begin prior to February 1 in the year of The Match, the position can be offered outside The Match; if training would begin after February 1, the position must be filled through The Match.

If a position can be offered outside The Match within the foregoing rules and guidelines of the NRMP, the following conditions should be met before an "out-of-Match" position is offered and accepted:

Candidates who are graduates of international medical schools must be ECFMG certified. Medical students who are on-cycle in the 4th year are ineligible for an "outside-of-Match" position.
The candidate should be evaluated in a manner as similar as possible to the method the program uses for candidates who are selected in the NRMP Match.
The candidate should at a minimum be interviewed for the position by 2 faculty members who make recommendations to the Program Director. The residency program director who wishes to offer a candidate an "out-of-Match" position is responsible for ensuring that all conditions of the institution's GME policy are met (this includes coordinating the planned offer with the GME office and obtaining DIO consent; see below.)
A candidate who wishes to accept an "out-of-Match" position must sign an official ETSU GME Letter of Agreement for an outside The Match residency position. All letters of offer for residency training outside The Match must be reviewed by the Designated Institutional Official (or designee) prior to submission to the residency applicant.
As soon as is feasible, the applicant who has accepted an "out-of-Match" position should be required to sign an official ETSU GME employment contract.
Applicants who accept "out-of-Match" positions must be governed by the same rules and regulations and are entitled to the same salary and benefits as residents accepted through the NRMP Match.

DELINQUENT MEDICAL RECORDS

IDENTIFICATION, INTERVENTION, ASSISTANCE AND RESOLUTION OF UNSATISFACTORY PERFORMANCE BY A RESIDENT

(Effective 08/01/2015, Revised/Approved 12/7/2017 by GMEC)

Purpose: This policy provides guidelines for proper response to problems by resident physicians associated with poor performance, failure to progress academically, alleged or actual non-professional behavior, substance abuse, physical disability, mental illness, or emotional impairment. An impaired resident physician shall be defined as any resident who, by virtue of substance abuse, physical disability mental illness, or psychological impairment, is unable or potentially unable to care for patients with reasonable safety and skill. The definition includes behavioral problems or unprofessional behavior which may or may not be readily attributable to substance abuse, physical disability, mental illness, or psychological impairment. If any ETSU or MEAC employee, medical staff member or resident has knowledge, substantiated concerns, or convincing reasons to suspect that patient care is, or may be, affected by any resident due to the resident being impaired, it is his or her duty to report this expeditiously to the program director.

Policy: In all that follows, when the term “resident” is used the policy is meant to apply to all residents and fellows. Residents shall abide by the rules and regulations set by the program directors, the hospitals and the Office of Graduate Medical Education. Failure of a resident to perform his/her duties or to abide by the College of Medicine's and the affiliated hospitals' rules and regulations shall be reported to his/her program director. The program shall then institute appropriate disciplinary action. If this rises to the level of written disciplinary or remedial actions, the following policy applies.

UNSATISFACTORY PERFORMANCE BY A RESIDENT; DOCUMENTATION REQUIREMENTS FOR ESTABLISHING THE PROVISION OF DUE PROCESS

(Effective 7/12/2007, Revised/Approved 12/7/2017 by GMEC).
Residents who evidence a deviation from their expected performance will be identified in a timely manner and reported to the program director. The program director has the authority for managing the residency and maintaining accreditation standards. The program director may be advised by the Clinical Competence Committee (CCC) or other GME faculty at any point in this process, but the program director is responsible for making the decisions and supervising the policy process as outlined below unless otherwise specified. Any instance of a resident being removed from his/her clinical duties requires the office of the Associate Dean for Graduate Medical Education to be notified as soon as possible.

A resident deemed to be deficient by the program director (with consultation when indicated by GME faculty or the CCC) in any aspect of his/her performance will be given verbal or, depending on the severity of the deficiency, written notification and may be given a notice of academic deficiency. When remediation action is required, the program director will inform the resident/fellow in writing by giving him/her a letter of deficiency that should include the following elements:

Notice of the academic deficiency
A description of the deficiency in behaviorally specific terms with examples
The program's general expectations for achievement in the competency or competencies
Defined goals, including points of assessment
Specific methods in which the program will assist with resident
A timeline for appropriate completion
Signature of the program director and the resident/fellow (copy kept by program)

Departmental remediation is utilized when it is anticipated that there will be a successful outcome on the part of the resident. The program director may skip the letter of deficiency and proceed to probation (next paragraph) if circumstances warrant. The remediation period will be left to the discretion of the program director, but generally will be 3 to 6 months.

When necessary, this approach will include the appointment of one or more faculty to work with the resident on a regular basis using a planned, individualized format. The resident's progress in successfully remediating said deficiencies will be reviewed by the program director (with advisement by the CCC if necessary) at the end of the remediation period identified in the letter of deficiency.

If the resident/fellow satisfactorily remediates deficiencies outlined in a letter of deficiency, no further action is necessary, but a signed notice of successful resolution of deficiency should be placed in the resident's file. If the resident does not satisfactorily remediate deficiencies during the remediation period and/or if, in the program director's opinion, the resident's original deficiency may result in termination, the resident will be placed on probation, generally not to exceed three (3) months. Again the resident must be given written notification with the elements outlined above included in an letter of probation and the additional element.

The resident/fellow must also be notified in the probation letter of the possibility that the deficiency may lead to termination from the program.

A copy of the signed letter of probation should be sent to the GME Office. Probation is an official action taken against a resident/fellow, and it is entered into the record of the resident/fellow for subsequent reporting/credentialing purposes.

At the end of the probationary period the resident/fellow's performance will be reassessed
and the resident will be notified in writing as to his/her status. The resident may be removed from probation if the stated deficiencies have been remediated, or the probation may be continued if the resident's performance has improved but deficiencies remain or new deficiencies are uncovered, or the resident may be terminated.

TERMINATION OF A RESIDENT

(Effective 7/12/2007, Revised/Approved 12/7/2017 by GMEC) Termination of a resident may occur based on either of two situations: 1) Failure to meet academic standards despite a carefully planned remediation program; 2) Unacceptable personal behavior serious enough to call for immediate suspension. This action may be taken when the resident's performance is grossly negligent, unprofessional and/or imminently endangers the health or safety of others. The resident will be suspended with pay while his/her performance is being investigated. After an investigation that includes asking all personnel, including the resident, that have direct knowledge of it for their perception of the resident's performance, the program director may decide that the resident should be terminated. Under each scenario, the program director must obtain approval of the Associate Dean for Graduate Medical Education and ETSU legal counsel prior to terminating a resident. The resident is given written notification of termination and the reasons for this action. The written notification must also inform the resident of his/her due process rights.

IMPAIRED RESIDENT PHYSICIAN POLICY Residents should be evaluated on the basis of performance as outlined above. Sometimes a resident's GME faculty, co-workers, program director, or others may suspect that a resident's performance is being affected by an impairment. The purpose of this policy is to identify and provide assistance to am impaired resident. The policy to correct an academic deficiency can be employed concurrently (in parallel), with the investigation of a possible impairment, and either policy man be followed or discontinued depending on whether an impairment is admitted/diagnosed or not.

Step 1. Program director receives work related performance problem information. In the event that the program director receives reports of alleged impairment-related work performance problems, the following policy applies. Confidentially is extremely important in suspected impairment. Notwithstanding the foregoing, the program director will consult the Associate Dean for GME after receipt of such allegations, and keep the Associate Dean for GME informed of interventions, if any occur, and outcomes during a treatment process. In the event that a resident voluntarily identifies impairment related work performance problems to anyone in the work environment, the program director will be notified and will follow the procedures outlined in this policy beginning with Step 4.

Step 2. Program director discusses work related performance problems with resident. The Program director will meet with the resident to discuss the allegations of impairment, framing the discussion in the context of information received related to work performance problems. The program director may determine that an impairment problem does not exist and what, if any, further action is warranted. See UNSATISFACTORY PERFORMANCE BY A RESIDENT; DOCUMENTATION REQUIREMENTS FOR ESTABLISHING THE PROVISION OF DUE PROCESS (above). If the resident indicates a desire to terminate discussions of this nature with the program director, he or she may do so at any time. The program director will document the resident meeting(s) and/or document unsuccessful attempts to meet with the resident to discuss work related performance problems. Depending on the acceptance or denial of the alleged impairment, Step 3 or Step 4 is then followed as appropriate.

Program director will notify the Associate Dean for GME.
For behavioral and professionalism problems that are not impairment related, the resident will be provided with documentation outlining the relevant concerns as outlined in the foregoing unsatisfactory performance by a resident. Expectations for improvement will be clearly outlined with a timeline for continued assessment. The program director will provide timely progress updates to the resident on performance and whether expected outcomes are being met. At the discretion of the program director, resources may be identified and provided to the resident to assist remediation. Such assistance is limited and cannot disrupt the financial, academic, or health care delivery services of the program.
In cases of impairment, the program director, in consultation with the Associate Dean for GME and ETSU legal counsel, will require the resident to follow all impairment, self-reporting requirements as stipulated by the Tennessee Medical Foundation (TMF) Physician’s Health Program (PHP).
1. Resident seeks and receives intervention. If not covered by medical insurance, the residency will not bear expenses incurred by the resident in the treatment process.
2. Program director makes work re-entry decision. The program director may decide whether or not to allow the resident to return to the residency program contingent upon considerations such as the nature of the work related performance problem, assurance of patient safety, and evidence from the treatment program that the resident is safe to return to work and interact with patients. The program director must present documentation to the Associate Dean for Graduate Medical Education that the resident’s treatment has been effective, that the program director has received reports on the resident’s progress in the treatment program, that the resident is in compliance with the treatment program, and that the resident is willing to adhere to an after-care program, as necessary.
3. Program director monitors resident’s compliance with the after-care program. The program director monitors the resident’s compliance with all components of the after-care program, as set forth by the prescribed treatment plan.
4. Resident compliance with after-care program and/or recurrence of impairment related work performance problems. The program director may terminate the resident’s training if the resident does not comply with all components of the after-care program and/or if impairment related work performance problems persist.

A. The program director documents the discussion with the resident including the resident's denial that a problem exists.

B. The program director provides copies of all relevant information to the Associate Dean for GME.

C. The GME program does not have a policy of mandatory diagnostic testing in cases of suspected impairment. Any exceptions would have to be made with the prior approval of the Dean for GME and ETSU legal counsel.

D. Program director follows policy in foregoing entitled: UNSATISFACTORY PERFORMANCE BY A RESIDENT/FELLOW; DOCUMENTATION REQUIREMENTS. FOR ESTABLISHING THE PROVISION OF DUE PROCESS.

E. Program director makes employment decisions.

Step 5. Program director determines if the resident should be terminated.

Step 6. Resident’s Training is Terminated

Step 7. Resident’s Training is Not Terminated

If the program director wishes to terminate the resident’s training, the program director must notify and receive prior approval of the Associate Dean and ETSU legal counsel. The resident will be afforded due process as outlined below. See TERMINATION OF A RESIDENT, above.

Program director monitors work related performance.

If the resident has denied the existence of an impairment problem and the program director does not have sufficient grounds to request entry into a treatment program or termination, no further action will be taken. However, the program director will continue to monitor the resident’s work performance and follow the policy outlined above. UNSATISFACTORY PERFORMANCE BY A RESIDENT; DOCUMENTATION REQUIREMENTS FOR ESTABLISHING THE PROVISION OF DUE PROCESS.

If suspected impairment related
work performance problems persist or if further allegations emerge, the program
director will return to Step 2.

APPEAL OF ADVERSE ACTION, INCLUDING TERMINATION, FOR LACK OF DUE PROCESS

(Effective 7/12/2007, Revised/Approved 3/28/2013)

This outline of Due Process is applicable to any resident who wishes to appeal an adverse decision by his/her program. Adverse actions include: non-renewal of contract; suspension from residency program; termination from residency program; imposition of formal disciplinary action (probation); or actions taken resulting from violation of residency policy or procedures which may delay promotion and/or extend the period of residency/fellowship training. In the case of an adverse action taken by the program following one or more attempts at remediation, "due-process" refers specifically to whether the resident was provided remediation in substantial compliance with the policies outlined in this document, in the case of imposition of an adverse action as a result of a resident's performance being judged grossly negligent, grossly unprofessional and/or imminently endangering the health of safety of others, the "due process" committee will provide a recommendation concerning whether the imposition of the adverse action by the program is justified by the behavior and circumstances that led to it.

A resident/fellow who wishes to appeal an adverse decision by his/her program director or department chair may appeal the decision of the department and request a due process hearing before an ad hoc committee. The resident must provide a written request to the GME office for a due process hearing within 4 weeks of the adverse action taken. This committee shall consist of not less than five (5) faculty members and two (2) residents to be appointed by the Dean. The five faculty members will be from programs other than the resident/fellow's program other than and will have little or no personal involvement with the resident's instruction or evaluation. One of the two resident representatives will be selected by the Associate Dean for Graduate Medical Education from a list supplied by the resident making the appeal and the other selected by the Associate Dean for Graduate Medical Education from the Chief Residents' Committee, but this resident shall not be from the appellant's program. The Associate Dean for Graduate Medical Education will appoint a member of the GME faculty outside of the resident/fellow's discipline to be chair of the committee. In the event that the actions of the Associate Dean for Graduate Medical Education are a factor in the hearing, the Dean will appoint the chair. The committee shall convene a hearing at a date agreeable to all parties, but in no case more than four (4) weeks after receiving the written request for the appeal.

Committee witnesses will include those on a list provided by the resident/fellow to speak on his/her behalf. The committee will also request testimony from those in the program responsible for the evaluations and decisions which led to the adverse action. The ad hoc committee may request from the department copies of all evaluations and documents leading to an adverse action. The resident making the appeal has the right to have an advocate present with whom the resident may consult during the hearing. The advocate cannot address the committee or question witnesses. The resident has the right to hear all witnesses and to ask any questions under the direction of the chair of the ad hoc committee. An electronic recording of the proceedings may be made, but only for the purpose of producing a written transcript, at which time all recordings will be destroyed. This transcript and all other records related to the appeal will be available to the appellant upon request. The chair of the committee will not have a vote in the committee's decision, but will create and submit his/her recommendation along with the committee's recommendation in a written report to the Dean. The report must include a numerical statement describing the result of a vote taken on whether to recommend upholding (i.e., the appellant received adequate due process via remediation plans to the adverse action was justified by behavior that was grossly negligent, unprofessional and/or imminently endangered the health or safety or others), or recommend overturning the adverse action taken against the resident/fellow, and it may include a narrative of considerations the committee used in reaching that conclusion. In addition to the committee report, the Dean has access to the transcript of the hearing. The decision of the Dean is final.

ETHICAL GUIDELINES GOVERNING GRADUATE MEDICAL EDUCATION

(Effective 4/1/2009, Reviewed/Approved 3/27/2014 by GMEC).
Policy and Guidelines for Interactions between the James H. Quillen College of Medicine, East Tennessee State University, and commercial interests ( i.e.,any entity producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients).

Purpose
The purpose of this policy is to establish guidelines for interactions with commercial interests for medical staff, faculty, staff, students, and trainees of the James H. Quillen College of Medicine, East Tennessee State University. The intent of this policy to recognize the potentially positive and important value of many of the interactions with commercial interests while providing a framework for an ethical relationship that avoids conflicts of interest that could influence patient care, research objectivity, the integrity of our education and training programs, or the reputation of individual faculty members or the institution.

Policy Statement
It is the policy of the James H. Quillen College of Medicine that interactions with commercial interests should be conducted so as to avoid or minimize conflicts of interest. When conflicts of interest do arise they must be managed appropriately, as described herein.

Principles for Interaction
As the James H. Quillen College of Medicine and commercial interests both share the goal of improving the health of our population, the following principles should be used in guiding interactions:

The interactions should serve to enhance the health of the public.
The interactions should be transparent.
All of the interactions must reflect high standards of medical professionalism that reach beyond applicable laws and regulations.
The interactions should involve reciprocal communications, with knowledgeable parties on both sides of the interactions.
The interactions should support and enable the free exchange of information in appropriate settings, assuring such exchanges are evidence-based and free of bias to the maximum possible extent.

Scope of Policy and Guidelines for Interaction
This policy addresses many types of interactions with commercial interests, e.g. pharmaceutical and device marketing, training, educational support of students and trainees, and continuing medical education. Its scope includes interactions with commercial interests both on-site and off-site.

1. Gifts to Individuals

Personal gifts from commercial interests may not be accepted anywhere at the Quillen College of Medicine, college clinical offices, or training sites. It is strongly advised that no form of personal gift from commercial interests be accepted under any circumstance.
Examples of prohibited transactions include but are not limited to the following:
1. Individuals may not accept gifts or compensation for listening to a sales talk by an industry representative.
2. Individuals may not accept gifts or compensation for prescribing or changing a patients prescription.
3. Individuals must consciously and actively divorce clinical care decisions from any perceived or actual benefits expected from any company. It is unacceptable for patient care decisions to be influenced by the possibility of personal financial gain.
4. Food supplied by a commercial interest is considered a personal gift and is not permitted at the Quillen College of Medicine, college clinical sites, or functions. This does not apply when food is provided in connection with ACCME accredited programming or through unrestricted grants to departments or divisions that follow ACCME guidelines.
5. Individuals may not accept compensation from commercial interests, including the defraying of costs, for simply attending a CME or other activity or conference unless the individual is speaking or otherwise actively participating or presenting at the event.

2. Pharmaceutical Samples

Sample medications are centrally managed at all ETSU facilities, in accordance with guidelines outlined by MEAC, ETSU Family Medicine and Associates, and individual departments.
Sample medications may only be dispensed to patients.

3. Site Access by Industry Representatives

Access of the representatives of commercial interests to individuals is limited to non-patient areas ( e.g., private physician offices at a practice location or conference rooms) and must take place by appointment or the invitation of a faculty member, with the following exceptions:
1. Access by device manufacturer representatives to patient care areas is permitted by appointment or invitation by faculty members or clinic supervisors.
2. Device manufacturer representatives may not be present during patient interactions unless there has been prior disclosure and consent by the patient. Such interactions must be limited to in-service training or assistance on devices and equipment.
3. Medical students and trainees may be included for educational purposes. These interactions must occur under the supervision of a faculty member.

4. Support for Educational and other Professional Activities

The Office of Continuing Medical Education administers all accredited CME activities to ensure compliance with ACGME standards ( www.acgme.org).
All educational events sponsored by the James H. Quillen College of Medicine and its departments or divisions must be compliant with ACGME Standards for Commercial Support ( www.acgme.org) whether or not CME credits are awarded, and whether or not they are held on or off campus.

5. Participation in Programs Sponsored by Commercial Interests

Faculty, staff, students, and trainees are strongly encouraged to avoid attending or speaking at meetings and conferences that are exclusively or primarily organized, underwritten, or presented by commercial interests because of the high potential for perceived or real conflict of interest. This provision does not apply to meetings of professional societies that may receive partial support from commercial interests or to meetings supported by commercial interests governed by ACGME Standards. It also does not apply to special and specific training on the use of new patient care medical devices for which alternate sources of education and training are not available.
Individuals who participate ( e.g., by giving a lecture, organizing the meeting) in meetings and conferences supported in part or in whole by commercial interests and not governed byACGME Standards should follow these guidelines:
1. Financial support by commercial interests is fully disclosed by the meeting sponsor.
2. The meeting or lecture content is determined by the speaker and not the commercial interest.
3. Participants, including the ETSU participant, are being expected to provide a fair and balanced assessment of therapeutic options and to promote objective scientific and educational activities and discourse.
4. The ETSU participant is not required by a commercial interest to accept advice or services concerning speakers, content, etc., as a condition of the sponsor's contribution of funds or services.
5. The ETSU participant makes clear that content reflects individual views and not the views of ETSU.
6. The use of the ETSU name in non-ETSU events is limited to the identification of the individual by his or her title and affiliation.

6. Sponsorship of Scholarships and Other Educational Funds for Trainees by Commercial Interests

Educational grants that are compliant with the ACGME standards ( www.acgme.org) may be received from commercial interests but must be administered by the Office of Continuing Medical Education, departments or divisions and not by individual faculty.
No quid pro quo may be involved for donated scholarship or educational funds.
The evaluation and selection of recipients of scholarships or grants is the sole responsibility of ETSU or of a nonprofit-granting industry, with no involvement by the donor commercial interest.

7. Professional Travel

a. Direct payments by commercial interests to ETSU faculty, staff, students, and trainees is not allowed other than for reimbursement of direct travel when the faculty, staff, student, or trainee is providing a legitimate service for which the travel is necessary and is reasonable in relation to the services provided.

8. Ghostwriting

ETSU faculty, staff, students, and trainees are prohibited from having publications or professional presentations of any kind, oral or written, ghostwritten by any party, industry or otherwise.
This does not apply to transparent writing collaboration with attribution between academic and industry investigators, medical writers, and/or technical experts.

9. Boards of Directors, Advisory Boards, and Consulting

ETSU faculty, staff, students, and trainees are allowed to interact as members of boards and/or as consultants via professional service agreements, as long as such activities are conducted in full compliance with the ETSU Conflict of Interest Policy and ETSU training program policies (https://www.etsu.edu/com/gme/reshandbook.aspx and Handbook2009.pdf)

10. Publications

In scholarly publications, individuals must disclose their related financial interests in accordance with the International Committee on Medical Journal Editors ( http://www.icmje.org)

11. Purchasing

Individuals having a direct role in making institutional decisions on equipment or drug procurement must disclose any financial interest they or their immediate family have in companies that might substantially benefit from the decision. They must also disclose any research or educational interest they or their department have that might substantially benefit from the decision. This provision does not include indirect ownership such as stock held through mutual funds.

EVALUATION POLICY

(Effective 7/12/2007, Revised/Approved 12/07/2017 by GMEC)
Residents are evaluated in writing at the end of each clinical rotation by their attending faculty. In addition, at least twice per year, formal meetings will be held with each resident to review rotational evaluations and other evaluative data relating to individual residents.

PROCEDURES:
Each residency program will have stated goals for the entire residency which are compatible with the ACGME special requirements and the appropriate specialty board.

Specific objective and performance standards will be defined for each rotation or curriculum segment of each residency program.

Each residency program will have a defined curriculum.

The residency program director for each program will be responsible for developing and implementing an on-going evaluation process of the program and of the individual residents in the program. The evaluation process will ensure that each resident is evaluated on a regular basis. This should include monthly rotation evaluations or periodic evaluations at a suitable interval of specific curriculum segments. Evaluations will be performed in writing and retain on file by the program director.

All faculty members will be expected to review their evaluations of a residents performance with that resident and to provide appropriate feedback and comments to the residents.

Periodically, formal meetings will be held with each resident to review rotational evaluations and other evaluative data relating to individual residents, such as results of in-training examinations. These feedback sessions should occur at a minimum of twice per year. These meetings will be conducted by the program director or by another faculty member designated by the program director and will be documented in writing. Such documentation will be signed by both the resident and the program director/designated faculty.

Evaluations will include cognitive, psychomotor and affective (or professional) domains of the residents experience.

The evaluation process will solicit residents to provide evaluations of their rotations, services, faculty and the institution, as well as other appropriate educational processes as deemed relevant by the program director.

GMEC POLICY

(Effective 7/1/2010, Revised/Approved 2/1/2018 by GMEC)
The Graduate Medical Education Committee is a standing committee of the Quillen College of Medicine. The GMEC is responsible for the oversight and administration of the ACGME-accredited programs and ensuring compliance with the ACGME Institutional, Common and specialty-subspecialty specific Program Requirements. All residency and fellowship programs at Quillen College of Medicine are overseen by the Associate Dean for Graduate Medical Education/Designated Institutional Official, chair of the GMEC. Voting members of the GMEC include all program directors, one fellowship program director, three peer selected resident/fellows, one peer selected program coordinator, and a Quality Improvement officer from the main training site.

Responsibilities of the GMEC to maintain oversight of training programs include the following:

Oversight of the accreditation status of the Sponsoring Institution and its ACGME-accredited programs.
Review all applications for ACGME accreditation of new programs and subspecialties.
Changes in resident complement.
Major changes in program structure or length of training.
Additions or deletions of training sites.
Appointments of new program directors.
Progress reports requested by any Review Committee including responses to proposed adverse actions.
Requests for exceptions of resident duty hours.
Requests to inactivate or reactivate a training program.
Voluntary withdrawals of ACGME-accredited programs.
Maintain oversight of the quality of the working environment of the programs and its participating sites.
Assure quality educational experiences that lead to measurable educational outcomes identified in the Common and specialty/subspecialty specific Program Requirements.
Develop and review policies and procedures that affect ACGME-accredited training programs and their trainees.

GMEC SPECIAL REVIEW POLICY

(Effective 7/1/2015)
The GMEC has established a process for conducting Special Review of programs. An individual program may be selected for Special Review based on underperformance, by request of its Program Director or at the direction of the GMEC or DIO. Any program with an ACGME accreditation status of continued accreditation with warning or probationary accreditation will undergo Special Review.

Criteria used in identifying underperformance may include, but are not limited to:

Program Attrition
1. Change in Program Director more often than once every two years
2. Decrease in core faculty >10% each year for two years
3. Residents/fellows withdrawing, transferring, or dismissed >10% for two consecutive years
Program Changes
1. major participating site has been added or removed
2. Consistently incomplete resident/fellow complement for two years
3. Major curricular changes
Scholarly Activity
1. Identified inadequate scholarly activity for either core faculty or residents/fellows
Board Pass Rates
1. Falling below the accepted specialty threshold over a three year period
Clinical Experience
1. Any significant changes in adequacy of clinical or didactic experience
ACGME Surveys
1. Poor response rate
2. Poor resident/fellow or faculty overall evaluation of the program
3. Problematic survey items
4. New or repeated problematic survey items previously identified
ACGME Responsibilities
1. Incomplete or inaccurate reporting of milestones or annual updates
2. Inability to meet common and program specific requirements
3. Inability to demonstrate success in the CLER focus areas
4. Incomplete or inaccurate annual program evaluation reports
  The DIO will convene a panel for each Special Review. The panel will consist of the DIO, the assistant deans in GME, and a team of participants from another program. Those individuals from another program will consist of a Program Director or associate Program Director, program coordinator, and resident/fellow member.
  
  Based on the identified concern, the program being reviewed may be asked to submit documentation prior to the Special Review visit that will help the panel gain clarity. Information used in the review process may include:
  1. The current ACGME common, specialty/subspecialty-specific program, and institutional requirements
  2. Letters of notification from the most recent ACGME review and any progress reports submitted to the RRC
  3. Reports from previous Special Reviews and old internal reviews
  4. Previous Annual Program Evaluations
  5. Results from ACGME resident/fellow and faculty surveys
  6. Other materials the panel considers necessary and appropriate

The Special Review panel will conduct interviews with the Program Director, key faculty members, selected residents/fellows from each year of training, and other individuals deemed appropriate. The panel will submit a written report to the program leadership and GMEC with recommendations of the panel. The DIO and GMEC will work with the Program Director on making necessary improvements, and continuing to monitor outcomes to ensure the program is meeting expectations.
The Program Director will provide an initial response to the report with specific details to demonstrate how the program is progressing in addressing concerns. Subsequently, the DIO may request additional reports from the program at future GMEC meetings as the program continues to make improvements based on individual program needs and the amount of progress made with action plans.

HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACTS OF 1996 (HIPAA)

HIPAA TRAINING, VIOLATIONS AND DISCIPLINARY ACTION (Effective 10/26/2017, Revised/Approved 10/24/2019 by GMEC)

The Health Insurance Portability and Accountability Act ("HIPAA") is federal law which protects the health information of individuals. This information is called Protected Health Information ("PHI"). During residency, residents will routinely be exposed to PHI. As part of their orientation, residents will receive HIPAA training which will be required to be completed annually thereafter. HIPAA violations can result in significant federal penalties for both individuals and organizations. Quillen College of Medicine and the Department of Graduate Medical Education regard HIPAA violations as serious offenses. Residents who do not know if a particular use or disclosure of PHI is appropriate should ask their supervisor or contact the ETSU HIPAA Compliance Officer for guidance.

Examples of HIPAA Violations:

Accessing your own medical records
Unauthorized copying of medical records
Leaving PHI in a public area
Discussing PHI in a non-secure area
Posting PHI on any social networking site
Removing medical records from a hospital or clinic without proper authority
Unapproved accessing of PHI when the Resident is not involved in the care of that particular patient
Intentionally assisting another person in gaining unauthorized access to PHI
Inappropriate sharing of ID/Password with another person
Unauthorized delivery of PHI to any third party
Use of PHI for research with IRB approval

These examples represent varying levels of severity.

Disciplinary actions for HIPAA violations can range from verbal counseling through dismissal from the residency program based on the severity of the violation. Each violation is evaluated on a case by case basic. Suspected violations should be reported to the HIPAA Compliance Office immediately. For further information please visit the ETSU HIPAA Compliance website https://www.etsu.edu/universitycounsel/hipaa/.

HOSPITAL SUSPENSION OF A RESIDENT

(Effective7/12/2007, Reviewed/Approved 12/7/2017 by GMEC)
The affiliated hospital administration and the Associate Dean for Graduate Medical Education may find cause to suspend a resident/fellow for clinical activities. When such a suspension occurs, the hospital administration will immediately notify the appropriate departmental chair and program director. The resident/fellow will be placed on paid Administrative Leave. Within five (5) working days the program director will convene a committee of two (2) departmental faculty selected by the program director and two representatives from the involved hospital selected by the hospital administration. This committee, chaired by the program director, will investigate the incident and recommend appropriate action to the departmental chair. Such action will also be communicated to the hospital administration representative in charge of graduate medical education. If the hospital administration is not agreeable with the committees recommendation to the chair, the issue will be submitted to the Executive Associate Dean for Graduate Medical Education. If an agreement can still not be reached with the hospital administration, the issue will be referred to the Dean of the College of Medicine and the CEO of the appropriate hospital. The ultimate decision regarding resident clinical privileges shall be made by the Hospital.

MECHANISM TO RESOLVE RESIDENT INITIATED GRIEVANCES It is desirable for residents' concerns to be resolved within the departmental structure. When resolution is not obtained the residents grievance regarding the residency program should be expressed to his/her preceptor, program director, department chair, or any other faculty member or administrative officer of the College of Medicine who will help to resolve the issue or agree on further action. If not resolved, the problem then will be brought by the involved resident and appropriate faculty member to the attention of the residents program director and the Executive Associate Dean for Graduate Medical Education. If there is still no resolution of the problem, the Executive Associate Dean for Graduate Medical Education will convene an ad-hoc committee and proceed with the due process. If the residents grievance is against the Executive Associate Dean for Graduate Medical Education, program director, department chair of any clinical department or any other person who might otherwise take part in the process of resolving the problem, the above steps will be structured to exclude the involvement of that person from the judging process.

MEDICAL LICENSES/EXEMPTIONS (Effective 7/12/2007, Revised/Approved 7/1/2017)
In accordance with Tennessee Code Annotated Section 63-6-207(d)(2), The Tennessee Board of Medical Examiners will exempt residents/fellows from the requirement of a Tennessee Medical License while participating in an accredited clinical training program in the State of Tennessee. Some programs may require residents/fellows to obtain a special training licenses. All residency programs will request and maintain the records of exemption.

Residents/fellows who moonlight must obtain a full licenses in the state in which the moonlighting occurs.

NON-RENEWAL OF RESIDENT CONTRACT (TIMELY) (Effective 7/12/2007, Revised/Approved 4/25/2013, Revised/Approved 12/4/2014 by GMEC)
Appointments are made on a year-to-year basis. Reappointment for subsequent years is dependent on the resident's satisfactory progress as monitored according to evaluation and promotion policies, the availability of training positions at the University, and funding. Should the University decide not to renew the appointment, the Physician will be notified by the program in as timely a manner as possible with the consent of the DIO.

OBSERVERSHIP/EXTERNSHIP POLICY (Effective 11/15/2012, Revised/Approved 7/1/2017)
The Quillen College of Medicine does not offer or provide the opportunity for externships or observerships to individuals holding the MD/DO degree (or its equivalent) who are not training in an ACGME or AOA approved residency. This policy does not apply to visiting faculty.

Medical students enrolled in an LCME or AOA accredited school may apply for M4 electives at the following link: https://www.etsu.edu/com/acadaffairs/visiting

OTHER LEARNER POLICY (Effective 1/1/2016)
The presences of other learners (including, but not limited to residents from other specialties, subspecialty fellows, medical students, pharmacy students and nursing students) must not interfere with the appointed residents' education. The program director should discuss the presence of other learners with the DIO to ensure the availability of adequate resources for resident education.

MOONLIGHTING POLICY (Outside Employment) (Effective 6/18/2002, Revised/Approved 12/7/2017 by GMEC)
Moonlighting (outside employment) refers to voluntary, compensated medically related work undertaken by a resident outside the context of the residency program. Resident/fellows may not engage in moonlighting activities that interfere with the responsibilities to their program, especially in the context of work hour limitations. Program Directors may establish a "no moonlighting" policy based on academic, workload, and/or work hour considerations. PGY I residents and residents holding a J1 Visa are not permitted to moonlight.

Residents may not engage in any outside employment or professional medical activity without first completing the QCOM Institutional Moonlighting Acknowledgment Form https://www.etsu.edu/com/gme/formslinks.aspx) and obtaining written approval of the program director. The Program Director is responsible for assuring there are no conflicts between their moonlighting schedule and requirements of the program. The program director is responsible for monitoring the health and program performance of the moonlighting resident and must take corrective action if these are adversely affected by the moonlighting activity. Additionally, the resident/fellow must enter moonlighting hours (both internal and external) as part of his/her duty hour log in New Innovations. Time spent moonlighting must be counted towards the 80-hour maximum weekly hour limit.

Program Directors reserve the right to deny moonlighting activity. Any resident/fellow failing to comply with moonlighting guidelines is subject to departmental disciplinary action. Any resident not in good standing may not moonlight.

Any resident/fellow engaged in moonlighting must be licensed for unsupervised medical practice in the state where the moonlighting occurs. It is the responsibility of the institution where moonlighting occurs to determine whether medical licensure is in place, whether adequate liability coverage is provided, and whether the resident/fellow has the appropriate training and skills to carry out assigned duties.

Professional liability insurance coverage provided by the QCOM DOES NOT extend to any medical practice or activities outside the medical education program of the University.

The QCOM does not encourage its residents/fellows to engage in outside employment. QCOM accepts no responsibility for the financial consequences to residents who engage in moonlighting.
Moonlighting Request Form

PERIODIC REVIEW OF GME POLICIES (Effective 3/28/2013)
The GMEC will review and revise its policies on an as-needed basis in response to changing circumstances, accreditation standards, etc., but the GMEC will review for educational appropriateness (and where indicated revise) all GME policies every 5 years.

PROFESSIONAL LIABILITY/MEDICAL MALPRACTICE INSURANCE (Effective 4/1/1980, Revised/Approved 9/22/2016;10/24/2019 by GMEC)

All residents/fellows are covered under the State of Tennessee for professional liability coverage by the Tennessee Claims Commission Act (TCA 9-8.301 et sq). The limits of liability are $300,000 per plaintiff/$1 million dollars per occurrence. State law provides that residents/fellows have absolute immunity from liability for acts or omissions within the scope of their employment, unless the acts or omissions are willful, malicious, criminal, or done for personal gain.

The immunity of resident/fellows under Tennessee law has no mandatory effect in the courts of other states. Residents who participate in rotations out of Tennessee must have additional malpractice. Please consult with your residency coordinator when planning an out of state rotation.

If you should receive a summons and complaint naming you or East Tennessee State University as a defendant in a civil lawsuit arising out of your residency with the University, please have them delivered to the University Legal Office.. Do not discuss the suit with anyone other than the University Legal Counsel or the Attorney General’s Office. Do not talk to the plaintiff or the plaintiff’s attorney. Refer all requests for documents to the University Legal Counsel or the Office of Graduate Medical Education.

The coverage does not extend to any medical practice or activities outside the medical education program of the University (moonlighting). Claims made after termination of training will be covered if based on acts or omissions of the resident within the course and scope of their assignments during training, therefore residents will not need to purchase tail coverage.

SECURITY BACKGROUND CHECK POLICY (Effective 11/15/2012; Revised 2/1/2018)

Quillen College of Medicine is committed to educating well-trained physicians who possess the traits of high moral character and standards. All prospective residents/fellows of Quillen must undergo a Criminal Background Check (CBC) as a condition for hire.
Review and approval of a completed CBC is a precondition to employment for new resident and fellow physicians. Based on requirements mandated by the State of Tennessee (T.C.A § 63-1-149), Quillen College of Medicine will not employee any resident or fellow who appears on any state's sexual offender registry, the national sex offender public registry website coordinated by the United State's Department of Justice, any state adult abuse registry, or the Tennessee Department of Health's elder abuse registry. The CBC may also reveal information not contained in the above registries that could disqualify one from being considered for employment.
Quillen College of Medicine uses an outside vendor contracted the Tennessee Board of Regents, for the CBC's of employee hires. The CBC will include a record of all arrests and convictions, including those that would lead to inclusion in the registry listings above. Failure of a resident or fellow to notify his/her program director of such events may result in disciplinary action up to and including termination. If the CBC evaluation identifies any issues that may preclude participation in activities when direct patient contact occurs, the case will be referred immediately to the Criminal Background Administrative Committee (CBAC) for evaluation. All post-hire employee reported events will also be referred to the CBAC committee. The CBAC is composed of the Executive Associate Dean for Academic Affairs, Associate Dean for Graduate Medical Education, and the Associate Dean for Student Affairs. This committee is responsible for making recommendations to the Dean who retains the authority to make the decision in all such matters about hiring or employee disciplinary action.Background Check Release Form

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SEXUAL HARASSMENT POLICY (ETSU Policy PPP-80, Effective 7/1/2007; Revised/Approved 10/26/2017; 10/24/2019 by GMEC)
East Tennessee State University desires to maintain an environment which is safe and supportive for students and employees and to reward performance solely on the basis of relevant criteria. Accordingly, the University will not tolerate sexual harassment of students or employees.

Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitute sexual harassment when: (1) Submission to such conduct is made either explicitly or implicitly a term or condition of an individuals employment or academic standing; (2) Submission to or rejection of such conduct by an individual is used as a basis for employment or academic decisions affecting an individual; or; (3) Such conduct has the purpose or effect of unreasonably interfering individuals work or academic performance or creating an intimidating, hostile or offensive working or academic environment.

Recommended actions to be taken by anyone who believes he or she is being sexually harassed:

In circumstances where you think you will not be jeopardizing your personal safety, your job, or your academic status, communicate clearly to the offender that the behavior is not humorous or welcome and should cease immediately.
Keep a record of what happened and when it took place. Should there be any witnesses, ask for their names to include in your documentation of the incident.
If the harassment continues, or if you choose not to confront the offender directly, you many report the situation to the Affirmative Action Officer, Office of the President. You may also report the situation to any of the other persons listed below who will assist you in preparing charges to be reported to the Affirmative Action Officer:

Associate Vice President of Student Affairs
Box 70725, (423) 439-4210

Affirmative Action Officer for ETSU
Office of the President, 206 Dossett Hall (423) 439-4211

Source: Tennessee Board of Regents (TBR) Personnel Policy No: 5:01:02:00; TBR Personnel Guide No. P-080.

Violations will be forwarded to Human Resources for employee incidents or Student Affairs for student incidents. The individual department will handle the progressive discipline for repeat violators. Visitor violations will be forwareded to Public Safety and contractor violations to the Facilities Office.

PROFESSIONALISM AND PERSONAL RESPONSIBILITY (Effective 3/27/2014)
The physician in training must:

Provide competent medical services and patient-centered care with compassion, respect and cultural sensitivity
Discharge patient care, educational and administrative duties in a timely manner
Maximize patient safety
Maintain patient confidentiality
Interact honestly, professionally and where appropriate, privately with patients, staff and colleagues
Recognize impairment, including illness and fatigue, in him/herself and in others
Adopt the habit of continuous self-improvement (lifelong learning)Maintain a professional appearance and demeanor (see Dress Code policy)

ETSU GME programs must model and residents must demonstrate adherence to these principles of professionalism and personal responsibility.

PROMOTION OF RESIDENTS (Effective 7/12/2007, Revised/Approved 2/24/2013 by GMEC)
Residents are promoted from one year to the next based upon meeting the academic standards and curricular requirements of the program as determined by the Program Director and the Resident Evaluation/Clinical Competency Committee. Evaluation of resident performance includes review of program specific milestones as determined by evaluations and performance measures.

QUALITY IMPROVEMENT/PATIENT SAFETY POLICY (Effective 7/1/2017; Revised/Approved 1/25/2018 by GMEC)

Purpose:
To provide quality health care services to patients and to create a culture that promotes performance assessment and improvement in the delivery of those services.

Policy:
East Tennessee State University in accordance with the Institutional Requirements of the Accreditation Council for Graduate Medical Education (ACGME), requires each Program to conduct a review of complications and deaths on a regular basis. Programs must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs. Programs must incorporate Quality Improvement/Patient Safety Conferences into its curriculum.

East Tennessee State University has purchased a group subscription with Institute for Healthcare Improvement (IHI) Open School. These online courses cover a range of topics in improvement capability; patient safety; triple aim for populations; person and family centered care; leadership; and Graduate Medical Education. All residents/fellows are required to complete the online courses.

RESIDENT SUPERVISION (Effective 7/12/2007, Revised/Approved 4/25/2013 by GMEC, Revised/Approved 10/27/2017 by GMEC)
The common program requirements for resident/fellow supervision shall be met. This includes but is not limited to:
In the clinical learning environment, each patient must have an identifiable, appropriately credentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patients' care. This information should be available to residents, faculty members, and patients; and the patients should be informed of these roles in their care.

The program must use the following classification of supervision:

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

The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members. The program director must evaluate each resident's abilities based on specific criteria. When available, evaluation should be guided by specific national standards-based criteria. Faculty members functioning as supervising physicians should delegate portions of care to residents, based on the needs of the patient and the skills of the residents. Senior residents or fellows should serve in a supervisory role of junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow. Programs must set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members, such as the transfer of a patient to an intensive care unit, or end-of-life decisions.

Each resident must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence. PGY-1 residents must be supervised either directly or indirectly with direct supervision immediately available. [Every discipline's Review Committee will describe the achieved competencies under which PGY-1 residents' progress to be supervised indirectly, with direct supervision available.] Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility.

RESTRICTIVE COVENANTS/ NON COMPETE CLAUSE (Effective 7/12/2007, Revised/Approved 11/15/2012 by GMEC)
In accordance with ACGME accreditation standards, no house staff member enrolled in an accredited training program sponsored by Quillen College of Medicine shall be required by ETSU or its teaching affiliates to sign any type of non-compete agreement or restrictive covenant.

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SECURITY BACKGROUND CHECKS FOR RESIDENT APPLICANTS (Effective 11/15/2012, Revised/Approved 2/01/2018 by GMEC)
Quillen College of Medicine is committed to educating well-trained physicians who possess the traits of high moral character and standards. All prospective residents/fellows of Quillen must undergo a Criminal Background Check (CBC) as a condition for hire.

Review and approval of a completed CBC is a precondition to employment for new resident and fellow physicians. Based on requirements mandated by the State of Tennessee (T.C.A. 63-1-149), Quillen College of Medicine will not employee any resident or fellow who appears on any state's sexual offender registry, the national sex offender public registry website coordinated by the United States Department of Justice, any state adult abuse registry, or the Tennessee Department of Health's elder abuse registry. The CBC may also reveal information not contained in the above registries that could disqualify one from being considered for employment.

Quillen College of Medicine uses an outside vendor contracted with the Tennessee Board of Regents, for the CBCs of employee hires. The CBC will include a record of all arrests and convictions, including those that would lead to inclusion in the registry listings above. A list of the information checked and evaluated in the CBC may change from time to time.

After hiring, all residents and fellows are required to disclose within five (5) working days of their occurrence, any criminal charges or events. Failure of a resident or fellow to notify his/her program director of such events may result in disciplinary action up to and including termination.

If the CBC evaluation identifies any issue that may preclude participation in activities where direct patient contact occurs, the case will be referred immediately to the Criminal Background Administrative Committee (CBAC) for evaluation. All post-hire employee reported events will also be referred to the CBAC. The CBAC is comprised of the Executive Associate Dean for Academic Affairs, Associate Dean for Graduate Medical Education, and the Associate Dean for Student Affairs. This committee is responsible for making recommendations to the Dean who retains the authority to make the decision in all such matters about hiring or employee disciplinary action.

The College reserves the right, at its sole discretion, to amend, replace, and/or terminate this policy at any time.

Release Authorization Form

SOCIAL NETWORKING (ETSU Policy PPP.44, Effective 7/12/2007; Revised/Approved 10/26/2017 by GMEC)
The Graduate Medical Education Committee recommends that residents and fellows exercise caution in using social networking sites such as Facebook, Instagram, Twitter and Snapchat. Items that represent unprofessional behavior posted by residents on such networking sites are not in the best interest of the University and may result in disciplinary action up to and including termination.

Residents and Fellows are expected to exhibit a high degree of professionalism and personal integrity consistent with the pursuit of excellence in the conduct of his or her responsibilities. They must avoid identifying their connection to the University if their online activities are inconsistent with the values or could negatively impact the University's reputation.

If using social networking sites, residents and fellows must use a personal e-mail address as their primary means of identification. Their University e-mail address must never be used for personal views. Residents/fellows who use these websites must be aware of the critical importance of privatizing their websites so that only trustworthy friends have access to the websites/applications.

In posting information on personal social networking sites, residents may not present themselves as an official representative or spokesperson for a residency/fellowship program, hospital, or the University. Patient privacy must be maintained and confidential or proprietary information about the University or hospitals must not be shared online. Patient information is protected under the Health Insurance Portability and Accountability Act (HIPAA). Residents/fellows have an ethical and legal obligation to safeguard protected health information and posting or e-mailing patient photographs is a violation of the HIPAA statute. Violations could result in residents/fellows immediate suspension and/or termination.

TOBACCO-FREE CAMPUS (Effective 08/11/2008, Revised/Approved 09/22/2016;10/24/2019 by GMEC)
Effective October 1, 2019, the James H. Quillen VA Medical Center has a no smoking policy on the VA Campus. This includes no smoking in vehicles, as well as the grounds on the ETSU Quillen College of Medicine areas of the campus. This policy covers all smoking material, including but no limited to:

Cigarettes
Cigars
Any other combustion of tabocca
Electronic nicotine delivery systems (ENDS), including but not limited to electronic or e-cigarettes, vape pens, or e-cigars.

August 11, 2008, ETSU is a Tobacco-Free Campus, with smoking and all other tobacco usage permitted only in private vehicles. This policy applies to all university buildings/grounds; ETSU-affiliated off-campus locations and clinics; any buildings owned, leased or rented by ETSU in all other areas; and ETSU facilities located on the campus of the James H. Quillen Veterans Affairs Medical Center at Mountain Home. Tobacco use is also prohibited in all state vehicles. This tobacco-free policy is in effect 24 hours a day year-round.
For purposes of the policy, "tobacco use" means, but is not limited to, the personal use of any tobacco product, whether intended to be lit or not, which shall include smoking tobacco or other substances that are lit and smoked, as well as the use of any electronic cigarette or any other tobacco; smokeless pouches; any form of loose-leaf, smokless tobacco; and the use of unlit cigarettes, cigars and pipe tobacco.

Background - The university promotes a healthy, sanitary environment free from tobacco smoke and tobacco-related debris. The ETSU community acknowledges that long-term health hazards may accrue to people who use tobacco products or who are subjected to second-hand smoke. The failure to address the use of tobacco products on campus would constitute a violation of the Americans with Disabilities Act, the Vocational Rehabilitation Act and Tennessee law Support

Support - Understanding the addictive nature of tobacco products, ETSU will make every effort to assist those who may wish to stop using tobacco. The university offers current information about available resources via Smoking Cessation Resources page.

Compliance - It is the responsibility of all members of the ETSU community to comply with this Tobacco-Free Campus Policy. Violations of the policy will be dealt with in a manner that is consistent with university procedures. There shall be no reprisals against anyone reporting violations of this policy.

Tobacco Free Campus Enforcement Policy

Violations to the tobacco free policy, particularly reoccurring violations, are to be reported to Public Safety 439-4480
Any violator of the policy that refuses to comply or that becomes abusive toward the responsible party will be handles by Public Safety.

TRANSFER OF RESIDENT POLICY AND PROCESS (Effective 9/25/2013, Revised/Approved 1/28/2016 by GMEC)
According to ACGME Institutional Requirement, the institution and our ACGME accredited programs are at risk for loss of accreditation if non-eligible residents are accepted into our training programs. For that reason, any applicant under consideration for transfer must be reviewed and approved by the Designated Institutional Official in the Office of Graduate Medical Education prior to an offer being extended.

The following documents are required for any resident being considered and must be provided to the Designated Institutional Official for review.

Written or electronic verification of the prior educational experience
Summative, competency-based performance evaluation of the transferring resident based on the Milestone assessment by the Clinical Competency Committee. Verification should also include evaluations, rotations completed, procedural/operative experience. **Please utilize the Transfer Checklist provided below.
Letter of recommendation from the resident's current program director.
Obtain confirmation from respective ABMS certifying board of the amount of credit that will be granted from prior program.
Fellowship programs must receive verification of each fellow's level of competency in the required field usually ACGME or CanMED's Milestones assessments from the core residency program.

For any resident transferring from a QCOM training program to another program prior to completion of training, the QCOM program director must provide:

Written or electronic verification of residency education
Summative, competency-based performance evaluation for the resident

A resident/fellow transferring out of a residency/fellowship program at Quillen College of Medicine must do the following:

Notify their program director in a timely manner.
Must complete all program specific requirements (i.e. call, medical records, documents, etc.) and all program specific exit requirements.
Must meet with their program director to review and sign the final verification of training form.

Transfer Process and Checklist

Supporting Information:

*ACGME Glossary: "Residents are considered as transfer residents under several conditions including: moving from one program to another within the same or different sponsoring institution; when entering a PGY2 program requiring a preliminary PGY 1 program and the PGY 2 program as part of the match (e.g., accepted to both programs right out of medical school). Before accepting a transfer resident, the program director of the 'receiving program' must obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation from the current program director. The term 'transfer resident' and the responsibilities of the two program directors noted above do not apply to a resident who has successfully completed a residency and then is accepted into a subsequent residency or fellowship program."

Direct communication with the ACGME establishes that any resident entering categorical residency from a preliminary year, even if this is occurring within the same department, is a transfer resident and the program must receive the list of previous education experiences and the summative evaluation prior to accepting him.

The ACGME Program Director Guide to the Common Program Requirements (July 1, 2007) also includes clarification of the expectation for documentation of resident transfers: For residents who have transferred into the program, written verification of prior educational experience and a summative competency-based performance evaluation should be available in the resident files for site visitors to review. Examples of verification of previous educational experiences could include a list of rotations completed, evaluations of various educational experiences, procedural/operative experience. Meeting the requirement for verification before accepting a transferring resident is complicated in the case of a resident who has been simultaneously accepted into the preliminary PGY 1 program and the PGY 2 program as part of the match. In this case, the "sending" program should provide the "receiving" program a statement regarding the resident's current standing as of one-two months prior to anticipated transfer along with a statement indicating when the summative competency-based performance evaluation will be sent to the "receiving" program.

An example of an acceptable verification statement is: (Resident name) is currently a PGY (level) intern/resident in good standing in the (residency) program at (sponsoring institution). She/he has satisfactorily completed all rotations to date, and we anticipate she/he will satisfactorily complete his/her PGY (#) year on June 30, (year). A summary of her/his rotations and a summative competency-based performance evaluation will be sent to you by July 31, (year).

TRANSITIONS OF CARE POLICY (Effective 1/1/2016, Revised/Approve 12/07/2017 by GMEC)

PURPOSE
To establish protocol and standards with the Quillen College of Medicine residency and fellowship Programs to ensure the quality and safety of patient care when transfer of responsibility occurs during Duty hour shift changes and other scheduled or unexpected circumstances.

POLICY
Each resident/fellowship program, in partnership with their Sponsoring Institutions must design schedules and clinical assignments to maximize the learning experience for their residents/fellows as well as to ensure quality care and patient safety, and adhere to general institutional policies concerning transitions of patient care within the context of other duty hour standards. All programs must design call and shift schedules to minimize transition of patient care. Schedule overlaps should include time to allow for face-to-face handoffs to ensure availability of information and an opportunity to clarify issues. The transition process may be conducted by telephone as long as both parties have access to an electronic or hard copy version of the sign-out sheet. Patient confidentiality must be observed. The transition process should include, at a minimum the following information in a standardized format that is universal across all services.

Identification of patient, including name, medical record number and date of birth.
Identification of admitting/primary/supervising physician and contact information.
Diagnosis and current status/condition (level of acuity) of patient.
Recent events, including changes in condition or treatment, current medication status, recent lab tests, allergies, anticipated procedures and actions to be taken.
Outstanding tasks-what needs to be completed in immediate future.
Outstanding laboratories/studies-what needs follow up during shift.
Changes in patient condition that may occur requiring interventions or contingency plans.

Each resident/fellowship program must develop components ancillary to the institutional transition of care policy that integrate specifics from their specialty field. Programs are required to develop scheduling and transition/hand-off procedures to ensure that:

Residents comply with specialty specific/institutional duty hour requirements.
Faculty are scheduled and available for appropriate supervision levels according to the requirements for the scheduled residents.
All parties involved in a particular program and/or transition process have access to one anothers' schedules and contact information. All call schedules should be available on department-specific-password-protected websites and also with hospital operators.
Patients are not inconvenienced or endangered in any way by frequent transitions of their care.
All parties directly involved in the patients care before, during and after the transition have opportunity for communication, consultation and clarification of information.
Safeguards exist for coverage when unexpected changes in patient care may occur due to circumstances such as resident illness, fatigue or emergency.
Programs should provide an opportunity for residents to both give and receive feedback from each other or faculty physicians about their handoff skills.

Each residency/fellowship program must include the transition of care process in their curriculum and ensure continuity of patient care. Residents must demonstrate competency in performance of this task. There are numerous mechanisms through which a program might elect to determine the competency of trainees in handoff skills and communication. These include:

Direct observation of a handoff session by a supervisory level clinician, by a peer or by a more senior resident.
Evaluation of written handoff materials by clinician, by a peer or by a more senior trainee.
Didactic sessions on communication skills including in-person lectures, web-based training, review of curricular materials and/or knowledge assessment.
Assessment of handoff quality in terms of ability to predict overnight events.
Assessment of adverse events in relationship to sign-out quality through:
1. Survey
2. Reporting hotline
3. Chart review

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

There is a standardized process in place that is routinely followed.
There is consistent opportunity for questions.
The necessary materials are available to support the handoff (including for example, written sign-out materials and access to electronic clinical information).
A setting fee of interruptions is consistently available for handoff processes that include face-to-face communications.
Patient confidentiality and privacy are ensured in accordance with HIPAA guidelines.

There are circumstances in which residents/fellows may be unable to attend work, including but not limited to fatigue, illness and family emergencies. Each program must have policies and procedures in place that ensure coverage of patient care responsibilities. These policies must be implemented without fear of negative consequences for the resident/fellow who are unable to provide the clinical work.

Residents/fellows must care for patients in an environment that maximizes communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty and larger health system.

VISAS AND FOREIGN MEDICAL GRADUATES (Effective 7/12/2007, Revised/Approved 2/1/2018 by GMEC)
The clinical departments of the Quillen College of Medicine each maintain policies for selecting and accepting candidates into graduate medical education (GME) residency and fellowship training programs. These policies must be followed for graduates of foreign medical school as for all other eligible candidates.

International graduates who are not permanent U.S. residents or U.S. citizens must be willing to obtain a J-1 exchange visitor visa sponsored by the Education Commission to Foreign Medical Graduates (ECFMG) if they are chosen according to the rules of the NRMP Match, or have an Employment Authorization Card (EAD). They are also expected to be willing to obtain a J-1 for placement in the unusual circumstance of being accepted outside of the NRMP Match.

WELL BEING POLICY (Effective 7/1/2017, Revised/Approved 2/1/2018 by GMEC)
East Tennessee State University, Quillen College of Medicine is committed to ensuring that residents and fellows remain physically and mentally healthy while completing their training program. Recognizing that residents and fellows are at increased risk for burnout and depression, Quillen College of Medicine will prioritize efforts to foster resident well-being while ensuring the competence of its trainees.

Each residency/fellowship program will have policies and schedules in place that define ways in which residents and fellows will be supported in their efforts to become a competent, caring and resilient physician.

These must include:

Ensure protected time dedicated to patient care;
Provide administrative support;
Provide oversight of scheduling, work intensity and work compression that may negatively impact a resident/fellow’s well-being;
Policies for time away from the residency/fellowship that allow the resident/fellow the opportunity to attend medical, mental health and dental care appointments, including those scheduled during their working hours;
Education regarding recognizing the symptoms of burnout, depression and substance abuse, including recognizing these symptoms in themselves and how to seek appropriate care;
Monitoring workplace safety date to address the safety of residents/fellows;
Have programs and resources available that encourage optimal resident/fellow well-being;
Provide information about the Resident Assistant Program (RAP) that provides access to confidential, affordable mental health assessment, counseling and treatment 24 hours a day, seven days a week.

All of these must be implemented without fear of negative consequences for the resident/fellow who may be having any issues interfering with their well-being.

WORKERS' COMPENSATION POLICY (Effective 7/1/1980, Revised/Approved 10/26/2017 by GMEC)
Residents/fellows are considered employees of East Tennessee State University for worker's compensation purposes. To receive workers' compensation benefits, you must be injured while performing some activity which falls within your scope of employment.

All injuries/illnesses (including needle sticks) to residents/fellows while they are performing services for ETSU may be compensable. All injuries/illnesses should be reported to the immediate supervisor and to the Workplace Injury Call Center (866) 245-8588 as soon as possible.

Failure to file an accident report and/or claim within a reasonable time may result in denial of a claim.

WHAT TO DO IN CASE OF INJURY AT WORK:
Call 911 for all emergencies that are life threatening. Notify your supervisor immediately.
If not an emergency, you and your supervisor must call the CorVel 24/7 Call Center at Corvel, 1-866-245-8588.
Select Option #1 to speak to a nurse for immediate care. The registered nurse will evaluate and determine care/treatment options over the phones.
Hospitals, doctor's office, labs, etc. should bill CorVel for services, not the resident. Please do not present your personal health insurance card for payment.

For additional information or questions call the Office of Human Resources at (423) 439-4787.