1. No category

Graduate Medical Education
Policy and Procedure Manual
Effective July 1, 2014
http://www.childrensmercy.org/Content/view.aspx?id=344
These Policies and Procedures establish the guidelines for residency and fellowship training at Children’s Mercy Hospital
(CMH). These guidelines reflect minimum training policies. Programs must meet these minimum guidelines, but are free to
adopt more rigorous policies as they see fit or as necessary to meet the requirements of the Accreditation Council for Graduate
Medical Education (ACGME) or other accrediting organizations.
When conflicts exist between Graduate Medical Education (GME) Policies and Procedures and individual Program policies, GME
Policies and Procedures will take precedence. Similarly, should conflict arise between GME Policies and Procedures or the
Program policies and the requirements of the ACGME or other accrediting organizations, the policy of the accrediting
organization will take precedence. Any other conflicts that arise between CMH written training policies and other guidelines or
policies will be resolved by the Chair or Vice Chair of GME and the CMH Executive Vice-President/Executive Medical Director.
The content of this manual is subject to change. Unless otherwise noted, all policies become effective upon publication on the
CMH external website.
Page 1 of 49
Last Updated: 7/1/2013
TABLE OF CONTENTS
1.
ABOUT CHILDREN’S MERCY HOSPITALS & CLINICS
1.1 Mission and Vision
2. INTRODUCTION TO GRADUATE MEDICAL EDUCATION
2.1
ACGME
2.2
Graduate Medical Education Committee
3. ACCREDITED RESIDENCY AND FELLOWSHIP TRAINING PROGRAMS
4. SELECTION AND APPOINTMENT OF RESIDENTS/FELLOWS
4.1
Eligibility
4.2
Application
4.3
Interviews
4.4
Selection
4.5
Appointment
5. AGREEMENT OF APPOINTMENT
5.1
Oversight of Appointments
5.2
Parties
5.3
Term
5.4
Appointment Level
5.5
Stipend (Salary)
5.6
Benefits
5.7
Modification of Amendment
5.8
Nonrenewal
5.9
Restrictive Covenants
5.10
Severance by the Resident/Fellow
5.11
Decision by the Sponsoring Institution not to Offer Subsequent Appointment
5.12
Closure of a Program
5.13
Annulment
5.14
Transfers
6. RIGHTS AND RESPONSIBILITIES
6.1
The Resident/Fellow Responsibilities
6.2
Hospital Responsibilities
6.3
Program Director Responsibilities
6.4
Levels of Supervision
6.5
Transitions of Care
6.6
Records Management
6.7
Needle Stick
6.8
Guidelines for Industrial Sales Representatives (Vendors)
7. BENEFITS
7.1
Health Care Plans
7.2
Income Protection & Security
7.3
Take CARE Wellness Programs
7.4
Retirement Plans
7.5
Time off Plans
7.6
Other Benefits
8. EQUAL OPPORTUNITY EMPLOYMENT
9. ANTI-DISCRIMINATION/ANTI-HARASSMENT
10. RESIDENTS/FELLOWS WITH DISABILITIES
10.1
Definitions
10.2
Procedure
11. CODE OF PROFESSIONAL AND PERSONAL CONDUCT
11.1
Professionalism
11.2
Personal Appearance
11.3
Name Badge
11.4
Smoking and Tobacco Free Environment
12. DRUG AND ALCOHOL POLICY
12.1
Employee Assistance for Drug or Alcohol Related Problems
12.2
Return to Work
12.3
Employee Knowledge of Substance Misuse and Illegal Activity
12.4
Testing of Employees
12.5
Definitions
12.6
Release of Information
Page 2 of 49
4
4
4
5
5
7
7
8
8
9
9
9
9
10
10
10
10
10
11
11
11
11
11
11
12
12
12
12
13
14
14
15
15
15
16
17
17
17
18
19
19
19
21
24
24
25
25
26
26
26
27
28
28
29
29
29
30
30
31
32
Last Updated: 7/1/2013
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
12.7
Workers Compensation and Employment
12.8
Exclusions
RESIDENT/FELLOW IMPAIRMENT
13.1
Definitions
13.2
Procedure
PERSONAL USE OF SOCIAL MEDIA
14.1
Guidelines for CMH Employees Participation in Non-Hospital Social Media
14.2
Inappropriate Postings
EDUCATIONAL PROGRAM & ACGME COMPETENCIES
INTERNATIONAL ROTATION/EDUCATIONAL UNIT
16.1
Eligibility Criteria for Internal Elective Rotation/Educational Unit
16.2
Travel Criteria
16.3
Return from Travel
DUTY HOURS AND CALL SCHEDULES
17.1
Limitations on Duty-hours
17.2
Minimum Time Off between Scheduled Duty Periods
17.3
Maximum Frequency for In-House Night Float
17.2
Call Frequency
EXTRA SHIFTS AND MOONLIGHTING
EVALUATION
19.1
Resident/Fellow Evaluation
19.2
Faculty Evaluation
19.3
Program Evaluation and Improvement
PROMOTION AND PROGRAM COMPLETION
20.1
Promotion/Advancement
20.2
Program Completion
CORRECTIVE ACTIONS, SUSPENSION AND TERMINATION
21.1
Categories and Criteria
21.2
Authority
21.3
Reporting Obligations
21.4
Remediation
21.5
Probation
21.6
Suspension
21.7
Termination
21.8
Due Process
21.9
Voluntary Withdrawal from a Program
GRIEVANCES
22.1
Grievable Matters
22.2
Non-Grievable Matters
22.3
Grievance Procedures
Page 3 of 49
32
32
32
32
33
34
35
36
36
37
37
38
38
38
38
39
39
39
39
40
40
41
41
41
41
42
42
42
42
43
43
43
43
44
45
46
46
46
46
47
Last Updated: 7/1/2013
1.
CHILDREN’S MERCY HOSPITALS & CLINICS
From our beginning as a single bed hospital in 1897, Children’s Mercy Hospital (CMH) in Kansas City has grown into the
pediatric specialty provider of choice for families throughout the region. Working closely with community physicians and
hospitals, CMH makes the highest quality pediatric expertise and care a priority. We are here for all children.
CMH is committed to providing service excellence and efficiency to everyone we serve. We achieve our high standards through
leadership in clinical care, education and research; all focused exclusively on children and their unique needs.
Clinical Care
 Medical staff of over 700 pediatric specialists
 A comprehensive range of programs and services, representing more than 40 pediatric specialties
 First hospital in Missouri or Kansas to receive magnet designation from the American Nurses Credentialing Center for
superior nursing quality
Education
 Affiliation with University of Missouri-Kansas City (UMKC) School of Medicine
 Pediatric Fellowship training in over 36 subspecialties
 Residency training in Pediatrics, Internal Medicine & Pediatrics, Clinical Child Psychology, Dentistry, Pediatric
Optometry, and an integrated Child Neurology Program
 Medical student clerkship in Pediatrics for the UMKC School of Medicine
 Medical student electives
Research
 A research vision that includes clinical pharmacology and personalized medicine, genetics, oncology, neonatology,
immunology and health outcomes
 A nationally designated Pediatric Pharmacology Research Unit that provides state-of-the-art facilities for clinical trials
 A collaborating partner for Frontiers: The Heartland Institute for Clinical and Translational Science Awards
Mission and Vision
Mission
CMH provides the highest level of medical care, technology, services, equipment and facilities in promoting the health and
well-being of children in the region, from birth through adolescence. Patients and their families are treated with compassion in
a family-centered environment that recognizes their physical, emotional, financial, social and spiritual needs. The
comprehensive health care environment provided by the hospital includes clinical services, research and teaching efforts which
are designed to serve today's and tomorrow's children and the community in which they live.
Vision
CMH commits to providing quality pediatric medical care with service excellence and efficiency to everyone we serve.
2. INTRODUCTION TO GRADUATE MEDICAL EDUCATION
The Graduate Medical Education (GME) Department prepares physicians for practice in a medical specialty or subspecialty.
GME focuses on the development of professional skills and clinical competencies as well as on the acquisition of medical
knowledge in a specialty or subspecialty. The GME process is intended to prepare the physician for the independent practice of
medicine and to assist in the development of a commitment to the life-long learning process that is critical for maintaining
professional growth and competency.
The single most important responsibility of the GME Department is to provide an educational training Program with guidance
and supervision of the Resident/Fellow that facilitates professional and personal growth while ensuring safe and appropriate
patient care. Residents/Fellows are expected to assume progressively greater responsibility through the course of training,
consistent with individual growth in clinical experience, knowledge and skill.
Page 4 of 49
Last Updated: 7/1/2013
The education of Residents/Fellows relies on an integration of didactics into a structured curriculum with the clinical care under
appropriate levels of supervision. The quality of the GME experience is directly related to the quality of patient care.
Upon satisfactory completion of a training Program, the Resident/Fellow is prepared to undertake independent practice within
the chosen specialty or subspecialty. Residents/Fellows in Programs accredited by the Accreditation Council for Graduate
Medical Education (ACGME) typically complete the educational requirements for certification by a specialty board recognized
by the American Board of Medical Specialties (ABMS).
The level of stipends (salaries), the provision of other “benefits,” the duty hours, the length of training Programs, the
rotation/educational unit of Residents/Fellows to various services, and the methods of testing and evaluating
Residents/Fellows, are necessarily determined by the hospital, the Programs and Sponsoring Institution based on ACGME and
specialty board guidelines.
CMH recognizes that with the authority vested in the Hospital to determine the terms of the Agreement of Appointment comes
the responsibility to provide levels of support sufficient to allow the Residents/Fellows to pursue their educational goals and to
administer the Programs fairly and uniformly.
2.1
ACGME
1
The ACGME is a private, nonprofit council that evaluates and accredits residency and fellowship programs in the United States.
The ACGME was established in 1981 from a consensus in the academic medical community for an independent accrediting
organization.
The mission of the ACGME is to improve health care by assessing and advancing the quality of resident physicians' education
through exemplary accreditation.
The ACGME has 28 Review Committees (one for each of the 26 specialties, one for a special one-year transitional-year general
clinical program, and one for institutional review). Each Residency Review Committee (RRC) comprises about 6 to 15 volunteer
physicians. Members of the RRC are appointed by the American Medical Association (AMA) Council on Medical Education and
the appropriate medical specialty boards and organizations. Members of the Institutional Review Committee and Transitional
Year Committee are appointed by the ACGME Executive Committee and confirmed by the Board of Directors.
The ACGME's member organizations are the American Board of Medical Specialties, American Hospital Association, American
Medical Association, Association of American Medical Colleges, and the Council of Medical Specialty Societies. Member
organizations each nominate four members to the Board of Directors, which also includes two resident members—the chair of
the Council of Review Committee Residents and a resident member appointed by the Resident and Fellow Section of the
AMA—three public directors, the chair of the Council of Review Committees, one to four at-large directors, and a non-voting
federal representative.
2.2
Graduate Medical Education Committee
2
CMH is the ACGME accredited institutional sponsor for the Child Neurology, Clinical Neurophysiology, Pediatric Otolaryngology,
and Pediatric Rehabilitation Medicine Fellowship Programs. CMH also sponsors and supports other programs that are
accredited by specialty boards or other accrediting or governing organizations. The UMKC School of Medicine is an ACGME
accredited institutional sponsor for CMH programs in Pediatrics and a number of Pediatric Subspecialties. Policy and Procedure
is defined by the applicable ACGME accredited Sponsoring Institution GMEC and by CMH.
The ACGME accredited Sponsoring Institution (UMKC or CMH) Graduate Medical Education Committee (GMEC) monitors the
regular review of all Residency/Fellowship training Programs regarding compliance with institutional policies and Program
requirements. CMH GMEC meetings are held quarterly and minutes are maintained.
The CMH GMEC is charged with establishing and implementing policies and procedures regarding the quality of education and
the work environment for the Residents/Fellows in ACGME Programs. These policies and procedures include the following:
1
2
http://www.acgme.org/acWebsite/newsRoom/newsRm_acGlance.asp
ACGME Institutional Requirements, III
Page 5 of 49
Last Updated: 7/1/2013
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Stipends (salaries) and position allocation: Annual review and recommendations to the Sponsoring Institution
regarding Resident/Fellow stipends (salaries), benefits, and funding for Resident/Fellow positions.
Communication with Program Directors (PDs):
i. ensure that communication mechanisms exist between the CMH GMEC and PDs; and
ii. ensure that PDs maintain effective communication mechanisms with the site directors at each participating site
for their respective Programs to maintain proper oversight at all clinical sites.
Resident/Fellow duty hours:
i. develop and implement written policies and procedures regarding Resident/Fellow duty hours to ensure
compliance with the Institutional, Common, and specialty/subspecialty-specific Program Requirements; and
ii. consider for approval requests from PDs prior to submission to an RRC for exceptions in the weekly limit on duty
hours up to 10 percent or up to a maximum of 88 hours in compliance with ACGME Policies and Procedures for
duty hour exceptions.
Resident/Fellow supervision:
i. provision of safe and effective patient care;
ii. educational needs of Residents/Fellows;
iii. progressive responsibility appropriate to Residents’/Fellows’ level of education, competence, and experience; and
iv. other applicable Common and specialty/subspecialty-specific Program Requirements.
Communication with Medical Staff: Communication between leadership of the Medical Staff regarding the safety and
quality of patient care that includes:
i. the annual report to the Office of Medical Staff;
ii. description of Resident/Fellow participation in patient safety and quality of care education; and,
iii. the accreditation status of programs and any citations regarding patient care issues.
Curriculum and evaluation: Assurance that each program provides a curriculum and an evaluation system that enables
Residents/Fellows to demonstrate achievement of the ACGME general competencies as defined in the Common and
specialty/subspecialty-specific Program Requirements.
Resident/Fellow status: Selection, evaluation, promotion, transfer, corrective action, and/or dismissal of
Residents/Fellows in compliance with the Institutional and Common Program Requirements.
Oversight of program accreditation: Review of all CMH ACGME program accreditation letters of notification and
monitoring of action plans for correction of citations and areas of noncompliance.
Management of CMH institutional accreditation: Review of CMH ACGME letter of notification from the IRC and
monitoring of action plans for correction of citations and areas of noncompliance.
Oversight of program changes: Review of the following for approval, prior to submission to the ACGME by PDs:
i. all applications for ACGME accreditation of new Programs;
ii. changes in Resident/Fellow complement;
iii. major changes in program structure or length of training;
iv. additions and deletions of participating sites;
v. appointments of new PDs;
vi. progress reports requested by a Review Committee;
vii. voluntary withdrawal of Program accreditation;
viii. requests for an appeal of an adverse action; and,
ix. appeal presentations to a Board of Appeal or the ACGME.
Experimentation and innovations: Oversight of all phases of educational experiments and innovations that may
deviate from Institutional, Common, and specialty/subspecialty-specific Program Requirements, including:
i. approval prior to submission to the ACGME and/or respective Review Committee;
ii. adherence to Procedures for “Approving Proposals for Experimentation or Innovative Projects” in ACGME Policies
and Procedures; and
iii. monitoring quality of education provided to Residents/Fellows for the duration of such a project.
Oversight of reductions and closures: Oversight of all processes related to reductions and/or closures of:
i. individual Programs;
ii. major participating sites; and,
iii. the Sponsoring Institution.
Page 6 of 49
Last Updated: 7/1/2013
3.
RESIDENCY AND FELLOWSHIP TRAINING PROGRAMS
Program
Length of
Program
3
2
3
5
1
1
2
1
3
2
3
3
1
Accrediting
Organization
ACGME
ACGME
ACGME
ACGME
APA
n/a*
ACGME
ACGME
ACGME
ABMG
ACGME
n/a*
n/a*
Institutional
Sponsor
UMKC
UMKC
UMKC
CMH
CMH
CMH
CMH
CMH
UMKC
CMH
UMKC
UMKC
CMH
Medical Specialty Board
offering Certification
www.abp.org
www.abai.org
www.abp.org
www.abpn.com
n/a*
n/a*
www.abmg.org
www.abpn.com
www.abp.org
www.abmg.org
www.abp.org
n/a*
n/a *
Pediatrics
Allergy/Immunology
Child Abuse Pediatrics
Child Neurology
Clinical Child Psychology Internship
Clinical Child Psychology Fellowship
Clinical Cytogenetics
Clinical Neurophysiology
Developmental-Behavioral Pediatrics
Molecular Genetics
Neonatal-Perinatal Medicine
Pediatric Adolescent Gynecology
Pediatric and Congenital
Cardiovascular Perfusion
Pediatric Cardiology
3
ACGME
UMKC
www.abp.org
Pediatric Clinical Pharmacology
3
ABCP
CMH
www.abcp.net
Pediatric Critical Care Medicine
3
ACGME
UMKC
www.abp.org
Pediatric Dentistry
1
CODA
CMH
n/a*
Pediatric Dermatology
1
ABD
CMH
www.abderm.org
Pediatric Emergency Medicine
3
ACGME
UMKC
www.abp.org
Pediatric Endocrinology
3
ACGME
UMKC
www.abp.org
Pediatric Ethics and Genomics
1
n/a
CMH
n/a*
Pediatric Gastroenterology
3
ACGME
UMKC
www.abp.org
Pediatric Hematology/Oncology
3
ACGME
UMKC
www.abp.org
Pediatric Hospital Medicine
3
AAP
CMH
www.aap.org
Pediatric Infectious Diseases
3
ACGME
UMKC
www.abp.org
Pediatric Nephrology
3
ACGME
UMKC
www.abp.org
Pediatric Ophthalmology
1
AAPOS
CMH
n/a*
Pediatric Optometry
1
ACOE
CMH
n/a*
Pediatric Otolaryngology
1
ACGME
CMH
n/a*
Pediatric Pathology
3
ACGME
UMKC
www.abpath.org
Pediatric Radiology
1
ACGME
UMKC
www.theabr.org
Pediatric Rehabilitation Medicine
2
ACGME
CMH
www.abpmr.org
Pediatric Surgery
2
ACGME
UMKC
www.absurgery.org
Sleep Medicine
3
ACGME
UMKC
http://www.absm.org/
Surgical Critical Care
1
ACGME
UMKC
www.absurgery.org
Surgical Scholars
1
n/a*
CMH
n/a*
AAP -American Academy of Pediatrics
AAPOS: American Association for Pediatric Ophthalmology and Strabismus
ABCP: American Board of American Pharmacology
ABD: American Board of Dermatology
ABMG - American Board of Medical Genetics
ACGME: Accreditation Council for Graduate Medical Education
ACOE: Accreditation Council on Optometric Education
APA: American Psychological Association
CODA: Commission on Dental Accreditation
* No national accrediting organization exists and/or no specialty certification offered at this time
4.
SELECTION AND ELIGIBILITY OF RESIDENTS/FELLOWS
Page 7 of 49
Last Updated: 7/1/2013
4.1
Eligibility
a.
b.
c.
d.
3
Applicants to the Clinical Child Psychology Internship training program must meet the following qualifications to be
eligible for appointment as an Intern:
i.
enrolled in a doctoral program in professional psychology that requires internship training;
ii.
expected completion of a practicum experience by the start of internship.
Applicants to the Pediatric Clinical Pharmacology Fellowship training program must meet the following qualifications
to be eligible for appointment as a Fellow:
i.
possess an M.D., D.O., Ph.D, or Pharm. D degree;
ii.
must have completed an academic training program in either Pediatrics or Pediatric Pharmacotherapy;
iii.
must have a desire to pursue an academic career with an emphasis on the evaluation of drugs in children.
Applicants for Clinical Cytogenetics and/or Molecular Genetic Fellowship training program(s) must meet the following
qualification:
i.
Possess an MD, DO or PhD degree; PhD degree must be in genetics, human genetics, or related field within
the biological sciences, as determined by the American Board of Medical Genetics and Genomics (ABMGG).
ii.
Individuals who hold doctoral degrees earned outside of the US, Canada or Puerto Rico or who have received
their medical training outside of the US, Canada or Puerto Rico need to meet additional requirements
determined by ABMGG (see web-site for details).
Applicants to all other programs must meet the following qualifications to be eligible for appointment as a
Resident/Fellow:
i.
graduation from a medical school in the United States, Canada or Puerto Rico accredited by the Liaison
Committee on Medical Education (LCME); or
ii.
graduation from a college of osteopathic medicine in the United States accredited by the American
Osteopathic Association (AOA); or
iii.
graduation from a medical school outside the United States with successful completion of a Fifth Pathway
Program provided by an LCME accredited medical school; or
iv.
graduation from a medical school outside the United States, Canada or Puerto Rico with a current, valid
certificate from the Educational Commission for Foreign Medical Graduates (ECFMG).
All Canadian citizens and eligible Canadian Landed Immigrants who are NOT graduates of a foreign medical school must hold a
Professional Worker (TN or Trade-NAFTA) non-immigrant Visa status and maintain proper TN status throughout the length of
the graduate medical training Program. Possession of a valid I-94 card with stated TN status and CMH as the sponsor is
required.
All Canadian citizens and eligible Canadian Landed Immigrants who ARE graduates of a foreign medical school must seek and
maintain sponsorship through the ECFMG for J-1 non-immigrant Visa status.
CMH primarily accepts applicants with J-1 Visa status. To be eligible for appointment, all international citizens must be
sponsored by the ECFMG for the J-1 nonimmigrant Visa classification and have and maintain valid ECFMG certification
throughout the length of their training Program. In some cases, CMH will sponsor an H-1B Visa. Residents/Fellows who wish to
change their immigration classification while pursuing a graduate medical training Program at CMH must seek prior written
approval from the GME Department. Failure to seek such approval will subject the trainee to immediate termination from
his/her training Program.
4.2
Application
Application to a Program is the first step in the process of credentialing a Resident/Fellow for appointment. Most Programs
either participate in the National Resident Matching Program (NRMP) or the San Francisco Match (SFM) as well as the
Electronic Residency Application Service (ERAS). A list of participating Specialties and Programs can be found on the ERAS
website at https://services.aamc.org/eras/erasstats/par/. Applicants to Programs, who do not apply through ERAS or the SFM,
must submit supporting credentials directly to the PD or Program Coordinator (PC). These include:
3
ACGME Institutional Requirements, II.A.1.
Page 8 of 49
Last Updated: 7/1/2013
a.
b.
c.
d.
e.
f.
g.
h.
application form (Program application or the GME application);
letters of recommendation;
Medical School Performance Evaluation/Dean’s letter;
medical school/graduate school transcript;
personal statement;
USMLE or COMLEX transcript;
ECFMG status report and copy of ECFMG certificate (for graduates of foreign medical schools); and
curriculum vitae.
Applicants beyond the PGY 1 level must also provide evidence of successful completion of Part III of the USMLE and successful
completion of previous PGY level(s).
4.3
Interviews
Applicants invited for an interview will arrange the date with the PC. The applicant will arrange for transportation. If the
applicant is traveling from outside the Kansas City metropolitan area, one night hotel accommodation at a designated local
hotel will be provided by CMH and up to $300 of applicable travel costs will be reimbursed.
4
During or prior to the interview day, the applicant will receive information on salary and benefits .
4.4
Selection
5
A selection committee consisting of the PD, Associate Program Director (APD), Chief Residents, if applicable, and representative
faculty will review each candidate’s application. The candidates will be ranked based on the strength of the application and
personal interview. For those programs participating in the NRMP, the rank order list will be forwarded to the NRMP prior to
the published deadline. Occasionally, candidates will be selected outside the NRMP in compliance with NRMP rules. It is the
policy of CMH not to discriminate on the basis of race, color, religion, sex, pregnancy, sexual orientation, national origin, age,
disability, veteran or military status, genetic information, or any other legally protected status in admissions or access to, or
treatment or employment in its programs and activities, or in the provision of physician/staff privileges.
4.5
Appointment
Before appointment and upon receipt of a contingent offer of appointment, the applicant will provide the Department of GME
with the following documents:
a. copy of signed Offer/Acceptance Letter;
b. copy of signed Agreement of Appointment;
c. proof of legal employment status (e.g., birth certificate, passport, naturalization papers, valid Visa) and verification of
immigration and Visa status as well as a copy of an ECFMG certificate indicating the validation dates, if applicable;
d. a copy of a current temporary or permanent license to practice medicine in the State of Missouri;
e. a copy of a current temporary or permanent license in the appropriate jurisdiction, if their Program requires
rotation/educational unit to affiliate institutions outside the State of Missouri;
f. evidence of current certification in Basic Life Support (BLS) and Pediatric Advanced Life Support (PALS) or Neonatal
Resuscitation Program (NRP), as required by the individual Programs, unless certification is provided by the Program
during orientation;
g. verification of a Missouri Bureau of Narcotic and Dangerous Drug certificate if Resident/Fellow;
h. a copy of a current Drug Enforcement Agency (DEA) registration. Residents/Fellows using the CMH DEA number and
authorized suffix can write only for CMH patients. Residents/Fellows writing for other populations/institutions in the
State of Missouri must obtain and use either an individual Missouri DEA number or use the other institution’s DEA
authorized suffix. A DEA registration issued for the State of Missouri is not valid for the State of Kansas or any other
state. If the Resident/Fellow has a rotation/educational unit at CMH South in the State of Kansas, the Resident/Fellow
must obtain a CMH DEA number and authorized suffix to write only for CMH South patients. If the Resident/Fellow
4
5
ACGME Institutional Requirements, II.C.
ACGME Institutional Requirements, II.A.2.
Page 9 of 49
Last Updated: 7/1/2013
i.
has a rotation/educational unit at an affiliate site in the State of Kansas, the Resident/Fellow must obtain an individual
Kansas DEA number or use the other institution’s DEA authorized suffix, and;
all complete documents required for employment by the Hospital such as complete immunizations and TB testing, a
complete and satisfactory background check, and a complete application for CMH employment.
At the time of orientation, Residents/Fellows will receive any immunizations that are lacking. The Resident/Fellow will
continue to meet the Hospital’s and the state's standards for immunizations in the same manner as all Hospital personnel for
the duration of their training.
5.
AGREEMENT OF APPOINTMENT6
5.1
Oversight of Appointments
Final approval of all Resident/Fellow Appointments is the responsibility of the GME Department.
No offer of a position should be made without the approval of the GME Department.
If the Resident/Fellow Appointment is based on incomplete, inaccurate or fraudulent information submitted by a candidate or
Program during the application, selection, or appointment process, the Appointment can be rescinded in accordance with
NRMP guidelines.
5.2
Parties
The Agreement of Appointment allowing a Resident/Fellow to participate in a GME Program is between CMH and the
individual Resident/Fellow (through the GME Department). Programs will not go into an Agreement of Appointment with a
candidate for professional or educational services independently from the CMH GME Department.
5.3
Term
7
Unless modified by the Program and approved by the GME Department, the Agreement of Appointment term is one year,
commencing on July 1st and ending on June 30th of the next year, and can be repeated yearly for the length of the training
Program.
The Agreement of Appointment does not constitute or imply a benefit, promise, option, or other commitment by the Hospital
to offer a subsequent Agreement of Appointment, or otherwise renew or extend the Agreement of Appointment of the
Resident/Fellow beyond the termination date of an existing Agreement of Appointment.
The decision to offer a subsequent Agreement of Appointment to a Resident/Fellow does not imply a duty or obligation to
simultaneously promote the Resident/Fellow to the next training level in the Program.
Residents/Fellows subject to corrective actions or pursuing appeal and hearing of a proposed corrective action will not be
offered a subsequent Appointment unless and until the corrective actions are completed or the appeal and hearing process
produces a finding for the Resident/Fellow.
5.4
Appointment Level
The Agreement of Appointment shall specify the Resident’s/Fellow’s training level of appointment by both the postgraduate
year level (PGY) and the Program training level.
5.5
Stipend (Salary)
8
6
ACGME Institutional Requirements, II.D.
ACGME Institutional Requirements, II.D.4.b)
8
ACGME Institutional Requirements, II.D.4.c)
7
Page 10 of 49
Last Updated: 7/1/2013
All Residents/Fellows in CMH Programs receive stipends (salaries) as prescribed in the Resident/Fellow Agreement of
Appointment. The base stipend (salary) is determined yearly by the Resident’s/Fellow’s PGY level and is set during the annual
budgetary process. The yearly stipends (salaries) are published and can be found on the GME Website. The stipends (salaries)
will be taxable to the Resident/Fellow.
5.6
Benefits
All Residents/Fellows employed by CMH have benefits as outlined in Section 7 (Benefits) of this manual.
5.7
Modification and Amendment
All modifications and amendments to an Agreement of Appointment will be in writing, attached as addenda to the Agreement
of Appointment, and referred to in the body of the Agreement of Appointment.
5.8
9
Nonrenewal
In instances where a Resident’s/Fellow’s Agreement of Appointment is not going to be renewed, CMH will ensure that its
programs provide the Resident(s)/Fellow(s) with a written notice of intent not to renew the Agreement no later than four
months prior to the end of the Resident’s/Fellow’s current Agreement of Appointment. However, if the primary reason(s) for
the nonrenewal occurs within the four months prior to the end of the Agreement of Appointment, CMH will ensure that its
programs provide the Residents/Fellows with as much written notice of the intent not to renew as the circumstances will
reasonably allow, prior to the end of the Agreement of Appointment.
5.9
Restrictive Covenants
Programs cannot make or enforce any covenants intended to restrict the choice of practice location, practice structure, or the
professional activity of individuals who have completed their post-graduate medical education programs through the
Agreement of Appointment. Any attempt to make or enforce such covenants will be grounds for sanction of the program.
5.10
Severance by the Resident/Fellow
The Resident/Fellow may sever his/her Appointment at any time after notice to the PD and Chair or Vice Chair of GME, unless
such notice is waived by the Sponsoring Institution.
The Resident/Fellow will provide at least 60 days written notice of severance to the PD and the GME Department.
5.11
Decision by the Sponsoring Institution not to Offer Subsequent Appointment
The treatment of the Resident/Fellow in the event of a decision to not offer a subsequent Appointment will be in compliance
with the applicable personnel policies of the Sponsoring Institution, state and federal laws and regulations, and ACGME
requirements.
Considerations that may cause the Sponsoring Institution or Hospital not to offer a subsequent Agreement of Appointment
include, but are not limited to, loss of funding for the position, reallocation of positions among the postgraduate Programs, loss
of accreditation by the Program or Institution, decreased financial resources, or closure of the Program or Hospital.
Such decisions, based solely on institutional factors, will be final and not subject to appeal or review under the provisions for
due process and fair hearing. Further, such decision will not be grievable.
In instances where an Agreement of Appointment is not going to be renewed, the Resident/Fellow will be provided notice of
intent not to renew the Agreement of Appointment no later than 90 days prior to the end of the current Agreement of
Appointment. However, if the primary reason for the nonrenewal occurs within the 90 days prior to the end of the Agreement
9
ACGME Institutional Requirements, II.D.4.d).(1)
Page 11 of 49
Last Updated: 7/1/2013
of Appointment, the Hospital or Sponsoring Institution will ensure that the Resident/Fellow receives as much written notice of
the intent not to renew as the circumstances will reasonably allow, prior to the end of the Agreement of Appointment. In the
event of nonrenewal, the Resident/Fellow shall have the right to due process as described in Section 21.8 (Due Process) of this
manual.
5.12
Closure of a Program
10
In the event that a Program or Sponsoring Institution is closing, de-accredited, or discontinued for any reason, through actions
by the accrediting bodies, the GMEC, DIO and Residents/Fellows will receive written notification.
The Sponsoring Institution will:
a.
b.
c.
5.13
allow Residents/Fellows already in the program(s) to complete their education or assist the Residents/Fellows in
enrolling in an ACGME-accredited program(s) in which they can continue their education;
provide stipend (salary) and benefits up until the conclusion of the term of the existing Agreement of Appointment;
and
provide appropriate notification to licensure and specialty boards.
Annulment
A Resident's/Fellow’s Appointment will be annulled and terminated automatically and immediately upon the rejection of the
application for Missouri medical licensure or the suspension or termination of the Resident’s/Fellow’s temporary or permanent
license(s) in any jurisdiction; or if the Resident/Fellow fails to provide valid documentation to process them through Human
Resources (e.g. valid social security number, valid identification, valid driver’s license)
The Resident/Fellow must report such rejection, suspension, or termination immediately to the PD and the GME Department.
If, after a previous rejection, suspension or termination, the Resident/Fellow succeeds in obtaining a valid Missouri license, or if
the suspended or terminated license is reinstated, the Resident/Fellow may again seek appointment.
An Appointment will also be immediately annulled if:
a.
b.
c.
5.14
the Resident/Fellow is a foreign citizen whose Visa is revoked;
the Resident/Fellow fails to provide valid credentials, including but not limited to diplomas, certificates of prior
training, valid ECFMG certificate or copies of medical licenses; or
the application or any documents submitted to the Hospital or any accrediting, certifying, or licensing agencies in the
process of seeking an Appointment or license contains inaccurate, incomplete, or fraudulent information.
Transfers
11
Programs can accept Residents/Fellows transferring from another Program. Before a Program can accept a transfer, the PD
must obtain written or electronic verification of previous educational experiences and a summative competency-based
performance evaluation of the transferring Resident/Fellow.
PD’s must also provide timely verification of residency/fellowship education and summative performance evaluations for
Residents/Fellows who leave a Program prior to completion.
6.
RIGHTS AND RESPONSIBILITIES12
The existence of a valid Agreement of Appointment between a Resident/Fellow and CMH establishes a series of explicit and
implicit expectations, rights, obligations and responsibilities beyond those codified in the Agreement of Appointment.
10
ACGME Institutional Requirements, II.D.5.
ACGME Common Program Requirements III.C.
12
ACGME Institutional Requirements, II.D.4.a)
11
Page 12 of 49
Last Updated: 7/1/2013
Although the Residents/Fellows are licensed to practice medicine in the State of Missouri and Kansas if applicable, their
participation in clinical activities during their GME training is at the discretion of the Hospital, and the PDs. The participation of
the Residents/Fellows in patient care must in no way interfere with the best interests and well-being of patients and is subject
to these policies and procedures and to the terms and conditions set forth in the Agreement of Appointment.
Residents/Fellows who do not comply with these policies and procedures or who violate the Agreement of Appointment may
be subject to corrective action, suspension and termination as outlined in Section 20 (Promotion and Program Completion) of
this manual.
6.1
The Resident/Fellow will:
a.
b.
c.
adhere to the policies and procedures for GME;
adhere to the corresponding policies and procedures of all training facilities;
adhere to the applicable federal, state, and local laws, as well as to the standards required to maintain accreditation
by the Joint Commission (JC), ACGME, and any other relevant accrediting, certifying, or licensing organizations;
d. participate fully in the educational and scholarly activities of the program, including the performance of scholarly and
research activities as assigned or as necessary for the completion of educational requirements, meet educational
conference attendance requirements, assume responsibility for teaching and supervising other Residents/Fellows and
students, and participate in assigned Hospital committee activities;
e. provide safe, effective, timely, efficient, equitable, and compassionate patient-centered care;
f. adhere to the highest standards of professionalism at CMH and other training facilities;
g. provide clinical services commensurate with his/her level of training, under appropriate supervision by the faculty
medical staff, and at sites specifically approved by the Program;
h. develop and follow a personal program of self-study and professional growth under the guidance of the PD and
teaching faculty;
i. acquire an understanding of ethical, socioeconomic, and medical/legal issues that affect the practice of medicine and
GME training as prescribed by the appropriate ACGME or other accrediting body;
j. fully cooperate with the Program and Sponsoring Institution in coordinating and completing ACGME accreditation
submissions and activities, including:
i.
the timely completion of patient medical records, reports, duty hour logs, operative and procedure logs
at CMH and training facilities; and
ii.
submission of timely and complete faculty and Program evaluations, and/or other documentation
required by the ACGME, Sponsoring Institution, Department, and/or Program;
k. acquire and maintain life support certification(s) as required by the Program and Hospital;
l. adhere to the Hospital’s Risk Management Program;
m. report immediately to the CMH Legal Affairs & Risk Management Department any inquiry by any private or
government attorney or investigator and refrain from communicating with any inquiring attorneys or investigators
except merely to refer such attorneys and investigators to the Legal Affairs & Risk Management Department;
n. report and refer any inquiry by any member of the press to the Hospital’s Department of Community Relations;
o. abide by the Hospital’s institutional policies prohibiting discrimination and sexual harassment;
p. meet CMH’s and the State's standards for immunizations;
q. return, at the time of the expiration or in the event of termination of the Agreement of Appointment, all Hospital and
department property, including but not limited to books, equipment, badges, pagers, and complete all medical charts
and Program evaluations;
r. settle all professional and financial obligations; and permit the Hospital to obtain from and provide to all proper
parties any and all information as required or authorized by law or by any accreditating body. Progress reports, letters
and evaluations will be provided only to individuals, organizations and credentialing bodies that are authorized by the
Resident/Fellow to receive them for purposes of pre-employment or pre-appointment assessments. This provision will
extend the completion, termination or expiration of the Appointment;
s. In those instances where a Resident/Fellow feels that a faculty physician’s practices or judgments are impaired or are
otherwise not in the best interests of a patient, the Resident/Fellow must report her/his concerns to the PD, Vice Chair
of GME, Chair of GME and/or Division Director;
t. participate in the CMH Quality and Safety Program;
u. abide by the Hospital’s Levels of Supervision as outlined in Section 6.4 (Levels of Supervision) of this manual; and
v. abide by the Programs policy on transitions of care;
Page 13 of 49
Last Updated: 7/1/2013
w. in the event of manmade, environmental, or other disasters, Residents/Fellows (classified as essential staff) are
required to report to the hospital and provide help as determined by the hospital administration. The PD will provide
the needed guidance to the Resident/Fellow during such emergencies.
6.2
The Hospital will:
a.
provide a stipend (salary) and benefits to the Resident/Fellow as stipulated in the applicable Agreement of
Appointment;
b. provide an educational training Program that meets the ACGME's accreditation standards or applicable accrediting
body;
c. use its best efforts, within the limits of available resources, to provide the Resident/Fellow with adequate and
appropriate support staff and facilities in accordance with federal, state, local, and ACGME requirements;
d. orient the Resident/Fellow to the facilities, rules, regulations, procedures and policies of the Hospital, Department and
Program and to the ACGME’s Institutional and Program Requirements;
e. provide the Resident/Fellow with appropriate faculty classification of supervision for all educational and clinical
activities;
f. allow the Resident/Fellow to participate fully in the educational and scholarly activities of the Program and Hospital
and in any appropriate institutional medical staff activities, councils and committees, particularly those that affect
GME and the role of the Resident/Fellow in patient care;
g. clearly communicate to the Resident/Fellow any expectations, instructions and directions regarding patient
management;
h. maintain an environment conducive to the health and well being of the Resident/Fellow;
i. provide adequate food service while on in-house-call or otherwise engaged in clinical activities requiring the
Resident/Fellow to remain in the Hospital overnight;
j. provide adequate sleeping quarters to the Resident/Fellow while on in-house overnight call;
k. provide personal protective equipment;
l. provide patient and information support services;
m. provide security;
n. evaluate the educational and professional progress and achievement of the Resident/Fellow on a regular and periodic
basis;
o. provide a fair and consistent method for review of concerns and/or grievances, without the fear of reprisal;
p. provide, upon satisfactory completion of the Program, a Certificate of Completion; and
q. incorporate and monitor the Residents/Fellows participation in the CMH Quality and Safety Programs.
13
6.3
The Program Director will :
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
13
administer and maintain an educational environment conducive to educating the Residents/Fellows in each of the
ACGME competency areas;
oversee and ensure the quality of didactic and clinical education in all sites that participate in the program;
approve a site director at each participating site who is accountable for Resident/Fellow education;
approve the selection of Program faculty as appropriate;
evaluate Program faculty and approve the continued participation of Program faculty based on evaluation;
monitor Resident/Fellow supervision at all participating sites using the classifications of supervision outlined in Section
6.4 (Levels of Supervision) of this manual.
prepare and submit all information required and requested by the ACGME, including but not limited to the program
information forms and annual program resident updates to the Accreditation Data System (ADS), and ensure that the
information submitted is accurate and complete;
provide each Resident/Fellow with documented semi-annual evaluation of performance with feedback;
ensure compliance with grievance and due process procedures as set forth in the Institutional Requirements and
referenced in Sections 21.8 (Due Process) and 22 (Grievances) of this manual;
provide verification of residency/fellowship education for all Residents/Fellows, including those who leave the
program prior to completion;
ACGME Common Program Requirements, II.A.4.
Page 14 of 49
Last Updated: 7/1/2013
k.
implement policies and procedures consistent with the Institutional and Program requirements for Resident/Fellow
duty hours and the working environment, including moonlighting, and, to that end, distribute these policies and
procedures to the Residents/Fellows and faculty;
l. monitor Resident/Fellow duty hours, according to Sponsoring Institution policies, with a frequency sufficient to ensure
compliance with ACGME requirements;
m. adjust schedules as necessary to mitigate excessive service demands and/or fatigue; and, if applicable, monitor the
demands of at-home call and adjust schedules as necessary to mitigate excessive service demands and/or fatigue;
n. monitor the need for and ensure the provision of back up support systems when patient care responsibilities are
unusually difficult or prolonged;
o. comply with the Sponsoring Institution’s written policies and procedures, including those specified in the Institutional
Requirements, for selection, evaluation and promotion of residents, corrective action, and supervision of residents;
p. be familiar with and comply with ACGME and Review Committee policies and procedures as outlined in the ACGME
Manual of Policies and Procedures;
q. obtain review and approval of the Sponsoring Institution’s GMEC/DIO before submitting to the ACGME information or
requests for the following:
i.
all applications for ACGME accreditation of new programs;
ii.
changes in Resident/Fellow complement;
iii.
major changes in program structure or length of training;
iv.
progress reports requested by the Review Committee;
v.
responses to all proposed adverse actions;
vi.
requests for increases or any change to Resident/Fellow duty hours;
vii.
voluntary withdrawals of ACGME-accredited programs;
viii.
requests for appeal of an adverse action;
ix.
appeal presentations to a Board of Appeal or the ACGME; and
x.
proposals to ACGME for approval of innovative educational approaches.
r. obtain DIO review and co-signature on all program information forms, as well as any correspondence or document
submitted to the ACGME that addresses:
i.
program citations; and/or
ii.
request for changes in the program that would have significant impact, including financial, on the program or
institution.
6.4 Levels of Supervision
14
To ensure oversight of Resident/Fellow supervision and graded authority and responsibility, the Program will use the following
classification of supervision:
a. Direct supervision - the supervising physician is physically present with the Resident/Fellow and patient.
b. Indirect supervision - with direct supervision available, the supervising physician is physically within the hospital or
other site of patient care, and is immediately available to provide direct supervision or the supervising physician is not
physically present within the hospital or the site of patient care, but is immediately available by means of telephonic
and/or electronic modalities, and is available to provide direct supervision.
c. Oversight - the supervising physician is available to provide review of procedures/encounters with feedback provided
after care is delivered.
6.5 Transitions of Care
15
Clinical assignments are designed to minimize the number of transitions in patient care. The Sponsoring Institution, CMH
and each Program will monitor effective, structured hand-over processes to facilitate both continuity of care and patient
safety. Programs will ensure that Residents/Fellows are competent in communicating with team members in the handover process. CMH will ensure the availability of schedules that inform all members of the health care team of faculty and
Residents/Fellows currently responsible for each patient’s care.
6.6 Records Management
14
15
ACGME Common Program Requirements, VI.D.3.
ACGME Common Program Requirements, VI.B.
Page 15 of 49
Last Updated: 7/1/2013
Resident/Fellow files serve as both records of employment and academic program records. They are the primary source
used for verification of training throughout the career of most physicians. As such, it is necessary that they are accurate
and contain all information needed for licensure and medical privileges applications. The files also serve as a record of a
Resident’s/Fellow’s performance and competency. In order to ensure that all Residents/Fellows trained at CMH have
training records that support their future needs, a uniform policy of minimal standards for records management is
implemented. This policy recognizes four categories of Resident/Fellow:
a. Residents/Fellows who are accepted into and complete their program;
b. Residents/Fellows who are accepted into but do not complete their program;
c. Individuals that apply and are interviewed for the program but do not enroll in the program;
d. Individuals that apply for the program but are not interviewed for a program position.
Program Applicants: It is important that an accurate description of the applicant pool is maintained for a minimum of
three years. This can be most effectively accomplished by maintaining each application (either electronically or in hard
copy). The application includes the standard application form plus all supporting documents (personal statement, exam
scores, letters of recommendation). A Resident/Fellow Selection Policy outlining the criteria used to select
Residents/Fellows for the training program is acceptable.
Interviewed Applicants: All records pertaining to interviewed applicants must be maintained for a minimum of three
years. In addition to the full application and supporting documents, this would typically include interview evaluation forms
used by the program to obtain feedback from program faculty and Residents/Fellows about each applicant.
Program Resident/Fellow: Resident/Fellow files are kept in three categories:
a. employment and immigration records maintained by CMH Human Resources;
b. contract, credentialing, and academic records maintained by GME; and
c. health records maintained by Occupational Health
GME will be responsible for maintaining records related to Resident/Fellow academic program participation, completion,
and medical/dental/optometry licensure. The required elements of the GME Resident/Fellow file should include:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
agreement of appointment;
state medical/dental license;
BNDD/DEA Certification;
ECFMG certificate (for graduates of foreign medical schools);
completion/Certificate of Completion;
consent for release of information;
written performance evaluations from faculty and others;
semi-annual summary evaluations from the PD or selected faculty;
record of the resident’s/fellow’s rotations and other training experiences;
record of surgical and procedural training;
corrective action;
moonlighting approval form (for applicable residents);
documentation of prior training and performance evaluation (for transferring residents); and
any other information specifically required by the training program accrediting body.
GME files will be kept electronically and will be available for the Resident/Fellow to review. Resident/Fellow should give
GME 48 hours to retrieve the documents.
6.7 Needle Stick
Residents/Fellows exposed to a needle stick need to report to Occupational Health immediately or page the CMH
Occupational Health Nurse Supervisor. If the needle stick occurs at a participating site other than CMH, the
Resident/Fellow will follow the policy at that facility and report to CMH Occupational Health the following day.
Page 16 of 49
Last Updated: 7/1/2013
6.8 Guidelines on Industry Gifts
16
Residents/Fellows will observe AMA Guidelines on Industry Gifts.
a. Unacceptable Gifts: Cash; Subsidies for travel, lodging or personal expenses, or in compensation of time spent for
physician attending conferences/meetings; Payment for token focus groups, consulting or advisory services; or Gifts
with “strings attached,” such as those given in relation to a physician’s prescribing practices.
b.
Acceptable Gifts: Textbooks and other educational gifts not of substantial value; Work-related gifts of minimal value;
pens, note pads and penlights; Subsidies to underwrite the costs of continuing medical education conferences or
professional meetings; Scholarships for medical students and Residents/Fellows to attend educational conferences, if
selection and payment is made by the academic institution; Reasonable compensation and reimbursement of
expenses sustained by consultants; and modest meals, in conjunction with educational programs.
7.
BENEFITS
7.1
Health Care Plans
The Resident/Fellow is eligible to participate in the following “Take Care” benefits plans at CMH’s expense. Coverage is
effective the first day of their Program.
Residents/Fellows are required to enroll/re-enroll in Health Care benefits on an annual basis. To maintain enrollment in the
Enhanced or Premium Medical Plans you must complete the Health Basics Check and Health Risk Assessment on an annual
basis.
a.
b.
c.
d.
e.
f.
17
Medical Coverage - CMH provides three account-based medical plan options, which provide comprehensive
coverage designed to promote your wellness.
Prescription Drug Coverage - CMH provides comprehensive prescription drug coverage when enrolled in a medical
plan. You must enroll in a medical plan to have prescription drug coverage.
Vision Coverage - CMH provides basic vision coverage when enrolled in a medical plan. Coverage for frames, lenses
and contacts is available at the Resident’s/Fellow’s expense.
Dental Coverage - CMH offers three dental plan choices, which differ in the services they cover. All three plans
provide coverage for preventative and basic services. Major services, including crowns/bridges/dentures, are covered
in two of the plans and orthodontia is only covered in one of the plans.
Flexible Spending Accounts (FSAs) - CMH offers two FSA plans, including the Health Care FSA and the Dependent Care
FSA. FSAs enhance financial wellness by saving you money; allowing you to set aside money from your paycheck pretax to pay for eligible health or dependent care expenses. The Health Care FSA reimburses for eligible out-of-pocket
health care expenses not covered by the health plans. The Dependent FSA reimburses for eligible dependent care
expenses.
18
Employee Assistance Program (EAP) - Residents/Fellows who are employed by CMH may use the ComPsych® EAP for
confidential assessment, short term counseling and referrals on a variety of topics. Residents/Fellows are encouraged
to first speak with their PD, APD, Vice Chair or Chair of GME before using the EAP.
i.
Services are available to all employees and their family members, whether enrolled in a medical plan or not.
ii.
There is no cost for short-term counseling with ComPsych®. Employees are responsible for costs not covered
by medical coverage when an outside referral is recommended by a ComPsych® counselor.
iii.
Services are available for:
Confidential Counseling - This no-cost counseling service helps you address stress, relationship and other
personal issues you and your family may face. It is staffed by GuidanceConsultants(SM) - highly trained
master’s and doctoral level clinicians who will listen to your concerns and quickly refer you to in-person
counseling and other resources for:
o
Stress, anxiety and depression
o
Job pressures
16
www.ama-assn.org
ACGME Institutional Requirements, II.D.4.g)
18
ACGME Institutional Requirements, II.D.4.k)
17
Page 17 of 49
Last Updated: 7/1/2013
o
Relationship/marital conflicts
o
Grief and loss
o
Problems with children
o
Substance abuse
Financial Information and Resources - Speak by phone with our Certified Public Accountants and
Certified Financial Planners on a wide range of financial issues, including:
o Getting out of debt
o Retirement planning
o Credit card or loan problems
o Estate planning
o Tax questions
o Saving for college
Legal Support and Resources
o Divorce and family law
o Real estate transactions
o Debt and bankruptcy
o Civil and criminal actions
o Landlord/tenant issues
o Contracts
Work-Life Solutions
o Child and elder care
o College planning
o Moving and relocation
o Pet care
o Making major purchases
o Home repair
GuidanceResources® Online
iv.
7.2
Income Protection & Security
a.
b.
c.
d.
19
20
For additional information about the program, contact CMH Human Resources at (816)234-3109. Call
ComPsych® at 888-737-6797 (TDD: 800-697-0353) or visit guidanceresources.com using our company Web ID:
CMH
Basic Life and Accidental Death and Dismemberment (AD&D) Coverage - CMH provides basic life and accidental death
and dismemberment (AD&D) insurance at no cost to Residents/Fellows. Basic life insurance coverage equals one
times your annual pay rate, rounded up to the nearest $1,000, to a maximum of $500,000. Basic AD&D coverage
matches your basic life insurance benefit, up to a maximum of $100,000.
Supplemental Life and Accidental Death and Dismemberment (AD&D) Coverage - CMH provides optional coverage to
Residents/Fellows. Coverage equal to 1, 2, 3, 4, or 5 times your annual pay rate is available, up to a maximum of $1
million. This request may require evidence of insurability to document proof of good health. Supplemental AD&D
coverage matches your supplemental life insurance benefit, up to a maximum of $100,000.
19
Long-Term Disability Coverage - CMH provides long-term disability coverage at no cost to Residents/Fellows. This
benefit pays 60% of your pay rate, up to $15,000 a month, if you are disabled and unable to perform the essential
duties of your job because of accidental bodily injury, sickness, mental illness, substance abuse or pregnancy.
Coverage is effective following a 90-day waiting period and ends when you are medically able to return to work.
20
Short-Term Disability Coverage - CMH provides this optional coverage to Residents/Fellows at their expense.
Residents/Fellows are encouraged to sign up for this benefit. This benefit pays 60% of your pay rate from the 15th to
the 90th day of your disability, or until you are released to work, whichever is earlier. The plan may “fill the gap” until
long-term disability coverage is effective.
ACGME Institutional Requirements, II.D.4.g)
ACGME Institutional Requirements, II.D.4.g)
Page 18 of 49
Last Updated: 7/1/2013
e.
f.
7.3
Critical Illness Coverage - CMH provides this optional coverage to Residents/Fellows who sign up for such. This benefit
pays a one-time tax-free payment upon diagnosis of a coverage critical illness or condition, e.g., heart attack, stroke,
and transplants.
Long-Term Care Coverage - CMH provides this optional coverage to Residents/Fellows who sign up. This benefit
covers services for individuals with chronic illnesses or injuries who are unable to care for themselves over relatively
long periods of time, including home-health, assisted living or nursing home care.
Take CARE Wellness Programs
CMH provides employees with a variety of wellness tools, including: access to a personal Health Coach who will work with you
to design a program to get you on the road to wellness; year-round programs on a variety of topics, including smoking
cessation, weight loss and more; a wellness newsletter to make you aware of upcoming wellness-related opportunities; and
online wellness tools and information, including recipes, exercise programs, articles, a health risk assessment and more.
7.4
Retirement Plan and Tax-Deferred Annuity (TDA) Plan
The CMH retirement plan is a money purchase pension plan. When eligible Residents/Fellows are automatically entered into
the retirement plan, it is effective the 1st of the month following two years of service. Children’s Mercy’s makes contributions
based on your age plus years of service:
If your age plus years of service is:
Children’s Mercy’s contributes:
<50
3.0%
50 – 59
3.5%
60 – 69
4.5%
>70
6.0%
All the money is tax-deferred and Residents/Fellows have the choice of investment options with TIAA-CREF.
CMH also provides employees with a 403(b) or tax-deferred annuity (TDA) plan. TDA plans allow you to save for retirement by
making pre-tax contributions to tax-deferred annuities beginning the first of the month following your date of hire. Employees
who have two or more years of service and who make contributions to a TDA plan will receive a matching contribution of up to
3 percent. To receive the full 3 percent match, you must make a 6 percent or greater contribution to your TDA.
7.5
Time off Plans
While Residents/Fellows have several options to have time off away from work, taking time away from your training can
extend the length of your program. Please check with your PC..
a.
b.
c.
Vacation - The Resident/Fellow is eligible for up to 20 days of paid vacation, exclusive of Saturdays, Sundays and
holidays annually. Vacation may be taken during approved rotations/educational units, and must be approved in
advance by the PD or his/her designee. Vacation also may be used concurrently with an approved leave of absence.
Vacation may not be carried over from Agreement of Appointment year to the next and no payment will be made for
unused vacation at the termination of the Appointment.
Paid Sick Time/Extended Illness Time (EIT) - The Resident/Fellow will accrue one day of paid time off for illness after
each full month of service. If the Resident/Fellow has no accrued paid time off for illness, time off for illness will be
without pay, unless the Resident/Fellow uses available vacation days or the Resident/Fellow qualifies for worker’s
compensation or long-term disability insurance. Accrued paid time off for illness may be used concurrently with an
approved leave of absence due to illness of self or family members. Accrued paid time off for illness may be carried
over from one Agreement of Appointment year to the next. Residents/Fellows are limited to a maximum EIT balance
of 60 days. No payment will be made for unused accrued paid time off for illness at termination of the Appointment.
Family Illness Paid Time (FIP) - The Resident/Fellow will have 10 days during their program for time off to care for an
immediate family member with a serious medical condition. FIP may also be used if you are the spouse or domestic
partner of a primary caregiver after the birth or adoption of a child. Anticipated leaves must be scheduled with the
approval of the PD. In these situations FIP must be used in the period immediately following the birth of the child
or placement of the adopted child in your home. Residents/Fellows must first utilize 2 workdays of vacation to
replace scheduled work hours before using FIP. FIP may be taken all at once, intermittently, or on a reduced work
schedule.
Page 19 of 49
Last Updated: 7/1/2013
d.
e.
f.
g.
h.
i.
j.
21
Bereavement Leave - Residents/Fellows are allowed five (5) days per year to attend funeral services of an immediate
family member (spouse, domestic partner, children, or parent). If the death involves an immediate family member
and the Resident/Fellow will require more time off, the Resident/Fellow should contact the PD as soon as feasible.
Extended time off may be taken as a leave of absence. Residents/Fellows also are allowed three (3) days per year to
attend funeral services for a sibling, grandparent, in-laws, or any person living in the Residents/Fellows household at
the time of death. Bereavement days do not count as vacation or sick days. The Resident/Fellow should notify the PD
as soon as possible so service coverage can be addressed.
21
Leave of Absence (LOA) - Residents/Fellows are eligible for an LOA after 90 calendar days of employment.
i.
These leaves of absence are not eligible under the Family and Medical Leave Act (FMLA) and are granted on a
case-by-case basis by the PD and are normally unpaid.
o The ability to use vacation and/or EIT time will be decided by the PD. The decision will be based on
the underlying need for the leave.
o Reasons for which an LOA may be granted include: the birth of a child or placement of a child by
adoption or foster care; the serious health condition of a Resident/Fellow; the serious health
condition of a Resident’s/Fellow’s family member; and other circumstances. The Resident/Fellow
may be required to make up all rotation/educational units missed.
o The Resident/Fellow may be terminated from the Program if the length of the LOA extends beyond
six (6) months.
o If the Resident/Fellow is terminated due to an extended leave, he/she may reapply to the Program.
ii.
Residents/Fellows are eligible for an LOA which may qualify for the benefits of FMLA, including up to 12
weeks of job protected leave, after one year of employment.
o A serious health condition, birth of a child, placement of a child for adoption or foster care in home,
care of an immediate family member with a serious injury or illness, exigency related to an
immediate family member’s active duty or call or order to active duty in the Armed Forces.
Personal Leave - Residents/Fellows unable to work due to a personal situation may request a personal LOA only after
90 days of employment. Personal LOA is available for personal reasons not covered elsewhere in the LOA policy. This
leave must be taken on a continuous basis, for a minimum of two weeks. Residents/Fellows may be asked to make up
the time missed from being on a personal LOA.
Jury Duty - Residents/Fellows are eligible for jury duty pay less jury service payment when summoned to appear for
jury duty and, therefore, not able to work.
Election Day - Residents/Fellows are eligible to be off for three consecutive hours in Missouri to vote or two
consecutive hours in Kansas to vote. Residents/Fellows must request the time off prior to the day of the election.
Military Leave
i.
A Resident/Fellow who enlists or is drafted into the Armed Forces of the United States, including reservists
and members of the National Guard who are activated to military duty, other than active duty for training
purposes, shall be granted military leave without pay.
ii.
A Resident/Fellow who is a member of the State Guard or National Guard or the Reserves of the United
States Armed Forces shall be granted 2 weeks time off per calendar year of military leave with pay for active
duty for training purposes. Any active duty for training purposes in excess of 2 weeks in a calendar year shall
be charged to military leave without pay, or at request, to vacation.
iii.
A Resident/Fellow who is a member of the State Guard or National Guard shall be granted military leave with
pay for the duration of any official call to state emergency duty.
iv.
EIT shall not be earned or accrued during a period of military leave without pay.
v.
When a Resident/Fellow is called for duty, the Resident/Fellow shall be permitted to return to the Program in
a similar position with status and pay like that which the Resident/Fellow occupied at the time of the
beginning of the military leave.
vi.
The time away for military leave does not count toward the Resident’s/Fellow’s time in the Program.
vii.
The Resident/Fellow should contact the PD within 30 days of the release from duty. The Resident/Fellow and
the PD should agree on the date of the next regular working period that will be required to work; provided
that such date is no later than ninety (90) days following the Resident’s/Fellow’s release from duty.
Professional Leave - The Hospital will consider paid professional leave for all Residents/Fellows at the discretion of the
PD for the following reasons:
i.
while in the due process phase of a hearing that has resulted in probation, suspension or termination;
ACGME Institutional Requirements, II.D.4.h)
Page 20 of 49
Last Updated: 7/1/2013
k.
7.6
ii.
scholarly presentations at national or regional conferences;
iii.
professional conference attendance;
iv.
taking medical board examinations; or
v.
interviews for fellowship or faculty positions.
Time off may also impact a Resident/Fellows eligibility for board certification. Standards for eligibility for specialty
board certification are developed by the individual specialty board (as recognized by the ABMS). Current policies for
selected specialty boards:
22
i.
Allergy and Immunology : Absences (including vacation and sick leave) in excess of two months over the 24
months of the training program should be made up. Exceptions may be considered, if supported by the PD.
23
ii.
Child Neurology and Clinical Neurophysiology : Vacation and sick leave in excess of allotted leave will need
to be made up. Vacation and leave time may not be utilized to reduce amount of required training or to
make up deficiencies in training.
24
iii.
Pediatric Clinical Pharmacology : The Resident/Fellow must show completion of two-years of post-doctoral
fellowship training in clinical pharmacology.
iv.
Pediatric Dentistry: The duration of the training program in Pediatric Dentistry is 24 months. Therefore
absences in excess of those available and approved through the program (including vacation, sick leave,
family illness paid time) should be made up or could extend training. Arrangements should be made with
approval of the Program Director in consultation with the Department Chair. Any additional leave in
excess of 6 weeks taken over the 24 months of the training program must be made up. Exceptions may be
considered, if supported by the Program Director and/or Department Chair.
25
v.
Pediatric Dermatology : It is necessary that 11 months of training are completed in order to qualify for
subspecialty certification. Thus, without exception, any absence (inclusive of vacation) resulting in less than
11 months of training during a 12-month Program will require an additional period of training to achieve 11
total months.
26
vi.
Pediatric Pathology : The Resident/Fellow must document an average of 48 weeks per year of full time
pathology training over the course of the training program.
27
vii.
Pediatrics and subspecialties : One month of absence is allowed each year for leave (vacation, sick, parental
leave). Absences beyond this should be made up by additional time of training. The PD may petition the
American Board of Pediatrics for exceptions to this policy.
28
viii.
Pediatric Rehabilitation Medicine : A Resident/Fellow must not be absent from the training Program for
more than six weeks (30 working days) annually. Regardless of institutional policies regarding absences, any
leave time beyond six weeks would need to be made up by arrangement with the PD. “Leave time” is defined
as sick leave, vacation, maternity/paternity leave, or leave for locum tenens. A Resident/Fellow may not
accumulate leave time or vacation to reduce the overall duration of training.
29
ix.
Pediatric Radiology : Leaves of absence and vacation may be granted to Residents/Fellows at the discretion
of the PD in accordance with local rules. Within the required training period, the total leave and vacation
time may not exceed six calendar weeks (30 working days) for Residents/Fellows in the Program for one year.
30
x.
Pediatric Surgery and Surgical Critical Care : Residents/Fellows must have no fewer than 48 weeks of
satisfactorily completed fulltime surgical/surgical critical care experience in each year of training.
Other Benefits
The intent of these additional benefits is to enhance the educational experience.
22
www.abai.org
www.abpn.com
24
www.abcp.net
25
www.abderm.org
26
www.abpath.org
27
www.abms.org
28
www.abpmr.org
29
www.theabr.org
30
www.absurgery.org
23
Page 21 of 49
Last Updated: 7/1/2013
a.
b.
c.
d.
e.
f.
g.
Professional Organizations - The Residents/Fellows are provided each year with one membership. For Pediatric
Residents the membership will be to the American Academy of Pediatrics. Memberships for Fellows will be
determined by the respective PD.
GME will provide all trainees with the required licenses needed to fulfill their training program.
Educational Stipend/Book Money - Residents/Fellows are provided educational funds to use towards books and other
educational materials. PGY 1 receives $500; PGY 2 receives $1,000; PGY 3 - 6 receives $1,500; and PGY 7 and above
will receive $2,250 per Agreement of Appointment year. These funds are non transferable and do not roll over from
Agreement year to the next.
i.
Residents/Fellows CAN use Educational Stipend/Book money for:
o medical/educational books/educational software
o board review and journal subscriptions
o additional professional memberships
o expenses for out of state rotation/educational units
o medical equipment
o scrubs and lab coats or Children’s Mercy approved apparel up to $150 per year
o iPad case and keyboard up to $150 per program
o board review course fees and approved travel expenses not covered by Section 7.6 d.
o approved travel expenses related to attending professional conference not covered by Section 7.5 c.
ii.
Residents/Fellows CANNOT use Educational Stipend/Book money for anything that cannot be justified as
related to your training. It CANNOT be used for licensing or DEA expenses related to moonlighting or any
other expenses related to future employment (eg. Interviews). The Vice Chair of GME makes the final
decision on whether an expense will be supported by the Hospital. If an expense is not on the list above,
please check in advance.
iii.
Residents/Fellows who want to utilize educational stipend/book money must complete the Educational
Expense Request Form, obtain PD signature, and return it to their respective PC. The Resident/Fellow will
receive an e-mail when their order is ready to be picked up. If the Resident/Fellow is requesting to utilize
stipend money for professional travel to a conference, travel with their PD must be approved 30 days prior to
traveling. Residents/Fellows must be in compliance with medical records, duty hour logs and evaluations
before a request will be approved.
iv.
Anything spent within the last 6 months of the program year is restricted to books, board review or
conferences.
Professional Development Presentation at National or Regional Conferences
i.
Residents/Fellows at the PGY 2 level and above who are accepted or invited as the presenting author at a
conference are eligible to access up to $2,250 per Agreement of Appointment year in support for travel to be
paid for by the Hospital. GME will only pay for one presenting author per poster.
ii.
Travel must be approved by the PD at least 60 days in advance and reasonable efforts should be made to
access external funding (travel grants).
iii.
The Resident/Fellow must book travel through the CMH travel agency at least 30 days in advance. If the
Resident/Fellow will be driving or renting a car, special guidelines and permission are required.
iv.
Only airline tickets and conference registration are pre-paid.
v.
Other expenses are reimbursable upon the Residents/Fellows return with submission of proper
documentation in accordance with CMH Travel Reimbursement Policies.
vi.
If the cost of travel exceeds $2,250, the Resident/Fellow may access unused educational stipend money, pay
out of pocket or ask the division for assistance.
vii.
If the conference is in an international location, Hawaii or Alaska, preapproval must be obtained from the
Executive Medical Director/Executive Vice President.
Residents/Fellows may use up to $2,250 for attending formal board review coursework if they have not used the
funding above for a presentation at a conference.
Board Exam Fees – CMH will contribute $500 for each Resident to register for a specialty board. CMH will pay for one
specialty board exam for each Fellow. Fellows must attest to CMH that they have not previously been reimbursed for
those expenses.
International Elective Rotation/Educational Unit Expenses - Expenses related to a Residents/Fellows international
elective rotation/educational unit will be reimbursed up to $1000 after returning from the trip and upon submitting
proper documentation and rotation/educational unit experience report. Residents/Fellows who have been approved
for an International Elective Rotation/educational unit must complete the Request for Approval of International Travel
Page 22 of 49
Last Updated: 7/1/2013
form. More information about International elective rotation/educational units can be found in Section 16
(International Rotation/Educational Unit) of this manual.
g. Adoption Assistance - Residents/Fellows are eligible for adoption assistance after 90 days of employment.
h. Domestic Partner Benefits - Domestic partners may be included as covered dependents for the following plans:
medical, dental, vision and the spouse life insurance programs.
i. Auto/Home Insurance – Residents/Fellows have access to MetLife Auto & Home’s group insurance program, which
comes with special employee discounts, and the unique benefit of automatic payroll deduction of your premium.
j. Back-Up Care Advantage Program – Residents/Fellows can utilize this affordable service that provides backup adult or
child care when there is a breakdown in the normal caregiver arrangement. Contact HR at (816)234-3109 for
additional questions and to see when this program can be used and what the costs will be.
k. Financial Assistance Plan – Residents/Fellows with immediate short-term financial needs are eligible to apply for
financial assistance up to $300 after 90 calendar days of employment.
l. Care at CMH for Your Children - Residents/Fellows are eligible for discounted inpatient or outpatient services at CMH
effective the date of hire. The total bill is discounted by 20 percent.
m. On-Site Childcare Center - Hospital Hill Learning Center is available to Residents/Fellows to provide care for children
ages 6 weeks to 12 years. Care is available on a first come, first served basis. Costs for this service may be paid pretax via payroll deduction.
n. Tuition Assistance - Residents/Fellows are eligible for tuition assistance effective 90 days after employment. The
maximum benefit is $3,000 for the 12-month period between July 1 and June 30. Funds may only be used to pay
tuition and fees. Residents/Fellows pursuing a Certificate or Masters Degree must contact their PD and the Vice Chair
of GME to discuss tuition assistance.
31
o. Professional Liability Insurance - Professional liability insurance is provided through the Hospital’s self-insured trust
in the amount of two million dollars ($2,000,000) at the Hospital’s expense, in accordance with the terms of the selfinsured trust.
i.
All Residents/Fellows are covered providing:
o service under direct supervision of a duly appointed member of the medical faculty of CMH.
o service under the direct supervision of a physician at an institution that has a formal, written
Affiliation Agreement for the Resident’s/Fellow’s services signed by the officers of the department
and Program, and approved by legal counsel, the Chair of GME, and the Vice Chair of GME, or
designee(s). Ideally, the supervising physician should hold a medical faculty appointment with the
Hospital or sponsoring medical school, but this is not an absolute requirement.
o service, but with the knowledge of, and under protocols developed and reviewed by the
Chairs/Directors of the department and Program. A formal written contract between the facility
requesting Resident/Fellow coverage and the department must be in place and approved by legal
counsel, the Chair of GME, and the Vice Chair of GME.
ii.
Coverage will specifically not be extended for:
o services under Agreements to which the Program, Department, and/or Hospital are/is not a party; or
o moonlighting activities outside of CMH.
iii.
The Resident/Fellow will cooperate fully in any investigation, discovery, and defense that may arise regarding
any claims or other legal actions. The failure to cooperate may result in personal liability.
iv.
The receipt of any summons, complaint, subpoena, or court paper of any kind relating to activities in
connection with this Agreement or the Resident's/Fellow’s activities at the Hospital by the Resident/Fellow,
or on his/her behalf by anyone with whom the Resident/Fellow works or resides, will be immediately
reported to the Office of Risk Management. Further, the Resident/Fellow will immediately submit the
document received to that office.
v.
The Resident/Fellow will cooperate fully with Hospital Administration, the Office of the Legal Affairs and Risk
Management, all attorneys retained by that office and all investigators, committees, and Departments of the
Hospital including, but not limited to Quality Assurance, Human Resources, particularly in connection with
the following:
o evaluation of patient care;
o review of an incident or claim; or
o preparation for litigation, whether or not the Resident/Fellow is a named party to that litigation.
31
ACGME Institutional Requirements, II.D.4.f)
Page 23 of 49
Last Updated: 7/1/2013
m. Worker’s Compensation - If a Resident/Fellow is injured on the job, Worker’s Compensation will pay authorized
medical expenses and a portion of lost work time, if claim is determined to be compensable and reported
appropriately.
n. BLS, PALS, and NRP Certification - Residents/Fellows are expected to hold Basic Life Support (BLS) Certification before
commencing training at CMH. Residents/Fellows are provided PALS or NRP training if required by the Program.
o. Meal Cards - The Resident/Fellow will be provided meals through the Hospital cafeteria at the Hospital’s expense
when on in-house call at night.
p. Pagers - Pagers are provided at no cost to Resident/Fellow by the Hospital.
q. Parking - The Resident/Fellow will be provided free parking at the Hospital during the term of the Appointment.
r. Housing - The Hospital does not provide Resident/Fellow housing.
s. White Coats/Scrubs - Residents/Fellows receive a limited number of white coats/scrubs at the beginning of their
Programs.
t. Moving Allowance - A moving allowance of up to $300 is provided for any Resident/Fellow moving from outside the
metropolitan Kansas City area.
8.
EQUAL OPPORTUNITY EMPLOYMENT
CMH is committed to equal employment opportunity and affirmative action. The Hospital makes employment decisions
without regard to an applicant's or employee's race, color, religion, sex, pregnancy, sexual orientation, national origin, age,
disability, veteran or military status, genetic information, or any other legally protected status. The Hospital provides equal
employment opportunities in all terms, conditions and privileges of employment, including but not limited to hiring, training,
compensation, promotion, transfer, corrective action, demotion, and termination.
The Hospital is committed to providing a work environment free from unlawful discrimination, and prohibits unlawful
discrimination by any Hospital employee.
Further, and in accordance with applicable law, the Hospital takes affirmative action to recruit for employment and for
promotion of qualified candidates who are minorities, females, individuals with disabilities, and protected veterans.
As part of the Hospital's commitment to equal opportunity employment, the Hospital will provide reasonable accommodations
to qualified individuals with disabilities unless doing so would result in an undue hardship.
Further, the Hospital will make reasonable accommodations for an individual's religious beliefs unless doing so would result in
an undue hardship. Individuals in need of accommodations due to disabilities or religious beliefs are encouraged to discuss
their needs with their manager or Human Resources.
Any concerns about possible violations of this policy should be raised, and will be addressed, in the manner outlined in the
Anti-Discrimination/Anti-Harassment Policy.
ANTI-DISCRIMINATION/ANTI-HARASSMENT 32
9.
CMH strives to offer an environment free from any type of unlawful discrimination and/or harassment, in any term, condition
or privilege of employment on the basis of race, color, religion, sex, pregnancy, sexual orientation, national origin, age,
disability, veteran or military status, genetic information, or any other legally protected status. However, it is the Hospital’s
main goal to ensure conduct never rises to the level of “unlawful” behavior. Accordingly, CMH prohibits conduct that is
inconsistent with the Hospital’s values, as expressed in this and other policies, even though it may not violate the law.
a.
32
Prohibited conduct - It is the Hospital’s policy to prohibit any unwelcome verbal, written or physical conduct that
denigrates or shows hostility or aversion toward another because of his/her race, color, religion, sex, pregnancy,
sexual orientation, national origin, age, disability, veteran or military status, genetic information, or any other legally
protected status, as well as such conduct toward another because of the legally protected status of one with whom
the individual is associated. This prohibition applies to all individuals who work for or are associated with the Hospital,
including managers, supervisors, employees, patients, visitors, or vendors. Examples of prohibited conduct include but
ACGME Institutional Requirements, II.D.4.m)
Page 24 of 49
Last Updated: 7/1/2013
b.
c.
d.
e.
f.
are not limited to employment decisions made based on an employee’s race, color, religion, sex, pregnancy, sexual
orientation, national origin, age, disability, veteran or military status, genetic information, or any other legally
protected status: verbal conduct such as racial epithets, derogatory comments, slurs or unwanted sexual advances,
comments, or invitations; physical conduct such as unwanted touching.
Complaint Procedure - If you believe you have been the subject of, or have witnessed, prohibited conduct as defined
in this policy, you must report the incident immediately to a supervisor or a member of the Employee Relations team,
regardless of whether the report is about a manager, co-worker, patient, or other individual. The Hospital encourages
prompt reporting of conduct that violates or is believed to violate this policy so that the concerns can be quickly
addressed. If you become aware of this type of incident and are in a supervisory position, you are required to report
the incident to a member of the Employee Relations Team immediately and in any event no later than 48 hours after
becoming aware of the incident.
Prohibition against retaliation - The Hospital prohibits retaliation against anyone for reporting
discrimination/harassment, assisting in making a discrimination/harassment complaint, or cooperating in a
discrimination/harassment investigation. The Hospital also prohibits retaliation against anyone because he/she is
closely associated with someone who reported, assisted, or cooperated with a discrimination/harassment complaint
or investigation. Any employee who believes he/she has experienced or witnessed retaliation should immediately
notify his/her supervisor or a member of the Employee Relations Team. If you become aware of this type of incident
and are in a supervisor position, you are required to report the incident to a member of the Employee Relations Team
immediately and in any event no later than 48 hours after becoming aware of the situation.
False Claim - An individual who knowingly alleges a false claim against another will be subject to the full range of
corrective action, up to and including termination.
Commitment to investigate - All reports of inappropriate conduct under this policy or the Hospital’s Equal Opportunity
Employment policy will be promptly and thoroughly investigated, and the Hospital will act to ensure that any
improper conduct ceases immediately and corrective action is taken to prevent a recurrence. Any employee, whether
supervisory, non-supervisory, or a member of management, who violates this policy will be subject to the full range of
corrective action, up to and including termination of employment. The Hospital will inform a complaining employee of
the conclusion of the complaint as appropriate. Any complaint received by the Hospital alleging an employee has
harassed a patient, visitor or other third party, will be referred to Employee Relations for an investigation under this
policy.
Confidentiality - All complaints will be treated confidentially to the extent practicable for an effective resolution.
RESIDENTS/FELLOWS WITH DISABILITIES33
10.
The Hospital’s administrative policy is to identify the resources and procedural mechanisms within CMH to assure compliance
with the Americans with Disabilities Act (ADA) (42 U.S.C. Section 12101-12213). CMH actively supports the intent of the ADA,
managers assuming responsibility and accountability for implementation of and compliance with this Act.
10.1
Definitions
a.
b.
c.
d.
33
Accessible: anything that is approachable, functional and can be used by people with disabilities, independently,
safely and with dignity.
Auxiliary aids: devices or services that compensate for a disabling condition. The term includes qualified interpreters
or other means of communications (such as telecommunications devices for the deaf – TDDS) for hearing-impaired
people; qualified readers, taped tests other devices for sight-impaired people; adaptive equipment and other similar
services and actions.
Barrier-free environment: containing no obstacles to accessibility and usability by disabled people. The ADA, which
emphasizes the concept of accessibility, mandates a barrier-free environment in new construction of public
accommodations.
Individual with a disability: this term refers to any person who: (1) has a physical or mental impairment that
substantially limits one or more life activities (i.e. caring for ones self, performing manual task, walking, seeing,
hearing, speaking, breathing, learning and working); (2) has a record of such an impairment that substantially limits
one or more major life activities; or (3) is regarded as having such an impairment.
ACGME Institutional Requirements, II.D.4.n)
Page 25 of 49
Last Updated: 7/1/2013
e.
f.
g.
h.
10.2
Non-discriminations mandated by the ADA. No otherwise qualified disabled individual can, solely by reason of his or
her disability, be subjected to discrimination. Covered entities are required under the ADA to ensure nondiscrimination by providing accessibility, equal opportunity and full participation in employment and public facilities
and services.
Qualified individual with a disability: with respect to employment, a disabled person who, with or without reasonable
accommodation, can perform the essential functions of the job in question, and (2) with respect to public services, an
individual who, with or without reasonable modifications to rules, policies or practices, the removal of architectural,
communication or transportation barriers, or the provision of auxiliary aids and services, meets the essential eligibility
requirement for the receipt of services or participation in the program or activity.
Reasonable accommodation: the principle by which employment and public accommodations are made accessible to
qualified disabled people. Employers are required under the ADA to make certain adjustments to the known physical
and mental limitations of otherwise qualified disabled applicants and employees, unless it can be demonstrated that a
particular adjustment or alteration (an accommodation) would be unreasonable or impose an undue hardship. For
example, an employer might be required to rearrange office furniture to allow for passage of a wheelchair, relocate
some offices or classrooms to a ground floor or other accessible location, or relieve a hearing-impaired secretary of
phone responsibilities.
Undue hardship: the point at which an employer is no longer required to make accommodations in employment
under Title I of the ADA since the action involved would require significant difficulty or expense. The factors to be
considered are the same determining whether an accommodation is readily achievable (see above). These include,
but are not limited to, the nature and cost involved in the accommodation, overall financial resources of the facility or
facilities involved, number of people employed at the facility, the type of operation(s) of the employer, including the
composition, structure and functions of the workforce.
Procedure
a.
b.
Employment Related Matters - TITLE I provides protection against discrimination to people with disabilities in
employment-related matters such as job application procedures, hiring, firing, promotions, compensation, training
and other conditions, terms, or privileges of employment.
i.
Resources Available: Resources available to employees and applicants will vary dependent upon the
disability and the reasonableness of the accommodation requested. Resources available to management
include training and consultation available through the Human Resources Department.
ii.
Department or Person with Primary Responsibility for Compliance: Hospital managers have primary
responsibility for compliance with Title I in consultation with the Human Resources Department.
iii.
Ways to Access Information or Resources: An overview of the Act and compliance guidelines is available on
the intranet, Human Resources, Management Resources. Included in this information are definitions under
the Act; procedures for applicants and employees who may request reasonable accommodations; and other
helpful information about Title I. Hospital staff may request accommodations by contacting their supervisors.
Relay Services - Telecommunications relay services are available twenty-four (24) hours per day.
11.
CODE OF PROFESSIONAL AND PERSONAL CONDUCT
11.1
Professionalism
Residents/Fellows will demonstrate conduct consistent with the dignity and integrity of the medical profession in all contacts
with patients, their families, their peers, the faculty, all Hospital and Sponsoring Institution personnel and all third parties
conducting business with the Resident/Fellow or Hospital or Sponsoring Institution.
The Resident/Fellow:
a. will protect and respect the ethical and legal rights of patients;
b. will abide by the policies and procedures governing GME and applicable Sponsoring Institution;
c. will, in a timely fashion, clearly communicate all information relevant to the safe, effective and compassionate care of
their patients to their supervising faculty;
d. will act in accordance with compliance policy including access to medical records;
e. The Resident/Fellow will, in a timely fashion, complete all assigned clinical, administrative and academic duties,
including medical records;
Page 26 of 49
Last Updated: 7/1/2013
f.
g.
h.
i.
j.
k.
l.
11.2
will not prescribe controlled or narcotic medications for members of their immediate families. Residents/Fellows are
discouraged from providing medical care to members of their immediate families;
will not accept fees for medical services from patients, patients’ families, or other parties;
will not charge or accept fees for expert testimony in medico-legal proceedings or for legal consultation;
will promptly discharge any and all financial obligations to the Hospital and its affiliates throughout the duration of
their appointment;
should provide at least 60 days written notice as provided by the terms of the Agreement of Appointment should they
desire to leave the training Program. Failure to provide such notice may be considered unprofessional conduct and
can adversely effect the summative evaluation and any future recommendation. In some cases, such conduct may be
reported to accrediting and credentialing bodies;
will inform the PD and the GME Department of any condition or change in status that affects her/his abilities to
perform assigned duties;
will be expected to fulfill any written Agreement of Appointment entered into with the Hospital provided such
Agreement of Appointment is not contrary to these policies and procedures. Any modification of such Agreement of
Appointment must be made in writing by the parties.
Personal Appearance
a.
b.
c.
d.
e.
Personal appearance must reflect concern and respect for the diverse group of individuals served at our Hospitals and
Clinics. It must also inspire confidence in the staff’s knowledge and skills, and assure staff and patient safety.
CMH is committed to ensuring that the Personal Appearance Policy is applied equally to both genders and will
accommodate, as possible, exceptions based on disability, religious, ethnic, or health reasons.
If you fail to comply with these requirements, you may be relieved from duty until you become compliant.
Requirements for all employees:
i.
Your clothing must be clean and fit appropriately.
ii.
Avoid using heavily scented perfumes, colognes and lotions.
iii.
Keep your fingernails clean and trimmed.
iv.
Keep your hair, sideburns, mustaches and beards neat and well groomed.
v.
If you wear jewelry and make-up, it should be moderate.
vi.
Ear piercing must be limited to three per ear.
vii.
Unacceptable body piercings include, but are not limited to, nose rings or posts, tongue posts, eyebrow rings
or posts, and lip rings.
viii.
Any tattoo that could be perceived as offensive or hostile or diminish the effectiveness of the employee as a
role model for our patients must be covered during your shifts.
ix.
All employees, while working in patient care areas, must wear closed-toed shoes as protection from
contaminated sharps or hazardous chemicals and materials.
x.
As recommended by the Centers for Disease Control and Prevention, employees working in patient care
areas are required to maintain natural nails at one-quarter (1/4) inch long or less. Only natural nails are
acceptable in patient care areas.
xi.
Employees who are required to wear uniforms are responsible for complying with the color and style
designated by the department manager.
xii.
Employees who do not wear uniforms must follow the attire requirements of this policy and are encouraged
to wear lab coats when participating in or providing direct patient care.
xiii.
Clothing contaminated with blood, body fluids, or other contaminants should be removed immediately and
laundered at the Hospital. If necessary, scrubs will be issued.
Requirements for all employees in non-patient care areas:
i.
Employees may choose to wear business attire or, for some positions, business casual attire. Examples
include suits, dresses, skirts, blouses, slacks, sport coats, casual slacks, sport or knit shirts, and sweaters.
Speak with your manager if you have questions about whether certain attire is appropriate.
ii.
Examples of unacceptable attire include, but are not limited to: denim jeans (unless designated as part of a
uniform), sweat pants, sweat shirts (unless the shirt is promoting a Hospital activity or logo), workout attire,
cutoffs or shorts, t-shirts, sheer clothing or clothing that is otherwise revealing, distracting or provocative,
canvas tennis shoes, or flip-flops.
iii.
Occasionally, the Hospital will approve a special “theme day.” On these days, an exception to these
guidelines may be made at your manager’s discretion.
Page 27 of 49
Last Updated: 7/1/2013
f.
g.
11.3
If you require an exception to the guidelines outlined above (for religious or health reasons, for example), please
speak with your supervisor and Human Resources.
Departure from appropriate grooming, hygiene and attire standards without proper approval may result in employee
counseling up to and including termination of employment.
Name Badge
The Resident’s/Fellow’s CMH Name Badge assigned must not be shared with anyone else at any time. This badge is issued for
security and identification purposes and must be worn at all times while on Hospital premises. The badge should be worn
above the waist so that it is clearly visible and easily read by others. Contact your Program Coordinator or the Security
Department at (816) 234-3345 for information on replacement name badges.
11.4
Smoking and Tobacco Free Environment
CMH, in concert with its mission to provide quality care, believes that a tobacco-free environment is in the best interest of our
patients, families, and staff. Smoking and tobacco use will not be permitted anywhere in the Hospital’s owned or leased
buildings or on Hospital grounds by:
a.
b.
c.
d.
e.
f.
g.
h.
employees
medical staff
contracted staff
students
volunteers
families
patients
visitors
Additionally, smoking and tobacco use is prohibited in Hospital parking lots, garages, vehicles parked in those lots and garages,
and vehicles owned or operated by the Hospital by employees, medical staff, contracted staff, students and volunteers.
Support for staff in order to provide a tobacco-free environment includes:
f. information about the policy given to new hires during orientation;
g. educational materials on smoking cessation printed by the American Cancer Society and the American Lung
Association;
h. referral to the Freedom from Smoking program by the American Lung Association for any employee smoking
cessation; and
i. referral to the Employee Assistance Program: NEW DIRECTIONS.
Support for families and visitors include:
a. an informational packet upon inpatient admission that contains the Hospital’s policy and resources available in the
community for smoking and tobacco use cessation; and
b. details about the policy at the Hospital’s information desk, outpatient clinics, and inpatient units for parents,
guardians and other visitors.
Employees and medical staff who violate this policy are subject to employee counseling up to and including termination of
employment. Non-employed medical staff, contracted staff, volunteers and students will be notified of the violation and will
have their affiliations with the Hospital terminated with repeated incidents.
If you see a visitor smoking (or expressing a desire to smoke):
a. In a courteous and diplomatic way, tell the visitor once that there is no tobacco use on Hospital property. Share the
location of the nearest public sidewalk bordering the Hospital campus.
b. If the visitor fails to comply, politely step away from the situation and alert the security department.
c. A Security Supervisor will respond and explain to the visitor the importance of complying with this policy.
d. If the visitor continues to be non-compliant, the Security Supervisor will request that the visitor leave the property.
Page 28 of 49
Last Updated: 7/1/2013
e.
12.
If the visitor refuses to leave the property, the Security Supervisor will issue the visitor a trespass warning. The
Security Supervisor will explain that failure to leave the property immediately will result in a report to the local police
department and being held for custody by the responding police department.
DRUG AND ALCOHOL POLICY
CMH recognizes the trust which the community places in our delivery of health care services. In an effort to maintain this
community trust and to provide a safe environment for our employees, patients, families and visitors, the Hospital reaffirms its
zero tolerance of substance misuse with the following policy, which applies to CMH employees and other covered individuals:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
The unauthorized or illegal use of drugs, the use of illegal drugs, the use of alcohol, or the unauthorized or illegal
possession, consumption, exchange, delivery, distribution or sale of any drug or alcohol while on duty for CMH, while
on CMH property, or while on CMH business will result in employee counseling, up to and including termination of
employment. Moderate consumption of alcoholic beverages served at Hospital-related functions will be considered a
limited exception to this policy.
The unauthorized or illegal use, possession, exchange, delivery, distribution, or sale of drug-related paraphernalia
while on duty for CMH, while on CMH property, or while on CMH business will result in employee counseling, up to
and including termination of employment.
Any employee who uses his or her position or CMH facilities, equipment or vehicles to engage in the illegal use of
drugs, use of illegal drugs, or unauthorized or illegal possession, distribution, exchange, delivery or sale of drugs,
alcohol or drug-related paraphernalia will be subject to employee counseling, up to and including termination of
employment.
Any employee who reports for work or works while under the influence of, or impaired by, drugs or alcohol, will be
subject to employee counseling, up to and including termination of employment. Moderate consumption of alcoholic
beverages served at hospital-related functions will be considered a limited exception to this policy.
Any employee who is lawfully using any prescribed medications when, in the opinion of the Hospital management,
such use may impair the ability of the employee to perform the duties of his/her job or poses a risk of safety to the
employee or others will be relieved of duty and placed on a leave, as applicable. Before returning to work, the
employee must provide certification from his/her prescribing physician stating the employee can perform the duties
of his/her job and that he/she is able to do so without posing a risk of safety to the employee or others or that the
employee is no longer taking the prescribed medication. Failure to provide this physician certification will prevent the
employee from being able to return to work.
Any employee who has patient care or driving responsibilities and/or if designated by the Hospital, based on other
circumstances, is required to notify his/her immediate supervisor and/or Human Resources of use of any lawfully
prescribed medications that may impair the employee's ability to safely perform the duties of his/her job, so a
determination can be made as to the appropriateness of a leave or other action to address such risks. Failure of the
employee to notify his/her immediate supervisor and/or Human Resources will result in employee counseling, up to
and including termination of employment.
Any employee who refuses to consent or submit to, or release the results of, an oral screening, urinalysis or
evidentiary breath test for the use of drugs or alcohol under this Policy will be subject to employee counseling, up to
and including termination of employment. An employee who does not produce a urine sample within 4 hours of
submitting to a drug test will be considered to have refused testing for the use of drugs or alcohol.
Any employee who has degraded, diluted, switched, altered or tampered with his or her screening sample will be
terminated.
Any employee who produces a positive test result for the current illegal use of drugs, the use of illegal drugs, or
alcohol will be subject to employee counseling, up to and including termination of employment.
All applicants for employment will be informed that a drug screening will be performed on or near the first day of
employment with the Hospital. Applicants will attest that the screening will produce negative results for the illegal
use of drugs and the use of illegal drugs. Upon employment, if the screening produces positive results for the illegal
use of drugs and/or the use of illegal drugs, the employee will be immediately terminated.
All employees must report to Human Resources within five (5) days any conviction of or guilty plea or nolo contendere
("no contest") to criminal offenses involving the illegal use or possession, distribution, delivery or sale of drugs or
drug-related paraphernalia. Failure to make such report will result in employee counseling, up to and including
termination of employment. All such reports to Human Resources will be treated confidentially to the extent possible.
Page 29 of 49
Last Updated: 7/1/2013
12.1
Employee Assistance for Drug or Alcohol Problems
When an employee's use of alcohol, illegal drugs, or illegal use of drugs affects that employee's ability to perform his or her job,
the Hospital shall attempt to assist the employee in meeting his or her responsibility to correct and alleviate the problem, as
follows:
CMH encourages employees to voluntarily request assistance with alcohol and drug problems. Employees may utilize EAP or
contact ComPsych® at 888-737-6797 (TDD: 800-697-0353). A voluntary request for assistance will not prevent employee
counseling, up to and including termination, for any violation of CMH policies; thus, a voluntary request for assistance before
any policy violation occurs is strongly encouraged. Confidentiality will be maintained with all voluntary requests for assistance,
consistent with EAP policy.
When use of alcohol, illegal drugs, or illegal use of drugs affects safe performance of job responsibilities, the employee will be
subject to employee counseling up to and including termination, and may be referred to EAP or another appropriate treatment
program approved by the Director of Employee Relations, the Occupational Health Nurse, and the employee's supervisor.
Nothing in this policy requires the Hospital to refer an employee to EAP, or another appropriate treatment program in lieu of
employee counseling, up to and including termination.
12.2
Return to Work Post-Treatment
If the employee is referred by the Hospital, voluntarily or involuntarily, for evaluation and treatment relating to drug or alcohol
use, medical leaves of absence, PTO and EIT may be used, as specified in those policies. In cases where the employee has
participated in a rehabilitation program approved by the Hospital, the employee will be allowed to return to work upon
completion of the program only if all of the following requirements are met:
a. The authority supervising the rehabilitation program certifies in writing that the employee is rehabilitated and
recommends him or her for continued employment, taking into consideration his or her access to controlled
substances.
b. Consistent with applicable law, there is a position available that the employee is qualified to perform.
c. The Occupational Health Nurse, the Director of Employee Relations or a designated Human Resources representative,
and the employee's department manager or division director agree that such a return to work is in the best interest of
the Hospital and the employee and that such return will not adversely affect the Hospital's effort to maintain an
environment free from persons involved with substance misuse.
d. The employee willingly cooperates in a proposed monitoring program designated by the Hospital.
e. For more information, please refer to “Testing of Employees", the "reasonable suspicion" definition, and the
"Employee Return to Work Agreement.”
12.3
Employee Knowledge of Substance Misuse and Illegal Activity
An employee who has knowledge of substance misuse activity involving other employees or any illegal activity involving drugs
on Hospital premises must report such activity to his/her supervisor, Human Resources, or Occupational Health. An employee,
who has knowledge of such activity and does not report it, will be subject to employee counseling up to and including
termination. CMHs & Clinics will cooperate with all regulatory enforcement agencies, including licensing authorities for
licensed employees, in an effort to detect and prevent substance misuse and illegal activity.
12.4
Testing of Employees
Testing may be performed on applicants, employees, or other covered individuals, under any of the following circumstances:
a. Upon employment for drugs.
b. When there is reasonable suspicion that an employee, or other covered individual, is using, is under the influence of,
or is impaired by drugs or alcohol.
c. When there is reasonable suspicion of diversion of drugs.
d. When an employee, or other covered individual, is found in possession of illegal drugs or alcohol on CMH property or
while engaged in CMH business.
e. When testing is required by a federal, state or local government statute, regulation or ordinance or when required by
contractual obligations of CMH.
Page 30 of 49
Last Updated: 7/1/2013
f.
g.
h.
i.
12.5
Following a work-related injury which results in treatment or work time lost, or occurs in connection with significant
damage to equipment or injury to another party.
For employees, on an unannounced and suspicionless basis, on return to work after receiving treatment for the use of
drugs or alcohol.
For employees, on an unannounced and suspicionless basis, after receiving a positive test result.
For employees, drug testing may be included as part of any fitness for duty examination; alcohol testing may be
included as part of any fitness for duty examination where warranted.
Definitions
a.
b.
c.
“alcohol” means any substance containing ethyl alcohol (ethanol).
“applicant” means someone to whom a job offer has been made.
"CMH property” means all property and facilities of Children’s Mercy Hospital and related and affiliated organizations
and companies, including parking lots and grounds (including hospital vehicles and personal vehicles) where
employees are conducting CMH business or otherwise acting in the course and scope of their employment.
d. “drug” means any drug, controlled substance, inhalant or perception altering substance.
e. “employee” for the purpose of drug and alcohol screening, means any CMH employee to whom the Hospital pays
wages; withholds income taxes, social security, medicare; and subsequently issues a form W-2.
f. “evidentiary breath test” means screening by a laboratory designated by CMH of a deep lung breath performed by an
applicant, employee, or other covered individual to detect the presence of alcohol.
g. “illegal drug” means any drug, controlled substance, inhalant or perception altering substance, the possession or use
of which is restricted, controlled or prohibited by state or federal law, and for which the user does not have a lawful
prescription.
h. "illegal use of drugs" means use of any drug, controlled substance, inhalant or perception altering substance, the
possession or use of which is restricted, controlled or prohibited by state or federal law, and for which the user does
not have a lawful prescription or for which use is not in accordance with such prescription.
i. “manager or division director” assumes that if the involved employee is in a manager or division director position the
next higher organizational chart level would take the steps outlined in this policy and procedure.
j. “negative test result” for drugs means not having a reportable level of drugs or their metabolites in the body as
determined by an oral screening or a urinalysis. For alcohol, this means an alcohol level in the body, as determined by
a Breathalyzer, less than 0.02%.
k. “non-negative test result” for drugs means having a reportable level of a drug or its metabolites in the body as
determined by an oral screening or a urinalysis.
l. “oral screening” means a test for drugs or their metabolites from a saliva sample to detect the illegal use of drugs.
m. “other covered individuals” includes independent contractors, travelers, contract or temporary employees including
non-employed physicians, residents, fellows, or other clinicians.
n. “positive test result” for alcohol means having an alcohol level in the body as determined by a Breathalyzer. For the
purpose of this policy, to be considered “positive”, the level must be a minimum of 0.02%. For drugs this means
having a reportable level of drugs or their metabolites in the body as determined by an oral screening or a urinalysis.
o. “rapid response test” means screening by urinalysis for use of drugs with a response of ‘negative’ (no drugs or
metabolites present) or a response of ‘non-negative’ (drugs or metabolites present).
p. “reasonable suspicion” means a belief that an employee or other covered individual is engaged in the current illegal
use of drugs, the use of illegal drugs, the use of alcohol at the workplace, or is otherwise in violation of this Policy.
Reasonable suspicion that an employee or other covered individual is under the influence of drugs or alcohol occurs
when that person exhibits behaviors which are obvious, significant or compelling and which a reasonable person
would believe are consistent with being under the influence of drugs or alcohol. A determination of whether
reasonable suspicion exists is reserved to the sole discretion of management and includes, but is not limited to, the
following:
q. observations while at work of drug or alcohol use, or the physical symptoms or manifestations of being under the
influence of alcohol or impaired by drugs;
i.
abnormal conduct or erratic behavior while at work or a significant deterioration in work performance;
ii.
a report of drug or alcohol use, provided by a reliable and credible source;
iii.
information that an individual has tampered with a screening sample or screening device or test;
iv.
information that an employee or other covered individual has used, possessed, sold, solicited, or transferred
drugs or alcohol while working for CMH or while on CMH property, while operating CMH vehicles or
equipment, or while operating a personal vehicle on CMH business.
Page 31 of 49
Last Updated: 7/1/2013
r.
s.
12.6
“under the influence” means that the employee or other covered individual is affected by drugs or alcohol in any
detectable manner.
“urinalysis test” means screening by a laboratory designated by CMH of a urine specimen provided by an applicant,
employee, or other covered individual to detect the illegal use of drugs.
Release of Information
The results of alcohol and drug tests will be released to only those persons within and outside CMH with a need to know the
information (including but not limited to individuals in workers' compensation and unemployment proceedings) or who are
involved in any rehabilitation program in which CMH, in its full discretion, allows the employee’s participation as a condition of
continued employment. Appropriate protocols will be followed for the release of information, according to applicable laws,
including the Americans with Disabilities Act. Organizations outside CMH may include appropriate impaired professional
organizations and licensing agencies.
12.7
Workers' Compensation and Unemployment
Termination from employment due to violation of this policy (including but not limited to a positive test result or refusal to
submit to testing) may adversely affect an employee's entitlement to unemployment benefits. Further, violation of this policy
(including but not limited to a positive test result or refusal to submit to testing) in connection with a workers' compensation
injury may adversely affect an employee's entitlement to workers' compensation benefits.
12.8
Exclusions
Board members and volunteers are subject to the same prohibitions against the use, possession, consumption, exchange,
delivery, distribution or sale of alcohol and drugs but are excluded from the testing and counseling sections of this policy.
Rather, board members and volunteers will be subject to their respective bylaws or policies.
RESIDENT/FELLOW IMPAIRMENT 34
13.
CMH seeks to promote the health and well-being of Residents/Fellows while assuring that our patients receive quality care.
CMH recognizes that, drug and chemical abuse, physical or mental illnesses and life stressors may adversely affect a
Resident’s/Fellow’s ability to deliver quality care.
13.1
Definitions
a.
b.
c.
d.
e.
f.
34
“advocacy agreement” is a document between the Resident/Fellow, the CMH Health and Wellness Program Medical
Director or designee and the PD or designee that includes one or more of the following: 1) acknowledgement of the
impairment and/or cause of the impairment; 2) the planned intervention; 3) methods of evaluation; 4) plan of
treatment; 5) schedule and methods for monitoring; 6) the conditions that must be met to return or continue training.
“CMH Health and Wellness Program” is a program designed to intervene with an impaired Resident/Fellow to provide
evaluation, resources or referral for treatment and monitoring of recovery.
“drug or chemical substances” include, but are not limited to, alcohol, over-the-counter medications or substances,
prescribed or unprescribed medications, controlled substances, or any other substance that alters the body’s
biochemistry or causes adverse psychological effects.
“drug-related misconduct” includes, but is not limited to, illegal use, possession, or distribution of drug or chemical
substances.
“evaluation” is an assessment of the impaired Resident/Fellow by a medical or mental health professional or
treatment facility on the recommendation of the Medical Director of the CMH Health and Wellness Program. A
chemically
“impaired Resident/Fellow” is a Resident/Fellow whose ability to safely perform the essential functions of the job has
been compromised due to the adverse affect of drug or chemical use or abuse, physical or mental illness or life
stressors.
ACGME Institutional Requirements, II.D.4.l)
Page 32 of 49
Last Updated: 7/1/2013
g.
h.
i.
j.
13.2
“Missouri Physician Health Program (MPHP)” is the impaired Resident’s/Fellow’s program sponsored by the Missouri
State Medical Association.
“intervention” is an organized approach by trained individuals for the purpose of encouraging and motivating the
physician to acknowledge the impairment and to seek evaluation and treatment. An intervention may involve a
representative of the MPHP, the Medical Director of the CMH Health and Wellness Program, a PD, an individual such
as a spouse, significant other, practice partner, relative, friend, or other professional whose involvement has been
consented by the impaired Resident/Fellow.
“monitoring” is the process for ongoing follow-up of treatment and recovery.
“treatment” is a process whereby the impaired Resident/Fellow is assisted in the acknowledgement of the cause of
impairment and therapy is initiated.
Procedures
a.
Reporting Concerns of Impairment
Residents/Fellows will notify their PD, an APD, Chair or Vice Chair of GME or the Medical Director of Center for
Professionalism and Wellbeing when they have reasonable suspicions or concerns that a physician is exhibiting signs
or behaviors of impairment. Residents/Fellows reporting suspicions or concerns of impairment will cooperate with
the CMH Director of Employee Relations in the conduct of an investigation.
b.
Concern for On-duty Chemical or Drug use Causing Impairment
When a PD or other designated individual receives a report involving a concern or suspicion of impairment in a
Resident/Fellow who is on duty at CMH or a CMH affiliated training facility, the following steps will occur:
i.
The PD will request that the Resident/Fellow consent to drug and alcohol screening as outlined in the CMH
Drug and Alcohol Policy.
ii.
In accordance with that policy, the Resident/Fellow will be relieved from duty until the results of the
screening have been received and reviewed. Residents/Fellows who refuse consent to immediate alcohol or
drug testing will be relieved of duty and suspended with pay pending investigation.
iii.
In all instances Residents/Fellows and PDs or their designees will cooperate with the CMH Director of
Employee Relations in the conduct and resolution of an investigation. If screening results are positive, the PD
or designee will meet with the Resident/Fellow to review the results and discuss the concern of chemical or
drug impairment.
iv.
The PD will review CMH GME Policies and Procedures with the Resident/Fellow.
v.
The Resident/Fellow will be immediately relieved of all clinical responsibilities and referred to the Medical
Director of the CMH Center for Professionalism and Wellbeing or designee for intervention and the creation
of an Advocacy Agreement.
vi.
The Advocacy Agreement must be signed before the Resident/Fellow can return to clinical duties. The
Resident/Fellow will continue to be paid until the Advocacy Agreement has been written and signed.
Residents/Fellows who refuse to enter into an Advocacy Agreement with the training program and CMH are
subject to corrective or disciplinary actions.
vii.
Residents/Fellows who disagree that chemical or drug impairment exists may follow the procedure outlined
below under Due Process for Residents/Fellows who disagree with a Diagnosis of Impairment.
viii.
If the screening results are negative, the PD or designee will meet with the Resident/Fellow to review the
results and discuss the concern for impairment. The PD or designee in accordance with the CMH Drug and
Alcohol Policy and in the interest of patient care and safety will determine when the Resident/Fellow can
return to clinical duties.
ix.
The PD or designee reserves the right to further monitor behavior or proceed with additional referral to the
CMH Center for Professionalism and Wellbeing Medical Director to evaluate for other causes of impairment.
c.
Concern for Physical or Mental Health Impairment or Impairment Due to Life Stressors
When a concern for physical, mental or life stressor related impairment has been raised, the following steps will occur:
i.
The Resident/Fellow will meet with the PD, an APD, and Chair or Vice Chair of GME and a referral to the
Medical Director or their designee of the CMH Center for Professionalism and Wellbeing will be made.
Page 33 of 49
Last Updated: 7/1/2013
ii.
iii.
iv.
v.
d.
The Medical Director or their designee of the CMH Center for Professionalism and Wellbeing will determine
the need for intervention.
Residents/Fellows with impairment due to physical or mental illness or life stressors will enter into written
and signed Advocacy Agreement with their training program and CMH. Residents/Fellows who refuse to
enter into an Advocacy Agreement are subject to corrective or disciplinary actions.
In all instances Residents/Fellows and PDs or their designees will cooperate with the CMH Director of
Employee Relations in the conduct and resolution of an investigation.
Residents/Fellows who disagree that physical or mental health impairment or impairment due to life
stressors exist may follow the procedure outlined below under Due Process for Residents/Fellows who
disagree with a Determination of Impairment.
Due Process for Residents/Fellows who Disagree with a Determination of Impairment
Residents/Fellows who disagree with a determination of impairment may follow the procedure outlined below:
i.
The Resident/Fellow may request a hearing before the Medical Staff Education Committee to rebut the
determination of impairment and the need for intervention and an Advocacy Agreement. The
Resident/Fellow must request the hearing within 10 weekdays of the meeting with the PD or the Medical
Director of the CMH Center for Professionalism and Wellbeing or designees notifying them of the
determination of impairment and the need for an Advocacy Agreement.
ii.
When a hearing is requested the Medical Staff Education Committee will meet within 5 weekdays to review
all documentation and testimony related to the determination of impairment. The Resident/Fellow must
appear before the committee to refute the allegations of impairment.
iii.
The PD, Medical Director of the CMH Center for Professionalism and Wellbeing, Director of Employee
Relations or others may appear before the committee to present the evidence or concerns for impairment.
iv.
The Medical Staff Education committee, after considering all documentation and testimony shall present
their written findings and recommendations to the Executive Vice President of Medical Affairs or their
designee who will make a final decision which is binding to all.
v.
Written notification of a final decision on the determination of impairment from the Executive Vice President
of Medical Affairs will be sent to the Resident/Fellow, Chair/Vice Chair of GME, PD, Director of Employee
Relations and Medical Director of the CMH Center for Professionalism and Wellbeing.
vi.
When the determination of impairment is upheld, the Resident/Fellow will enter into intervention and an
Advocacy Agreement with the training program and CMH. If the Resident/Fellow disagrees with the decision
of the Executive Vice President of Medical Affairs, they will be subject to corrective or disciplinary action.
vii.
When the determination of impairment is not upheld the Resident/Fellow will be allowed to return to clinical
duties. The PD or designee reserves the right to further monitor behavior and take corrective or disciplinary
action when indicated.
e.
Failure to Comply with the Terms of an Advocacy Agreement
Residents/Fellows who do not satisfactorily comply with the terms of a signed Advocacy Agreement are subject to
corrective or disciplinary actions.
f.
Medical Clearance for Return to Work
Resident’s/Fellow’s who, as part of their intervention and Advocacy Agreement are under the care of a physician or
other mental health professional, must have a signed release to return to patient care responsibilities.
g.
Confidentiality and Storage of Records Related to Intervention
All records related to impairment and the Advocacy Agreement will be kept in a designated locked file cabinet in the
office of the Medical Director of the CMH Center for Professionalism and Wellbeing. Access to these records will be on
a need-to-know basis as determined by the Medical Director of the CMH Center for Professionalism and Wellbeing.
These records will not be placed with the Resident/Fellow’s personnel file and with the exception of attorney client
privileged documents will not be released to anyone. Confidentiality of the impaired Resident’s/Fellow’s identity will
be maintained by all concerned and the proceedings of any meetings or hearings will remain confidential except as
limited by law, ethical obligation, concerns of patient safety or on a need-to-know basis.
Page 34 of 49
Last Updated: 7/1/2013
14.
PERSONAL USE OF SOCIAL MEDIA
The Hospital recognizes that the Internet provides unique opportunities to participate in interactive discussions and to share
information on particular topics using a wide variety of media, such as Facebook, Twitter, blogs and wikis. As such, the Hospital
understands that CMH employees may be participating in social media on their personal time and for personal use.
Employees’ personal use of social media may pose unintended risks to CMH’S patient privacy, confidential and proprietary
information, reputation and brands, and can jeopardize the Hospital’s compliance with business rules and laws. This policy
offers guidance for employee’s personal use of social media.
14.1
Guidelines for CMH Employees Participation in Non-Hospital Social Media
Each CMH employee is an “Ambassador of the Hospital” both at work and outside of work. For this reason, it is important that
employees follow some simple guidelines when posting information about their work life or experiences by remembering:
a.
b.
c.
d.
e.
f.
Each Employee’s commitment to follow the Hospital’s Service Excellence Policy
i.
Post only appropriate language.
ii.
Do not post any offensive, derogatory, threatening, discriminating or harassing content.
iii.
Do not engage or participate in inflammatory disputes in postings.
iv.
Do not post defamatory, libelous comments or statements that infringe on the rights of others.
v.
Do not post pictures or comments about your co-workers without their permission.
vi.
Do not post comments about work concerns or conflicts. The proper method of resolution of work issues or
conflicts can be handled through your supervisor or by contacting the Employee Relations Department.
Ensure patient privacy and confidentiality
i.
Do not post information about patients and their families. Even if the post appears to be de-identified, there
is the possibility that the patient or family could be identified and your comments may be seen as
unprofessional by others.
ii.
Do not post pictures of patients or their families.
Respect and preserve the patient/provider relationship and boundaries by following the Preserving Professional
Boundaries Policy
i.
Do not invite patients (including minors) or families (current or previous) to be a “friend” to your social
networking site.
ii.
Employees may view a patient or parents community page (such as CarePages or Caring Bridge).
iii.
Do not comment on patient or patient family sites.
Use the Hospital Internet and Computer Systems appropriately
i.
Use of Internet for personal purposes should be done in moderation and only during breaks or after all
patient care and downtime tasks (stocking, cleaning, etc.) are completed.
ii.
Certain Web sites will be blocked on computers in public areas where patients/parents or visitors may be
able to view the computer.
iii.
Only computers in designated areas where the screen is not visible to the parents may be used for personal
social media use.
iv.
Use of Internet or Social Networking cannot interfere with employee productivity or job duties.
v.
The Hospital has the right to monitor staff activity on CMH email and on these sites. Misuse of such may
result in corrective actions. Requests for monitoring staff activity will be approved and coordinated through
the Director of Employee Relations.
vi.
CMH email address is the property of the Hospital and staff should use discretion in using their assigned
Hospital email (i.e; [email protected]) for personal use. When setting up personal use of social media,
staff are strongly discouraged from using their assigned Hospital email address.
Follow the law - Do not post content or participate in any activity which does not conform to any and all applicable
local, state or federal laws.
Respect copyright laws - Before you post material (text, images, graphics, etc.) that you yourself did not create, obtain
permission from the person or organization that did create that material, or from the copyright owner of that
material. Instead of directly including material created by others, you can sometimes meet the same purpose by giving
Page 35 of 49
Last Updated: 7/1/2013
g.
h.
i.
j.
14.2
a citation to a source, such as a public Web site that contains the material. For additional detail, review the Hospital's
Copyright Policy.
Protect Hospital confidential or proprietary information - Do not post information that the Hospital received from
another organization under a Confidential Disclosure Agreement, information that the Hospital generated in its
research laboratories, or information that is confidential by its nature, whether it pertains to the Hospital or some
other organization or individual. As a general guideline, the more specific the information, the more likely it is to be
confidential (unless it is already available from some public source such as a Web site).
Protect the discoverability of Hospital information - Do not post or disclose any Attorney-Client Privileged information.
Comply with research and grant sponsors confidentiality and disclosure of information criteria. Do not post the
following information without the required written approvals from the sponsor as defined in the contract:
i.
Information about research or studies as this may violate contractual arrangements and compromise the
integrity of the research.
ii.
Proprietary information, including investigational product names or other information.
iii.
Information which may affect intellectual property rights.
Prevent potential conflict of interests and Federal Trade Commission Guideline violations - Do not advertise or
promote healthcare products or provide testimonials or endorsements for health care products.
Inappropriate Postings
Inappropriate postings can occur by an employee, patient/family member or from the community.
Employees who become aware of any inappropriate postings by an employee should report the incident to their manager or
the Employee Relations department. The employee’s manager and the Employee Relations employee will investigate the
incident per the Hospital Human Resource process.
Employees should report inappropriate postings by patients/families or the community in accordance with the Hospital Use of
Social Media Policy guidelines.
EDUCATIONAL PROGRAM & ACGME COMPETENCIES35
15.
a.
b.
35
Each Program’s curriculum will contain the following educational components:
i.
Overall educational goals for the program, which the program will distribute to Residents/Fellows and faculty
annually;
ii.
Competency-based goals and objectives for each assignment at each educational level, which the program
will distribute to Residents/Fellows and faculty annually, in either written or electronic form. These should be
reviewed by the Resident/Fellow at the start of each rotation/educational unit;
iii.
Regularly scheduled didactic sessions;
iv.
Delineation of Resident/Fellow responsibilities for patient care, progressive responsibility for patient
management, and supervision of Residents/Fellows over the continuum of the program; and,
v.
ACGME Competencies.
The program must integrate the following ACGME competencies into the curriculum:
i.
Patient Care. Residents/Fellows must be able to provide patient care that is compassionate, appropriate, and
effective for the treatment of health problems and the promotion of health.
ii.
Medical Knowledge. Residents/Fellows must demonstrate knowledge of established and evolving
biomedical, clinical, epidemiological and social behavioral sciences, as well as the application of this
knowledge to patient care.
iii.
Practice-based Learning and Improvement. Residents/Fellows must demonstrate the ability to investigate
and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously
improve patient care based on constant self-evaluation and life-long learning. Residents/Fellows are expected
to develop skills and habits to be able to meet the following goals:
o identify strengths, deficiencies, and limits in one’s knowledge and expertise;
o set learning and improvement goals;
ACGME Common Program Requirements IV.
Page 36 of 49
Last Updated: 7/1/2013
o
o
iv.
v.
identify and perform appropriate learning activities;
systematically analyze practice using quality improvement methods, and implement changes with
the goal of practice improvement;
o incorporate formative evaluation feedback into daily practice;
o locate, appraise, and assimilate evidence from scientific studies related to their patients’ health
problems;
o use information technology to optimize learning; and,
o participate in the education of patients, families, students, Residents/Fellows and other health
professionals.
Interpersonal and Communication Skills.
Residents/Fellows must demonstrate interpersonal and
communication skills that result in the effective exchange of information and collaboration with patients,
their families, and health professionals. Residents/Fellows are expected to:
o communicate effectively with patients, families, and the public, as appropriate, across a broad range
of socioeconomic and cultural backgrounds;
o communicate effectively with physicians, other health professionals, and health related agencies;
o work effectively as a member or leader of a health care team or other professional group;
o act in a consultative role to other physicians and health professionals; and,
o maintain comprehensive, timely, and legible medical records, if applicable.
Professionalism. Residents/Fellows must demonstrate a commitment to carrying out professional
responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:
o
o
o
o
o
vi.
compassion, integrity, and respect for others;
responsiveness to patient needs that supersedes self-interest;
respect for patient privacy and autonomy;
accountability to patients, society and the profession; and,
sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender,
age, culture, race, religion, disabilities, and sexual orientation.
Systems-based Practice. Residents/Fellows must demonstrate an awareness of and responsiveness to the
larger context and system of health care, as well as the ability to call effectively on other resources in the
system to provide optimal health care. Residents/Fellows are expected to:
o work effectively in various health care delivery settings and systems relevant to their clinical
specialty;
o coordinate patient care within the health care system relevant to their clinical specialty;
o incorporate considerations of cost awareness and risk benefit analysis in patient and/or populationbased care as appropriate;
o advocate for quality patient care and optimal patient care systems;
o work in inter professional teams to enhance patient safety and improve patient care quality; and,
o participate in identifying system errors and implementing potential systems solutions.
The curriculum will advance Residents’/Fellows’ knowledge of the basic principles of research, including how research
is conducted, evaluated, explained to patients, and applied to patient care. Residents/Fellows should participate in
scholarly activity. The Sponsoring Institution and program will allocate adequate educational resources to facilitate
Resident/Fellow involvement in scholarly activities.
16.
INTERNATIONAL ROTATION/EDUCATIONAL UNITS
Residents/Fellows participating in a training Program at CMH, who are interested in completing an International elective
rotation/educational unit, must follow the guidelines below. Residents/Fellows must present the required report and should
be willing to make a presentation at a Grand Rounds or International Day.
16.1
Eligibility Criteria for International Elective Rotation/Educational Unit
a.
a.
b.
c.
d.
Residents who entered the Program after July 1, 2011, must meet all the requirements of the Global Health Track.
Fellows must be in their second year of training.
Residents/Fellows must have a faculty Global Health Track advisor at CMH
Goals and objectives must be clearly outlined for the experience with the Global Health Track advisor.
The onsite international faculty member who will complete the evaluation must be identified in advance.
Page 37 of 49
Last Updated: 7/1/2013
e.
f.
16.2
July is excluded.
Pre-requisites:
i.
Must meet conference attendance requirements
ii.
No incomplete rotation/educational units
iii.
Evidence of compliance with documentation of procedures and medical records must be up to date
iv.
Must have taken In-service exams as appropriate
v.
Must have completed post rotation/educational unit tests where applicable
vi.
Must have a call free month available for the international rotation/educational unit (PD has the discretion
for approval)
vii.
Additional appropriate immunizations as necessary
Travel Criteria
a.
b.
c.
d.
16.3
The international elective must be approved by the Global Health Track Director.
Country of travel must not be listed on the state department travel warning sites.
Resident/Fellow must have all travel documentation in order:
i.
Complete the International Medicine Personal Information Sheet and return to the GME Department.
ii.
Copy of the passport
iii.
Copy of Visa (if applicable)
iv.
Travel insurance
v.
Risk and release form
vi.
Documentation of immunizations
Resident/Fellow will be provided information regarding US Embassy/consulate, travel registration and other relevant
information.
Return from Travel
a.
b.
Resident/Fellow must have an appointment set with occupational services to meet immediately upon return. This
should be within 24 hours or before returning to regular work schedule.
Upon return, Resident/Fellow must meet with Global Health Track Director to review the experience and to confirm
that all goals and objectives of the rotation/educational units as stated are met.
17.
DUTY-HOURS AND CALL SCHEDULES36
17.1
Limitations on Duty-hours
The Hospital and/or Sponsoring Institution policy is that duty-hours will be in compliance with the guidelines established by
ACGME.
a.
b.
c.
36
The Hospital and/or Sponsoring Institution policy is that no exceptions to the ACGME duty-hour requirements are
allowed.
Duty-hours are defined as all clinical and academic activities related to the program; i.e., patient care (both inpatient
and outpatient), administrative duties relative to patient care, the provision for transfer of patient care; time spent inhouse during call activities, and scheduled activities such as conferences. Duty-hours do not include reading and
preparation time spent away from the duty site.
i.
Maximum Hours of Work per Week - Duty-hours must be limited to 80 hours per week, averaged over a fourweek period, inclusive of all in-house call activities and moonlighting.
ii.
Mandatory Time Free of Duty - Residents/Fellows must be scheduled for a minimum of one day free of duty
every week (when averaged over four weeks). At-home call cannot be assigned on these free days.
iii.
Maximum Duty Period Length
Duty periods for PGY-1 Residents/Fellows must not exceed 16 hours in duration. Duty periods of PGY-2
Residents/Fellows and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital.
Programs must encourage Residents/Fellows to use alertness management strategies in the context of patient care
ACGME Institutional Requirements, II.D.4.i) & ACGME Common Program Requirements, VI
Page 38 of 49
Last Updated: 7/1/2013
d.
e.
f.
g.
h.
i.
17.2
responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 pm
and 8:00 am, is strongly suggested.
It is essential for patient safety and Resident/Fellow education that effective transitions in care occur.
Residents/Fellows may be allowed to remain on-site in order to accomplish these tasks; however, this period of time
must be no longer than an additional four hours.
Residents/Fellows must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
In unusual circumstances, Residents/Fellows, on their own initiative, may remain beyond their scheduled period of
duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of
required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic
attention to the needs of a patient or family. Under those circumstances, the Resident/Fellow must:
Appropriately hand over the care of all other patients to the team responsible for their continuing care; and,
Document the reasons for remaining to care for the patient in question and submit that documentation in every
circumstance to the PD.
The PD must review each submission of additional service, and track both individual Resident/Fellow and programwide episodes of additional duty.
Minimum Time Off between Scheduled Duty Periods
a.
b.
c.
17.3
PGY-1 Residents/Fellows should have 10 hours, and must have eight hours, free of duty between scheduled duty
periods.
Intermediate-level Residents/Fellows should have 10 hours free of duty, and must have eight hours between
scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty.
Circumstances of return-to-hospital activities with fewer than eight hours away from the hospital by residents in their
final years of education must be monitored by the PD.
Maximum Frequency of In-House Night Float
a.
b.
17.4
Night float is a rotation/educational unit or educational experience designed to either eliminate in-house call or to
assist other resident during the night. Residents/Fellows assigned to night float are assigned on-site during
evening/night shifts and are responsible for admitting or cross-covering patients until morning and do not have
daytime assignments. Rotation/Educational Unit must have an educational focus.
Residents/Fellows must not be scheduled for more than six consecutive nights of night float.
Call Frequency
The objective of on-call activities is to provide Residents/Fellows with continuity of patient care experiences throughout a 24hour period. In-house call is defined as those duty hours beyond the normal work day, when Residents/Fellows are required to
be immediately available in the assigned institution. No new patients may be accepted after 24 hours of continuous duty.
a.
b.
c.
d.
e.
f.
g.
h.
i.
PGY-1 Residents/Fellows are not scheduled for in-house call.
PGY-2 Residents/Fellows and above must be scheduled for in-house call no more frequently than every-third-night
(when averaged over a four-week period).
At-home call is the same as Pager Call (a call taken from outside the assigned site). Time in the hospital, exclusive of
travel time, must be documented as at-home call.
Time spent in the hospital by Residents/Fellows on at-home call must count towards the 80-hour maximum weekly
hour limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the
requirement for one-day-in-seven free of duty, when averaged over four weeks.
At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each
Resident/Fellow.
Residents/Fellows are permitted to return to the hospital while on at-home call to care for new or established
patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate
a new “off-duty period.”
The call schedule and schedule of duty assignments will be published and made available for review by the
Residents/Fellows on a monthly basis.
Changes to the call and duty schedules will be made and the revisions published by the PD or a designee.
Every month, the PC will verify that the Residents/Fellows time reported is accurate.
Page 39 of 49
Last Updated: 7/1/2013
EXTRA SHIFTS AND MOONLIGHTING37
18.
Residents are only allowed to do Extra Shifts; Residents/Fellows are allowed to do Internal Moonlighting and Extra Shifts.
Extra Shifts are defined as shifts above and beyond their training requirements but still supervised; Residents/Fellows DO NOT
practice independently; DO NOT bill; Use hospital DEAs and have been not been credentialed through Medical Staff.
Internal Moonlighting is defined as voluntary, compensated, medically-related work (not related with training requirements)
performed within the hospital or any related sites. Fellows must work in an area where they have already been fully trained
and certified; have their own DEA number, go through Medical Staff credentialing; and must have a permanent license in the
state in which they are moonlighting
External Moonlighting is defined as voluntary, compensated, medically-related work performed outside the hospital or related
sites where the Resident/Fellow is in training. External Moonlighting is not permitted
a.
b.
c.
d.
e.
f.
g.
h.
i.
Extra Shifts/Moonlighting must not interfere with the ability of the Resident/Fellow to achieve the goals and
objectives of the educational program.
Time spent by Residents/Fellows in Extra Shifts/Moonlighting (as defined above) must be counted towards the 80hour maximum weekly hour limit.
PGY 1 Residents are not permitted to take Extra Shifts.
Residents/Fellows are not required to engage in Extra Shifts/Moonlighting activities.
Residents/Fellows must keep up to date duty hour logs which include all Extra Shifts/Moonlighting activities.
Residents/Fellows are monitored on performance, and if the PD feels the Extra Shifts/Moonlighting activities are
interfering with patient care, may withdrawal permission for Extra Shifts/Moonlighting activities without notice.
Each Program will develop its own policies to govern extra-institutional practice activities by its Residents/Fellows PGY
2 and above. These Program policies will conform to any ACGME and RRC guidelines.
A Resident/Fellow who wishes to engage in Extra Shifts/Moonlighting activities must seek approval by completing the
GME Extra Shift Form or GME Moonlighting Approval Form. The form requires the PD’s signature and the signature of
the site where the Extra Shifts/Moonlighting will take place. Once complete the Resident/Fellow must submit to the
GME Department for final approval.
Residents/Fellows seeking internal moonlighting approval, and after final approval is provided, must contact the
Hospitals Medical Staff Office to obtain and complete the required forms to apply for “privileges” pursuant to the
Hospitals Appointment and Credentialing Policy, Article II.D.4-6, page 31-32.
EVALUATION38
19.
All faculty and Resident/Fellow evaluations are overseen and managed by the GME Department for review by appropriate
representatives of the Hospital or external reviewing bodies.
19.1
Resident/Fellow Evaluation
a.
b.
37
38
Formative Evaluation
i.
The faculty will evaluate Resident/Fellow performance in a timely manner during each rotation/educational
unit or similar educational assignment, and document this evaluation at completion of the assignment.
ii.
The program will provide objective assessments of the competencies in Section 15 (Educational Program &
ACGME Competencies), using multiple evaluators (e.g., faculty, peers, patients, self, and other professional
staff), and document progressive Resident/Fellow performance improvement appropriate to educational
level, and will provide each Resident/Fellow with documented semiannual evaluation of performance with
feedback.
iii.
The evaluations of Resident/Fellow performance are accessible for review by the Resident/Fellow.
Summative Evaluation
ACGME Institutional Requirements, II.D.4.j) & ACGME Common Program Requirements VI.G.2.
ACGME Common Program Requirements, V.
Page 40 of 49
Last Updated: 7/1/2013
i.
ii.
iii.
19.2
The PD will provide a summative evaluation for each Resident/Fellow upon completion of the Program.
This evaluation will become part of the Resident’s/Fellow’s permanent record maintained in the GME
Department, and is accessible for review by the Resident/Fellow.
The evaluation will document the Resident’s/Fellow’s performance during the final period of education, and
verify that the Resident/Fellow has demonstrated sufficient competence to enter practice without direct
supervision.
Faculty Evaluation
At least annually, the program will evaluate faculty performance as it relates to the educational program. These evaluations
will include a review of the faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge,
professionalism, and scholarly activities, and will include written confidential evaluations by the Residents/Fellows.
19.3
Program Evaluation and Improvement
The Program will document formal, systematic evaluation of the curriculum at least annually. The program will monitor and
track each of the following areas:
a.
b.
c.
d.
Resident/Fellow performance;
faculty development;
graduate performance, including performance of Program graduates on the certification examination; and
Program quality, specifically: Residents/Fellows and faculty will have the opportunity to evaluate the Program
confidentially and in writing at least annually, and the Program will use the results of Residents’/Fellows’ assessments
of the program together with other Program evaluation results to improve the Program.
If deficiencies are found, the Program should prepare a written plan of action to document initiatives to improve performance
in the areas listed above. The action plan should be reviewed and approved by the teaching faculty and documented in
meeting minutes.
20. PROMOTION AND PROGRAM COMPLETION
While the Hospital does not allow the term of an Agreement of Appointment to exceed one year, the Hospital does recognize
that candidates accepting appointments to the program have an expectation that they will be allowed to complete their
training, provided they show satisfactory progress in their educational Programs. While the Hospital cannot guarantee that this
expectation will be met in all cases, every effort will be made to preserve from year to year the position of a Resident/Fellow
who is advancing and progressing toward completion of her/his training.
Changes in the size of a program will be accomplished, whenever possible, through changes in the numbers of candidates
accepted into the first year of a Program rather than through elimination of more current positions.
A Resident/Fellow whose performance conforms to established evaluation criteria in a consistent and satisfactory manner will
be considered to be “in good standing” with the Program and Institution. Resident/Fellow misconduct, failure to comply with
the policies and procedures governing GME, or unsatisfactory performance based on one or more evaluations may adversely
affect the standing in his/her Program. In such cases, the Resident/Fellow may be placed on corrective action, suspension or
termination as discussed in Section 21 (Corrective Actions, Suspensions and Termination) of this manual.
20.1
Promotion/Advancement
After satisfactory completion of each year of training, a Resident/Fellow in good standing may be promoted/advanced to the
next year of their training program subject to the terms, limitations and conditions described in this document and the
Agreement or Appointment.
Promotion/advancement to the next level of training is at the sole discretion of the PD, Hospital, and the Sponsoring
Institution. The decision to promote is expressly contingent upon several factors, including but not limited to:
Page 41 of 49
Last Updated: 7/1/2013
a.
b.
c.
satisfactory completion of all training components, including demonstration of ACGME competencies outlined in
Section 15 (Educational Program & ACGME Competencies);
sitting for and passing Part III of the USMLE or COMLEX prior to completion of PGY 1 level of training; and
full compliance with the terms of the Agreement of Appointment.
A Resident/Fellow who is in remediation or on probation will be promoted at the discretion of the PD. If the decision is made
to promote the Resident/Fellow, the probation remains in effect until the terms and conditions are met. Residents/Fellows will
not promote while under suspension or during an appeal and hearing process.
20.2
Program Completion
Each Residency/Fellowship training Program will have specific criteria for satisfactorily completing the entire program as well as
each level (year) of training. These criteria will, at a minimum, meet the criteria necessary for certification by the appropriate
medical specialty board. The criteria may be more rigorous than the criteria set by the specialty board, at the discretion of the
PD.
A Resident/Fellow who successfully completes a program’s specified requirements will be issued a Certificate of Completion.
Prior to leaving their training Program, or being eligible to receive a Certificate of Completion, each Resident/Fellow must
return his/her ID badge, pager, call food card, parking sticker, complete all medical record charts, procedure logs, duty hours
and evaluations. Residents/Fellows pursuing an appeal or hearing of a proposed corrective action will not be issued a
Certificate of Completion until the status is resolved.
21.
CORRECTIVE ACTIONS, SUSPENSION AND TERMINATION
21.1
Categories and Criteria
Criteria for corrective action, suspension or termination may include but are not limited to:
a.
b.
c.
Academic
i.
unsatisfactory performance based on in-service examinations, quizzes, and/or oral/written examinations and
evaluations;
ii.
failure to show expected rate of improvement in fund of knowledge; or
iii.
unsatisfactory participation and/or performance in conferences.
Clinical
i.
unsatisfactory acquisition of clinical or technical skills;
ii.
unsatisfactory performance in the clinical setting;
iii.
deviation from the professional standard of care;
iv.
provision of care without appropriate staff supervision; or
v.
if the safety of the patients is threatened.
Administrative
i.
misconduct;
ii.
violations of institutional and/or program policies and procedures or those of an affiliate;
iii.
unsatisfactory completion of charts or other deficiencies or delinquencies of the medical record;
iv.
unexcused absences;
v.
if Resident/Fellow is impaired, intoxicated or shows evidence of substance abuse;
vi.
if Resident/Fellow is convicted of a felony or a crime that could have an adverse effect on the reputation of
CMH or an Affiliated Hospital;
vii.
if Resident/Fellow shows unethical or unprofessional behavior;
viii.
if Resident/Fellow shows insubordination;
ix.
if Resident/Fellow harasses staff or personnel including sexual harassment or racial/ethnic discrimination;
x.
if Resident/Fellow is unable to perform the essential duties regularly required of all trainees in a program; or
xi.
if Resident/Fellow is placed on the excluded providers list maintained by the Federal Government.
The program can site multiple criteria within a single category and/or deficits in more than a single category when dealing with
corrective action, suspension or termination.
Page 42 of 49
Last Updated: 7/1/2013
21.2
Authority
The authority to propose or initiate a corrective action, suspension or termination is reserved to specific officials of the Hospital
and Sponsoring Institution. They are:
a.
b.
c.
d.
the PD
the Chair of the Department/Division Director;
the Chair of GME; and/or
the Vice Chair of GME.
In the event that patient welfare is jeopardized by the Resident/Fellow, the PD or an Associate PD, in the absence of PD, is
empowered to suspend a Resident/Fellow from clinical activity, pending a hearing. The Chair of GME, Vice Chair of GME and
applicable Department Chair will be notified immediately of a suspension from clinical activity.
Depending on the situation, the corrective action may be or may not include verbal warning, a written warning, mandatory
counseling, remediation, probation, administrative leave, suspension, non-renewal or termination of the Resident’s/Fellow’s
Agreement of Appointment or other corrective action as determined by the PD.
21.3
Reporting Obligations
The Hospital and Sponsoring Institution will comply with the obligations imposed by state and federal law and regulations to
report instances in which a Resident/Fellow is subject to corrective action for reasons related to alleged mental or physical
impairment, incompetence, malpractice or misconduct, or impairment of patient safety or welfare. Probation will be reported
to various boards when required. When remediation results in an extension of training or further corrective action, it will
become part of the permanent record. Successful remediation will not be part of the Resident/Fellow’s permanent record..
21.4
Remediation
Remediation is the process in which the Program faculty works with a Resident/Fellow judged to be performing at a less than
satisfactory level of work to identify, understand, and correct the cause(s) for the Resident’s/Fellow’s deficiencies. The process
can include the repetition of rotation/educational units or the extension of training. All remediation must be in compliance
with the appropriate RRC of the specialty in question. Residents/Fellows who disagree with the remediation plan, may contact
the Chair of their Department within 5 working days. The decision of the Department Chair is final.
21.5
Probation
Placing a Resident/Fellow on probation is another corrective action that may be taken by a program. Probation identifies a
Resident/Fellow as requiring more intensive levels of supervision, counseling and/or direction than is required of other
Residents/Fellows at the same training level in the same Program. Placement of a Resident/Fellow on probation implies that
the Program will be responsible for documenting the necessary increase in staff supervision, counseling and evaluation that will
allow the Resident/Fellow to address the deficiencies, if possible. Unlike other corrective actions which occur at the Program
level, placement on probation also serves to notify the GME Department that the Resident/Fellow is experiencing difficulty in
the training Program. A corrective action that includes probation is reviewed by the Medical Staff Education Committee as
outlined in Section 21.8 (Due Process).
21.6
Suspension
Suspension is the revocation of any or all of a Resident’s/Fellow’s clinical, academic, and/or administrative privileges, rights
and/or responsibilities. A period of suspension is intended to:
a.
b.
allow a full investigation of an alleged complaint, problem or incident; or
allow the Resident/Fellow an opportunity to definitively address significant, persistent, or recurrent deficits in his/her
performance or behavior that, if uncorrected, would prevent his/her successful completion of the Program.
Terms and Conditions
Page 43 of 49
Last Updated: 7/1/2013
At the end of the initial period of administrative leave following notice of suspension, during the meeting to review the
corrective action with the Resident/Fellow, they will be informed of:
a.
b.
c.
d.
e.
f.
the specific deficits in performance or behavior that are considered the cause(s) for the suspension;
the specific clinical, academic and administrative duties and activities from which the Resident/Fellow is to be
suspended;
the specific length of the suspension;
the specific steps that must be taken to correct the cause(s) for the suspension;
the right of the Program and Institution to pursue termination of their appointment should the cause(s) for the
suspension persist; and
the provisions for due process and the right of the Resident/Fellow to pursue an appeal and hearing.
Once a suspension is imposed, the PD will meet with the Resident/Fellow on the last day of the specified period of suspension
and advise him/her of the resolution of the suspension. There are three possible resolutions:
a.
b.
c.
the Resident/Fellow is allowed to return to duty;
the Resident/Fellow will be proposed for termination; or
the Resident/Fellow may be placed on a leave of absence until appropriate treatment or therapy has progressed to
the point that he/she can return to duty. Such leave of absence will commence on the last day of the period of
suspension. The Hospital and Program policies with regards to leaves of absence will apply. Should treatment or
therapy be incomplete or unsuccessful, the Resident/Fellow may be proposed for termination.
Limitations
a. The maximum cumulative time that any one Resident/Fellow may spend on suspension is 30 days during their
Program length of training.
b. The maximum number of suspensions for a given Resident/Fellow is one (1).
c. Residents/Fellows exceeding these limits will be proposed for termination.
d. A corrective action that includes suspension is reviewed by the Medical Staff Education Committee (MSEC).
21.7
Termination
Termination is the severance of an appointment to the Resident/Fellow and of all obligations of and benefits to the parties of
the Agreement of Appointment, excepting those specifically identified below.
Residents/Fellows who are proposed for termination will be placed on suspension and relieved of all Program duties and
activities pending final resolution of their status.
At the end of the initial period of suspension following notice of proposed termination, during the meeting to review the
proposed corrective action with the Resident/Fellow, they will be informed, in writing, of:
a. the specific deficits in his/her performance or behavior that are considered the cause(s) for the proposed termination;
b. the effective date of the proposed termination, after the initial notification of the proposed corrective action and
initiation of administrative leave;
c. the continuation of their administrative leave pending final resolution of the Resident’s/Fellow’s status; and
d. the provisions for due process and of the right to appeal and have a fair hearing.
The Resident/Fellow proposed for termination will:
a. receive his/her stipend (salary) up to the effective date of the termination;
b. receive any and all health insurance and other benefits due as determined by the Policies and Procedures of the
Hospital;
c. have all electronic and clinical access suspended pending the review by MSEC; and
d. continue to receive all compensation and benefits during any periods of administrative leave, or suspension, and
during the period between notification of proposed termination and its final resolution.
If after Due Process, the termination is finalized, the Resident/Fellow will:
a. vacate any and all call rooms, laboratories, and/or office spaces provided by the Hospital, if any, on or before the
effective date of the termination;
Page 44 of 49
Last Updated: 7/1/2013
b.
c.
21.8
return to the Hospital and Affiliates all property owned by it on or before the close of business on the effective date of
the termination of their appointment;
be billed for any monies owed to the Hospital and Affiliates including, but not limited to, activity fees, tickets and fees,
fees for hospital and professional services, and/or library fees or fines.
Due Process
a.
b.
Medical Staff Education Committee
The following procedure will apply if the corrective action includes probation, suspension, or termination of the
Resident/Fellow.
i.
The PD will notify the Department Chair, the Chair of GME and/or Vice Chair of GME to apprise them of the
action taken.
ii.
The PD, within 5 weekdays, shall notify the Chair of MSEC who will convene (as defined in the Medical Staff
Bylaws) which shall meet within 5 week days. The MSEC by a majority vote may decide:
iii.
To take no further action but approve the action taken by the PD; or
iv.
To change the corrective action which may include a written warning or remediation plan, placing the
Resident/Fellow on probation, suspending the Resident/Fellow, determining that unsatisfactory
rotation/educational units must be satisfactorily repeated, non-renewing an Agreement of Appointment,
terminating a Resident/Fellow, or other actions as agreed upon by the MSEC.
v.
The MSEC will send a letter to the Resident/Fellow within 5 weekdays regarding the actions of the committee
with a copy to PD and to the Chair of GME.
Appeal Process
In the event the Resident/Fellow disagrees with the decision of the MSEC, the Resident/Fellow has the option to
appeal the decision in writing within 5 weekdays, and appear in person before the Residency Program Committee
(“RPC”).
i.
ii.
iii.
c.
39
39
RPC Membership
o Two members of the clinical faculty selected by the Executive Medical Director* (Voting Members)
o A PD selected by the Executive Medical Director (Voting Member)
o A Resident/Fellow selected by the Resident/Fellow (Voting Member)
o A clinical faculty member selected by the Resident/Fellow (Voting Member)
o The applicable Department Chair (Voting Member)
o The Chair of the MSEC or his/her designee (Non-Voting Member)
o The Chair of GME or Vice Chair of GME will attend the hearing as an impartial observer or a witness
depending on the situation.
o In the absence of the Executive Medical Director or his designee the Chair or Vice Chair of GME will
perform his/her duties.
o The Executive Medical Director reserves the right to modify the membership to assure the integrity
and impartiality of the hearing committee.
o No member of the committee shall have been personally involved in the events that led to the
proposed corrective action or have any other interest that would affect the objectivity and fairness
of the hearing.
Chair - The Chair is to be elected or appointed by the committee from among the medical staff members on
the committee.
Quorum - A quorum consists of the majority of the voting-members present with at least one
Resident/Fellow and two faculty representatives.
Hearing Process
The hearing before the RPC shall take place within 20 weekdays of the notification to the Resident/Fellow. Written
notice of the time and location of the hearing will be sent to the Resident/Fellow at least 10 weekdays prior to the
hearing. The Resident/Fellow is required to attend the hearing and present his/her views on the matter that resulted
in corrective action. The Resident/Fellow will be allowed to present evidence to the RPC. The Resident/Fellow may
bring witnesses to the hearing and may be represented by legal counsel or another representative. The
ACGME Institutional Requirements, II.D.4.e)
Page 45 of 49
Last Updated: 7/1/2013
Resident/Fellow must inform the RPC in writing of the names of any witnesses and representative/counsel. If the
Resident/Fellow chooses to be represented by legal counsel the person presenting information to the RPC on behalf of
the MSEC also has the right to be represented by legal counsel at the hearing, and will notify the Resident/Fellow of
counsel’s attendance at least 5 weekdays prior to the hearing date. The Resident/Fellow and the PD may remain while
the hearing takes place but must leave when the RPC starts the deliberations. The RPC Chair will inform the
Resident/Fellow that he/she cannot contact any member of the committee regarding the deliberations or decision
unless the RPC Chair states otherwise in the decision. All communication will only come from the Chair of the RPC.
Any violation of this requirement may result in immediate termination of the Resident/Fellow without any further
notice.
i.
ii.
iii.
iv.
v.
vi.
vii.
21.9
The RPC may conclude that no corrective action was warranted when there is proof that the Resident/Fellow
was falsely accused or where GME policy has not been followed. In such situations, the Resident/Fellow will
be reinstated immediately and the RPC will make non-binding recommendations to the Chair or Vice Chair of
GME regarding any follow up that should take place either regarding the process followed by the GME
Department or the Resident/Fellow.
The RPC may affirm the corrective action of the PD.
The RPC can determine that corrective action was warranted, but disagree with the action taken, define
points of disagreement with the action taken, determine a plan for remediation that has not yet been
undertaken and detail the actions required by the Resident/Fellow to bring about a conclusion of the
remediation program.
All communication to the Resident/Fellow will be copied to the PD and the Chair or Vice Chair of GME.
The decision of the RPC is final.
If the Resident’s/Fellow’s program is sponsored by UMKC School of Medicine, the PD will inform the DIO at
UMKC of the suspension/termination for a process review by the UMKC GMEC. If UMKC GMEC finds that the
due process was not followed, the RPC will reconvene to follow the due process appropriately.
Complaints by the Resident/Fellow of illegal discrimination or harassment are processed through the
Hospital’s Human Resources Department.
Voluntary Withdrawal from a Program
Consistent with Hospital policy and applicable state and federal law, the Resident/Fellow proposed for corrective action may
voluntarily withdraw from a Program at any time after the initial notice of the proposed action, or at any time up to the actual
commencement of the appeal hearing.
22.
GRIEVANCES
Residents/Fellows are encouraged to seek resolution of grievances relating to their appointments or responsibilities, including
differences with the Sponsoring Institution, Program, Hospital or any representative thereof. The Sponsoring Institution
ensures the availability of procedures for redress of grievances, including complaints of discrimination and sexual harassment,
in a manner consistent with the law and with the general policies and procedures of the Hospital and the Sponsoring
Institution. The grievance process is available to all Residents/Fellows in CMH programs.
22.1
Grievable Matters
Grievable matters are those relating to the interpretation and application of, or compliance with the provisions of the
Agreement of Appointment, the policies and procedures governing graduate medical education, the general policies and
procedures of the Hospital, or Sponsoring Institution. Questions of capricious, arbitrary, punitive or retaliatory actions or
interpretations of the policies governing GME on the part of any faculty member are subject to the grievance process.
22.2
Non-Grievable Matters
Actions on the part of the Hospital or Sponsoring Institution based solely on administrative consideration policies and
procedures (except regarding corrective action, non-renewal or termination covered by the procedures under the corrective
actions, suspension and termination guidelines in Section 21) are not subject to interpretation and are therefore not
grievances.
Page 46 of 49
Last Updated: 7/1/2013
22.3
Grievance Procedures
40
Residents/Fellows who feel they have been treated unfairly or have complaints are encouraged to use the following procedure:
a.
b.
c.
d.
Discuss the problem with the appropriate faculty Physician and/or Chief Resident when applicable as soon as possible,
usually within 30 days of the event.
If the problem is not resolved under step a, the Resident/Fellow should contact the PD. Except in unusual
circumstances, the Resident/Fellow shall put the complaint in writing. Confidentiality, to the extent feasible, will be
maintained. The Resident/Fellow shall be informed of the result of the PD’s investigation. In the event that the
Resident/Fellow has an unresolved grievable complaint with the PD, they need to contact the Chair or Vice Chair of
GME.
If the matter is still unresolved after steps a and b, the Resident/Fellow may request that the MSEC consider the
matter. The request should be submitted to the Chair of the MSEC in writing after the determination under step a &
b.
If the matter is still unresolved after step c, the Resident/Fellow may submit the complaint in writing to the Executive
Medical Director, who will meet with the Resident/Fellow and make a final decision.
Any Resident/Fellow who feels he cannot use the above procedure should contact the Hospital Human Resources Department
for confidential assistance. A Resident/Fellow will not suffer adverse consequences for making a complaint or taking part in
the investigation of a complaint. Residents/Fellows who knowingly allege a false claim shall be subject to correction actions,
suspension and termination.
The Hospital will make appropriate arrangements to assure that disabled persons can make use of this grievance process on
the same basis as the non-disabled. Such arrangements may include, but are not limited to, the provision of interpreters for
the deaf, providing taped cassettes of material for the blind or assuring a barrier-free location for the proceedings.
40
ACGME Institutional Requirements, II.D.4.e)
Page 47 of 49
Last Updated: 7/1/2013
Addendum to the GME Policy and Procedures Manual
6-4-14
With the exception of the outlined policies below, the Pediatric & Congenital Cardiovascular Perfusion
Fellowship (PCCP) will follow the procedures and policies outlined by the Department of Graduate
Medical Education (GME). One overarching difference is that the governing department for the Pediatric
& Congenital Cardiovascular Perfusion Fellowship is the Ward Family Heart Center. In all instances where
GME plays a role in implementing policy, this function will be carried out by Heart Center leadership.
4. Selection
4.1 Eligibility
d) Applicants to the Pediatric & Congenital Cardiovascular Perfusion Fellowship training program
must meet the following qualifications to be eligible for appointment as a Fellow.
i. graduate of an accredited cardiovascular perfusion education program by the Accreditation
Committee for Perfusion Education (AC-PE) of the Commission on Accreditation of
Allied Health Education Programs (CAAHEP).
ii. eligible for American Board in Cardiovascular Perfusion certification and Missouri State
Board of Healing Arts License as a perfusionist (either provisional or full).
iii. possess a Master's of Science in Perfusion/Perfusion Technology or a doctorate or master's
degree in a related field with 5 years clinical experience as a clinical perfusionist.
iv. must have a desire for a career in pediatric & congenital cardiovascular perfusion with
emphasis in quality improvement, research, and publication.
4.2 Application
Applicants must submit supporting credentials directly to the PD or Program Coordinator (PC). These include:
a. application form (Program application or the GME application);
b. letters of recommendation;
c. perfusion school transcript and/or master's/doctorate degree transcript;
d. personal statement;
e. ECFMG status report and copy of ECFMG certificate (for graduates of foreign medical schools); and
f. curriculum vitae.
5.5 Stipend (Salary) and 5.6 Benefits
Salary and benefits for the CPPC Fellow will be coordinated with Human Resources. No additional
benefits are available except those offered to regular employees of Children’s Mercy.
6.6 Records Management
The Heart Center will be responsible for maintaining records related to Fellow academic program participation,
completion, and licensure. The required elements of the Fellow file should include:
a. agreement of appointment;
b. perfusion license;
c. DEA certification (if applicable);
d. ECFMG certificate (for graduates of foreign medical schools);
7.5
j. Pediatric & Congenital Cardiovascular Perfusion Fellowship: Leaves of absence and vacation may be
granted to Fellows at the discretion of the PD. A fellow must not be absent from the training program for
more than 4 weeks (20 working days) annually. Regardless of institutional policies regarding absences, any
leave time beyond 4 weeks would need to be made up or extend the length of training by arrangement
Page 48 of 49
Last Updated: 7/1/2013
with the PD. "Leave time" is defined as sick leave, vacation, or maternity/paternity leave. Fellow may not
accumulate leave time or vacation to reduce the overall duration of training.
7.6 Other Benefits
No additional benefits are available accept those offered to regular employees of Children’s Mercy.
Page 49 of 49
Last Updated: 7/1/2013