Manual of Policies & Procedures for Graduate Medical Education …€¦ · The Medical School endorses the “Essentials of Accredited Residencies in Graduate Medical Education: Institutional

Manual of Policies & Procedures for

Graduate Medical Education Programs

March 23, 2018

Chicago Medical School at

Office of Graduate Medical Education

Approved by GME Committee on February 16, 2018

GME Policy Manual | March 2018 | Page 1

Manual of Policies & Procedures for Graduate Medical Programs

Table of Contents All of the following have been reviewed and reapproved as of February 16, 2018.

POLICY & PROCEDURES EFFECTIVE ____________________________________________________________________________________ 1. Statement of Commitment to Graduate Medical Education 12/18/15 2. The Office of GME 5/17/13

2a. Definitions 5/17/13 2b. Introduction 5/17/13

2c. Healthcare Industry Interactions with Graduate Medical Education 5/17/13 3. Endorsements 4/20/12 4. Resident Eligibility 4/20/12 5. Selection of Residents and Fellows 12/19/14

5a. Acceptance of Residents or Fellows Transferring from Another Program 4/20/12 6. Promotion Policy 5/17/13 7. Resident Evaluations 5/17/13 8. Deficiency in Performance or Progress 5/17/13

8a. Misconduct Policy 5/17/13 9. Non-Renewal of Contract 5/17/13

9a. Dismissal from Residency Program 5/17/13 10. Resident Supervision Plan 9/18/15 11. Evaluations by the Trainees 4/20/12 12. Attendance at Conferences 4/20/12 13. Dress Code 5/17/13 14. Duty Hours, On-Call Activities, Patient Loads & Service Obligations 4/20/12 15. Ancillary Support 4/20/12 16. Learning and Working Environment 4/20/12 17. Quality Assurance and Administrative Activities 4/20/12 18. Wellbeing 2/16/18 19. Competency-Based Curricula and Educational Goals 4/20/12 20. Provisions for Program Closure or Reduction 4/20/12 21. Scholarly Activity 4/20/12 22. Professional and Personal Conduct 4/20/12 23. Infection Control 4/20/12 24. Immunization Recommendations 4/20/12 25. Leave Policies

a. Educational Leave 12/18/15 b. Annual Leave 12/18/15 c. Maternity/Paternity/Adoption Leave 12/18/15 d. Sick Leave 12/18/15 e. Bereavement Leave 12/18/15 f. Military Leave 12/18/15 g. Leave of Absence 12/18/15 h. The Family and Medical Leave Act 12/18/15 i. RFU Parental Leave 2/16/18 j. Short-Term Disability 2/16/18 k. Long-Term Disability 2/16/18

26. Salary and Benefits 6/19/15 27. Malpractice Insurance 5/17/13 28. Medical Records 4/20/12 29. “Moonlighting” Policies 4/20/12


30. Complaints and Grievances Rights and Procedures 5/17/13 30a. Appeal Rights and Procedures 5/17/13 31. Impaired Physicians: Policies and Procedures 4/20/12 32. Sexual Harassment 4/20/12 33. Counseling and Support Services 4/20/12 34. Orientation Programs 4/20/12 35. Residents’ Councils 4/20/12 36. Restrictive Covenants 4/20/12 37. Monitoring for Fatigue 4/20/12 38. Extension of Permissible Duty Hours 4/20/12 39. Actions Requiring the Approvals of the GME Committee and of the the Dean or Associate Dean for GME 4/20/12 40. Actions Requiring DIO Countersignature 4/20/12 41. Technical Standards for GME Programs 4/20/12 Appendix I: Statement of Commitment to Graduate Medical Education 12/18/15 Appendix II: Salary Scale for Residents and Fellows for the AY 2015-16 5/17/15 Appendix III: Request for Permission to “Moonlight” 4/20/12 Appendix IV: ACGME Requirements for Duty Hours and On-Call Activities 4/20/12 Appendix V: Sample Residency and Fellowship Agreement 12/18/15 Appendix VI: Technical Standards for Graduate Medical Education Programs 5/17/13 Distribution and Review Form


STATEMENT OF COMMITMENT TO GRADUATE MEDICAL EDUCATION

February 16, 2018

Chicago Medical School is committed to supporting Graduate Medical Education (GME) programs of the highest caliber. The goal of these programs, consistent with the strategic goals of Chicago Medical School and Rosalind Franklin University of Medicine & Science, is the training of highly skilled, scholarly physicians whose practices will engender the highest ideals of compassion and professionalism. To this end, the Medical School commits to: I. Support an Office of GME headed by an Associate Dean serving as the ACGME’s Designated Institutional Official and charged with the administrative oversight and management of the School’s GME programs, II. Support a Graduate Medical Education Committee, composed of the Associate Dean for GME /Designated Institutional Official, selected faculty, residents and administrators, which has responsibility for monitoring, advising and establishing policies as defined by the Accreditation Council for Graduate Medical Education, III. Establish an effective, competency-based curriculum, the efficacy of which is continually monitored and improved through the use of outcomes-based methodology, IV. Establish partnerships with medical centers sharing the same goals and offering academic, educational environments for residents, and V. Provide the monetary, space, material and human resources to support the GME programs and their administrative infrastructure in collaboration with the affiliated medical centers. _______________________________________________________ Michael J. Zdon, MD Date Designated Institutional Official (DIO) Associate Dean for GME _______________________________________________________ James M. Record, MD, JD, FACP Date Dean, Chicago Medical School _______________________________________________________ Chair of the Board of Directors Date [Adopted by the GMEC on August 28, 2009; by the Faculty Executive Council on September 4, 2009; and by the Academic Assembly on October 23, 2009, approved April 20, 2012. Reviewed and approved on December 19, 2014 and December 18, 2015, March 23, 2018].


2. THE OFFICE OF GME The Office of GME, under the direction of the Associate Dean for GME, is located in the Medical School, Room 1. 381, 3333 Green Bay Road, North Chicago, IL 60064. Phone: (847) 578-8714 and (847) 578-3341; Fax: (847) 578-3320. (Email inquiries will be answered within 24 hours during weekdays). Business hours are 8:00 a.m. to 4:30 p.m., Monday through Friday, except for RFUMS recognized holidays. Office personnel include: Michael J Zdon MD [email protected] Associate Dean for GME and Designated Institutional Official (DIO); (847) 578-8714 Elsa Kurien, MA, M.Ed. [email protected] Director for GME and CME; (847) 578-3341 Octavia Franklin [email protected] Administrative Assistant; (847) 578-3329 The Office of GME may be able to assist you in matters common to all postgraduate residency programs which include, but are not limited to: a. University and Medical School policies and procedures, including grievances, b. State of Illinois medical licenses, c. Visas and IAP-66’s, d. Residency program contracts,

e. Salaries and benefits for trainees paid by CMS, and f. Graduation from postgraduate residency programs.

On most matters, your Residency Program Director and departmental education office should be able to help you. If not, call the Office of GME at (847) 578-3341 and (847) 578-3329. House officers must notify the GME Office within 14 days of any change in legal name, address, visa status and/or telephone number, and provide supporting documentation. 2a. DEFINITIONS Residency Program Unless specifically distinguished in a particular section of this Manual, the term “residency program” or simply “residency” refers to the program for specialty residents and subspecialty fellows. Resident Unless specifically distinguished in a particular section of this Manual, the term “resident” refers to both specialty residents and subspecialty fellows. 2b. INTRODUCTION This Manual is intended to promote compliance with the established standards and requirements promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and is to be interpreted in a manner consistent with those standards and requirements. The italicized words below are excerpts of the ACGME Common Program Requirements and are adopted as part of this Manual. Residency is an essential dimension of the transformation of the medical student to the independent practitioner along the continuum of medical education. It is physically, emotionally, and intellectually demanding, and requires longitudinally-concentrated effort on the part of the

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resident. The specialty education of physicians to practice independently is experiential, and necessarily occurs within the context of the health care delivery system. Developing the skills, knowledge, and attitudes leading to proficiency in all the domains of clinical competency requires the resident physician to assume personal responsibility for the care of individual patients. For the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context, and meaning to those interactions. As residents gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater independence. This concept--graded and progressive responsibility--is one of the core tenets of American graduate medical education. Supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care to the individual patient; assuring each resident’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishing a foundation for continued professional growth. 2c. HEALTH CARE INTUSTRY INTERACTIONS IN THE GRADUATE MEDICAL EDUCATION The University policy entitled “Healthcare Industry Interactions in Education” is applicable to residents and is available on the University intranet (“Insite”) on the Office of Compliance page. https://insite.rosalindfranklin.edu/OurUniversity/Compliance/COI%20Policies/117-Health%20Care%20Industry%20Interactions%20in%20Education%20041014.pdf The following italicized words are selected excerpts from that policy:

For purposes of this policy, “health care industry” means a commercial entity (or one of its representatives) that manufactures, sells, or otherwise provides medical devices, pharmaceuticals, medical equipment, research equipment, health services, or other similar products/services. Gifts to [a resident] from the health care industry are prohibited. A “gift to [a resident]” means any payment to [a resident] or provision to [a resident] of free or discounted items, medical samples for personal use, food, or travel when the [resident] is not providing, in return therefore, a service of similar or greater value. For example: pens, notepads, free textbooks, free meals, payment for attending a meeting, and samples are all considered gifts. [Residents] may not attend or participate in any purported professional continuing education program that is sponsored by the health care industry but that is not accredited [by the ACCME].

Each residency program must include within its curriculum, training on the University policy entitled “Healthcare Industry Interactions in Education.” 3. ENDORSEMENTS The Medical School endorses the “Essentials of Accredited Residencies in Graduate Medical Education: Institutional and Program Requirements” as presented on the website of the Accreditation Council for Graduate Medical Education (ACGME). [Adopted by the GMEC on January 27, 2006 as a replacement for the policy of the same title, approved June 27, 1997, approved April 20, 2012. Reviewed on December 2014, March 2018]. 4. RESIDENT ELIGIBILITY House officers and fellows in accredited programs at CMS/RFUMS are selected based on qualifications that meet or exceed the standards outlined below. Applicants with one of the following qualifications are eligible for appointment:


a. Graduates of medical schools in the U.S. and Canada accredited by the Liaison Committee on Medical Education (LCME).

b. Graduates of medical schools in the U.S. and Canada accredited by the American Osteopathic Association (AOA).

c. Graduates of medical Schools outside the U.S. and Canada who meet both of the following qualifications:

1. Have received a currently valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG); and

2. Have a full and unrestricted license or a temporary license to practice medicine in the State of Illinois.

d. Graduates of medical schools outside the U.S. and Canada who have completed a Fifth Pathway program provided by an LCME accredited medical school.

[Adopted by the GMEC on October 25, 1996, approved on April 20, 2012. Reviewed on December 19, 2014, March 2018]. 5. SELECTION OF RESIDENTS AND FELLOWS The Medical School’s postgraduate residency programs select candidates based on their preparedness and ability to succeed in the program to which they have applied and to achieve the stature of the complete physician envisioned by the Medical School in its Statement of Commitment. In compliance with federal law, including the provisions of Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendment of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990, the ADA Amendments Act of 2008, Executive Order 11246, the Uniformed Services Employment and Reemployment Rights Act, as amended, and the Genetic Information Nondiscrimination Act of 2008, the policy of the School is to consider candidates regardless of race, sex, sexual orientation, gender identity, religion, color, national or ethnic origin, age, disability, veteran status, or genetic information. Performance in medical school and on achievement tests, character endorsements and official letters of recommendation, accomplishments, humanistic and other qualities deemed important for the success of the candidate, will be used in the selection process. The Medical School participates in the Electronic Residency Application Service (ERAS). The Medical School’s standard residency/fellowship ERAS application requires, among other items, submission of a transcript from the applicant’s medical school [optional for fellowship applicants], a Dean's letter [optional for fellowship applicants] and at least two letters of recommendation. International medical graduates must also meet all the requirements for temporary licensure in Illinois, minimum undergraduate college requirements, medical school basic science and core clerkship requirements, ECFMG certification and other requirements for appropriate visa status and Milestones assessments or equivalent performance evaluation/grades from the prior training program. In addition to academic, licensing and administrative credentials, the candidates’ personal characteristics and ability to communicate are considered in the selection process. Invitations for interview are sent out selectively after receipt and review of completed applications. Applicants are responsible for ensuring that they meet all program prerequisites and institutional policies regarding eligibility for appointment to a residency position prior to ranking a program through the National Residency Matching Program (NRMP). The Graduate Medical Education Committee reviews each program’s selection criteria on an annual basis.


Adopted by the GMEC on March 26, 2010 as a replacement for the policy of the same title of June 27, 1997, approved April 20, 2012. Reviewed on December 19, 2014, March 2018]. 5a. ACCEPTANCE OF RESIDENTS OR FELLOWS TRANSFERRING FROM ANOTHER PROGRAM Residents or fellows may be accepted in transfer from an extramural residency program if they are, or may reasonably be expected to become, appropriately credentialed with respect to prior education, training, visa status and licensing. Failure to confirm appropriate credentials, or to acquire appropriate credentials within the timeframe anticipated by the CMS Program Director, will constitute adequate cause for voiding any verbal or written agreements to accept the individual in transfer. [Adopted by the GMEC on November 7, 2008, approved April 20, 2012. Reviewed December 19, 2014, March 2018]. Before accepting a resident who is transferring from another program, the program director must obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the transferring resident including Milestones assessments from the prior training program. A program director must provide timely verification of residency education and summative performance evaluations for residents who leave the program prior to completion. LENGTH OF APPOINTMENT: Appointments are made for a one-year term, with renewal of the appointment based on satisfactory performance by the house officer and the availability of a position. 6. PROMOTION POLICY 1. Introduction. Residency is an essential dimension of the transformation of the medical student to the independent practitioner along the continuum of medical education. It is physically, emotionally, and intellectually demanding, and requires longitudinally-concentrated effort on the part of the resident. Within a residency program, there are formal levels of education. Each formal level of education in the residency program is scheduled to coincide with each year the resident is in the residency program and, accordingly, is normally signified by the label “PGY- #” where the # would be the particular year of postgraduate training. Within each formal level of education in a residency program, there are requirements to be fulfilled, which are consistent with the accreditation standards and requirements established by ACGME. Those requirements include the resident demonstrating proficiency in established competencies and demonstration of specific specialty Milestones as deemed appropriate for that formal level of education in the residency program. 2. Promotion and Basis for Promotion. Promotion is a determination made by the Program Director to advance a resident to the next formal level of education within the residency program. This would be appropriate only when the Program Director determines, through the use of academic judgment, that the resident has achieved the appropriate level of progress in the residency program and has fulfilled the requirements and Milestones associated with the current formal level of education in the residency program. Promotions that occur as scheduled would be concurrent with a renewal of the residency contract. 3. Non-Promotion of a Resident. A resident shall not be promoted if the Program Director determines, through the use of academic judgment, that the resident has not achieved the


appropriate level of progress in the residency program or has not fulfilled the requirements or Milestones associated with the current formal level of education in the residency program. A decision to not promote a resident as scheduled could lengthen the duration required to complete the residency program.

a. Notice Requirement. In the event the Program Director determines that the resident might not be promoted as currently scheduled, the resident will be so notified. This notice will be at least four (4) months prior to the date of the promotion would have occurred as currently scheduled. However, if the primary reason(s) for the non-promotion occurs or becomes apparent within that four-month period, then this notice will be provided as soon as the circumstances allow. This notice will be in writing and may be included within a written evaluation (as described in paragraph 3 of Section 7 of this Manual), in a notice of deficiency (as described in paragraph 3 of Section 8 of this Manual), or other written document signed by the Program Director.

b. Appeal Rights. A resident has a right to appeal an action of the Program Director of non-

promotion to the next formal level of education within the residency program as scheduled. See Section 30a describing the rights and procedures associated with this appeal. 7. RESIDENT EVALUATIONS 1. Evaluation of Rotation or Similar Education Assignment. Assigned faculty shall evaluate the performance and progress of each resident during each rotation or similar education assignment. That evaluation shall be documented at the completion of that assignment and included in the resident’s file. 2. Evaluation by Clinical Competency Committee. Each residency program shall have a Clinical Competency Committee (CCC) that consists of core teaching faculty and the Program Director. That committee shall meet on a regular basis for the purpose of evaluating the performance and progress of the residents in meeting specific Milestones in that residency program. Candid comments from the membership of the committee are essential in this evaluation process of residents in order for the Program Director to identify any relevant issues that might not be reflected in rotation written evaluations. 3. Evaluation by Program Director. The Program Director shall, on at least a semi-annual basis, evaluate the performance and progress of each resident within the residency program, document that evaluation in a written document, and ensure delivery of that written evaluation to the resident. In conducting this evaluation, the Program Director will consider evaluations from multiple evaluators (e.g. faculty, peers, patients, self, and other professional staff), the documented rotation evaluations by faculty described in paragraph 1 of this Section, and the information discussed during committee reviews described in paragraph 2 of this Section. A copy of the evaluation by the Program Director shall be included in the resident’s file. 8. DEFICIENCY IN PERFORMANCE OR PROGRESS 1. Policy. In the event the Program Director determines, through the exercise of academic judgment, that a resident has not performed or progressed within the residency program in a satisfactory manner or pace, the resident will be so notified and will be provided a reasonable opportunity to address and correct that deficiency. Failure of the resident to then adequately correct that deficiency in a timely manner, maintain proficiency, and progress in a satisfactorily pace may result in non-promotion, non-renewal of the residency contract, or dismissal from the residency program.


2. Examples. Examples of deficiencies in performance or progress in the residency program include:

a. The failure to achieve or maintain proficiency in any component of any ACGME competency that is deemed appropriate for the current formal level of education;

b. The failure to progress in the residency program at an appropriate pace;

c. The failure to timely achieve or maintain a prerequisite for any training activity in the

residency program; and

d. The failure to comply with University policies or policies of affiliated hospitals or other sites.

Note: It is possible that a situation may reflect a deficiency in performance or progress but also meet the definition of “misconduct” described in Section 8a of this Manual. In such a situation, the Program Director should use the process described in Section 8a of this Manual.

3. Notification. This requirement will normally be accomplished by the Program Director issuing a written notification to the resident that includes the following:

a. The nature and a brief description of the deficiency and a brief description of how this deficiency was identified;

b. Statements that (i) the resident will be given a reasonable opportunity to address and

correct the deficiency; (ii) it is the responsibility of the resident to correct the deficiency; (iii) the failure of the resident to correct the deficiency in a timely manner may result in non-promotion, non-renewal of the residency contract, or dismissal from the residency program;

c. The specific date by which the resident is required to correct the deficiency;

d. If and when considered appropriate by the Program Director, a requirement for the resident

to participate in the development of a written plan of specific actions that the resident will take in an effort to correct the deficiency (e.g. an academic action plan);

e. When applicable, a statement that, based on the current evaluation of the resident’s

performance and progress, the Program Director does not intend to promote the resident to the next formal level of education and/or does not intend to renew the resident’s contract, but that this intent will be reconsidered upon the receipt of additional information.

4. Meeting with the Resident and Program Director’s Determination. After notice of a deficiency has been provided and after the expiration of the reasonable opportunity to correct the deficiency, the Program Director shall meet with the resident and provide the resident the opportunity to characterize his/her current status and explain what he/she considers to be the proper context. The resident, upon request, will have access to his/her resident file; however, the resident’s file shall always be under the supervision of the Program Director, faculty, or administrative staff of the residency program. The Program Director will then determine, through the exercise of academic judgment and based on the relevant information gathered (including resident’s entire file and any information that was provided by the resident), whether or not the resident has timely corrected the deficiency.

a. Deficiency Corrected. In the event the Program Director determines that the deficiency had been corrected such that the resident is now expected to be eligible for promotion and


renewal of the residency contract, then the Program Director shall so notify the resident in writing and include in that letter a statement that (1) the resident is required to perform and progress within the residency program in a satisfactory manner and pace and (2) any failure to do so may result in non-promotion to the next formal level of education within the residency program, non-renewal of the residency contract, or dismissal from the residency program.

b. Continuing Deficiency. In the event the Program Director determines that the resident has

failed to timely correct the deficiency, the Program Director shall make one or more of the following determinations:

(1) Extension of the Notification of Deficiency. The Program Director may decide to extend the opportunity to correct the deficiency. This would normally be appropriate when the Program Director determines that the resident acted in good faith, that external factors beyond the control of the resident precluded or inhibited successful correction of the deficiency, and that a reasonable amount of additional time is likely to result in the successful correction of the deficiency. This may be appropriate in other circumstances, as determined by the Program Director. When the determination is to extend the notification of deficiency, a new written notice shall be issued to the resident. (2) Non-Promotion. The Program Director may decide to not promote the resident to the next formal level of education within the residency program, as further explained in Section 6 of this Manual. In this situation, the Program Director shall issue a written letter to the resident that notifies the resident of the Program Director’s determination and of the resident’s right to appeal, as described in Section 30a of this Manual.

(3) Non-Renewal of Residency Contract. The Program Director may decide to not renew the resident’s contract in the residency program, as further described in Section 9 of this Manual. In this situation, the Program Director shall issue a written letter to the resident that notifies the resident of the Program Director’s determination and of the resident’s right to appeal, as described in Section 30a of this Manual. (4) Dismissal. The Program Director may decide to dismiss a resident from the residency program, as further described in Section 9a of this Manual. In this situation, the Program Director shall issue a written letter to the resident that notifies the resident of the Program Director’s determination and of the resident’s right to appeal, as described in Section 30a of this Manual 5. Administrative Leave. The Program Director may, at any time, summarily place a resident on administrative leave, with or without pay, when the Program Director determines that there is reason to believe any of the following: a. There would be an unreasonable risk of harm to patients, to faculty, to any resident (including the resident to be placed on administrative leave), or to the administrative staff of the residency program, should the resident continue in the specific rotation or generally in the residency program; or b. There would be an unreasonable disruption of the residency program, of the normal activities of the University, or of the normal activities of any affiliated site,


should the resident continue in the specific rotation or generally in the residency program.

8a. MISCONDUCT POLICY 1. Misconduct Defined. For purposes of this Section of the Manual, the term “misconduct” means:

a. any act or acts of a resident that amounts to or attempts to amount to:

(1) assault or other acts of violence toward a person, threat of harm to persons, theft, intentional wrongful destruction of property, making deceptive false statements or deceptive false documents, or acts of a similar nature;

(2) cheating, plagiarism, lying, or acts of a similar nature; (3) patient abuse, child abuse or neglect, intentional breach of patient

confidentiality, diversion of controlled substances, sexual harassment or other forms of unlawful discrimination, boundary violation with medical students or with faculty, or acts of a similar nature;

(4) violation of the University Code of Conduct; or (5) violation of a condition of probation imposed from a prior finding of misconduct;

b. when such act or acts relate to the residency program.

Note: “Relates to the residency program” includes:

• the resident using his/her status as resident physician to facilitate the act or • the resident engaging in any act that impacts, affects, or involves the residency

program curriculum, a University student, faculty, staff, or property, or an affiliated site patient, medical staff, personnel, or property.

Note: It is possible that a situation may meet the definition of “misconduct” and also appear to reflect a deficiency in performance or progress, as described in Section 8 of this Manual. In such a situation, the Program Director should use the process in this Section.

2. Obligation to Report. Residents shall promptly report any known or suspected resident misconduct to the Program Director. There shall be no retaliation, retribution, or reprisal for making a good faith report of known or suspected resident misconduct. 3. Investigation. Upon becoming aware of an allegation of resident misconduct, the Program Director shall take steps to gather the relevant information in a fair and reasonable manner (i.e. by using methods deemed reasonably efficient in time and resources and that are reasonably likely to result in reliable information within this learning and working environment); however, the fact-gathering efforts shall not be subject to any formal investigative or other criminal procedure requirements that are applicable to government law enforcement officials. The Program Director may do this by personally gathering information and/or by receiving information from another who has conducted an investigation into the matter. This fact-gathering stage will normally include seeking information directly from the resident. 4. Notice of Allegation of Misconduct. After completion of the investigation, if the Program Director determines the process should continue, then the Program Director shall issue to the resident a written notice of allegation of misconduct. This notice shall including the following: a. The allegation in sufficient detail to enable the resident a meaningful opportunity to respond, along with a brief description of how it was identified;


b. A statement that the resident will be given a reasonable opportunity to respond to this allegation, to characterize his/her behavior, and explain what he/she considers to be the proper context; c. The specific date and time that has been scheduled to provide the resident the opportunity to meet with the Program Director to respond to the allegation in person, and, if the resident declines the opportunity to meet in person, the specific date and time before which any information submitted in response to the allegation must be received by the Program Director; and d. A statement that the Program Director will consider all relevant information, including the resident’s entire file and information provided by the resident, to make a determination, through the use of academic judgment, regarding the allegation of misconduct and the resident’s future status in the residency program. 5. Resident’s Opportunity to Respond. The resident has the opportunity to respond to the allegation of misconduct, consistent with the Notice of Allegation of Misconduct (see paragraph 4 of this Section). The Program Director has discretion to conduct the meeting with the resident as the Program Director deems fair and reasonable (i.e. by using methods deemed reasonably efficient in time and resources and that are reasonably likely to result in reliable information within this academic environment) in order to fairly resolve the matter; however, this meeting shall not be bound by any legal procedural formality commonly utilized in formal legal proceedings, shall not be bound by rules of evidence commonly utilized in formal legal proceedings, and shall not include the presence of attorneys. The resident, upon request, will have access to his/her resident file; however, the resident’s file shall always be under the supervision of the Program Director, faculty, or administrative staff of the residency program. 6. Program Director Determination. The Program Director will make a determination, through the exercise of academic judgment, based on the information gathered and the entire file of the resident, of one of the following:

a. That there was no misconduct and no further action is warranted.

b. That there was no misconduct but there is a deficiency in performance or progress in the residency program. In this situation, the Program Director shall take action consistent with Section 8 of this Manual.

c. That the resident committed misconduct and the resident should be placed on probation. In

this situation, the Program Director shall issue a letter to the resident that includes the conditions of probation, a notification that a violation of any condition of probation would be considered an act of misconduct, which may result in the dismissal from the residency program, and a notification of the right to submit a grievance, as described in Section 30 of this Manual. The duration of probation shall be the remainder of the time in the residency program and the conditions of probation must include a condition that the resident not engages in misconduct.

d. That the resident committed misconduct and the resident’s contract in the residency

program should not be renewed, as further described in Section 9 of this Manual. In this situation, the Program Director shall issue a written letter to the resident that notifies the resident of the Program Director’s determination and of the resident’s right to appeal, as described in Section 30a of this Manual.


e. That the resident committed misconduct and the resident should be dismissed from the residency program, as further described in Section 9a of this Manual. In this situation, the Program Director shall issue a written letter to the resident that notifies the resident of the Program Director’s determination and of the resident’s right to appeal, as described in Section 30a of this Manual.

7. Administrative Leave. The Program Director may, at any time, summarily place a resident on administrative leave, with or without pay, when the Program Director determines that there is reason to believe any of the following: a. There would be an unreasonable risk of harm to patients, to faculty, to any resident (including the resident to be placed on administrative leave), or to the administrative staff of the residency program, should the resident continue in the specific rotation or generally in the residency program; or b. There would be an unreasonable disruption of the residency program, of the normal activities of the University, or of the normal activities of any affiliated site, should the resident continue in the specific rotation or generally in the residency program. 9. NON-RENEWAL OF CONTRACT 1. Introduction. Non-renewal of the residency contract means that, upon expiration of the current term of the residency contract, a new contract would not be entered into as otherwise previously scheduled and, accordingly, the individual would no longer be a resident in that residency program and all terms and conditions that are incidental to the status of continuing to be a resident would expire (e.g. financial support). 2. Bases for Non-Renewal of Contract. The Program Director may decide to not renew a resident’s contract in either of the following situations: a. As further described in Section 8 of this Manual, the Program Director may decide to not renew the resident’s contract in the residency program when the Program Director concludes that the resident has a continuing deficiency in performance or progress. b. As further described in Section 8a, the Program Director may decide to not renew the resident’s contract in the residency program when the Program Director concludes that the resident has committed misconduct. c. The Program Director may decide to not renew a resident’s contract in the residency program when the Program Director concludes that the resident is not able, not qualified, or is not eligible to perform or progress in the residency program and that the reason or basis could not be affected by any reasonable corrective efforts by the resident. 3. Notice of Anticipated Non-Renewal of Contract. In the event the Program Director determines that the residency contract for a particular resident might not be renewed as currently scheduled, the resident will be so notified. This notice will be at least four (4) months prior to the date the renewal of residency contract would have occurred as currently scheduled. However, if the primary reason(s) for the non-renewal occurs or becomes apparent within that four-month period, then this notice will be provided as soon as the circumstances allow. This notice will be in writing and may be included within a written evaluation (as described in paragraph 3 of Section 7 of this Manual), in a notice of deficiency (as described in paragraph 3 of Section 8 of this Manual), or other written document signed by the Program Director.


4. Appeal Rights. A resident has a right to appeal an action of the Program Director of non-renewal of the residency contract. See Section 30a describing the rights and procedures associated with this appeal. 9a. DISMISSAL FROM RESIDENCY PROGRAM 1. Introduction. Dismissal means the individual is immediately removed from the status of resident in that residency program, results in the immediate termination of the residency contract, and results in the immediate cessation of all terms and conditions that are incidental to the status of continuing to be a resident (e.g. financial support). 2. Bases for Dismissal. The Program Director may decide to dismiss a resident in any of the following situations: a. As further described in Section 8, the Program Director may decide to dismiss a resident from the residency program when the Program Director concludes that the resident has a continuing deficiency in performance or progress.

b. As further described in Section 8a, the Program Director may decide to dismiss a resident from the residency program when the Program Director concludes that the resident has committed misconduct. c. The Program Director may decide to dismiss a resident from the residency program when the Program Director concludes that the resident is not able, not qualified, or is not eligible to perform or progress in the residency program and that the reason or basis could not be affected by any reasonable corrective efforts by the resident. 3. Appeal Rights. A resident has a right to appeal an action of the Program Director of dismissal from the residency program. See Section 30a describing the rights and procedures associated with this appeal. 10. RESIDENT SUPERVISION POLICY Each residency program will have a written plan for the graduated supervision of its residents as proscribed by the Program Requirements of their specialty as well as the Common Program Requirements. The Supervision plans will be reviewed and approved annually by the GMEC. [Adopted by the GMEC on November 22, 1996, approved April 20, 2012. Reviewed on December 19, 2014, Approved on September 18, 2015, February 26, 2018]. In general supervision for all programs should follow the requirements as outlined in the Common Program Requirements as stated below. In the clinical learning environment, each patient must have an identifiable, appropriately-credentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient’s care. This information should be available to residents, faculty members, and patients. Residents and faculty members should inform patients of their respective roles in each patient’s care.


The program must demonstrate that the appropriate level of supervision is in place for all residents who care for patients. Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervising faculty member. For many aspects of patient care, the supervising physician may be a more advanced resident or fellow. Other portions of care provided by the resident can be adequately supervised by the immediate availability of the supervising faculty member or resident physician, either in the institution, or by means of telephonic and/or electronic modalities. In some circumstances, supervision may include post-hoc review of resident-delivered care with feedback as to the appropriateness of that care. Levels of Supervision To ensure oversight of resident supervision and graded authority and responsibility, the program must use the following classification of supervision: Direct Supervision:

• The supervising physician is physically present with the resident and patient. Indirect Supervision:

• With direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.

• With direct supervision available – the supervising physician is not physically present within

the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision.

Oversight:

• The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

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


Each resident must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence. In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. [Each Review Committee will describe the achieved competencies under which PGY-1 residents progress to be supervised indirectly, with direct supervision available.] Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility. 11. EVALUATIONS BY THE TRAINEES The resident will be given the opportunity to complete an anonymous formal written evaluation of each rotation and of his/her attending physicians and faculty preceptors, addressing among other features of the rotation the provisions of clinical supervision, i.e. availability, responsiveness, depth of the interaction and knowledge gained. The evaluations will be reviewed by the Program Director and integrated into discussions with and evaluation of attending physicians and faculty members. [Adopted by the GMEC on September 17, 2004 as a replacement for the policy of October 25, 1996, approved April 20, 2012. Reviewed December 19, 2014, March 2018]. 12. ATTENDANCE AT EDUCATIONAL CONFERENCES Unless specified otherwise, attendance at conferences is mandatory. In recognition of the occasional need to attend to simultaneous patient care emergencies, a percentage of mandatory conferences at which the trainee is expected to be present, e.g. 80%, may be specified by the residency program. Residents are required to attend all conferences that are not precluded by emergencies, rather than to attend only the expected minimum percentage of conferences. Documentation of attendance will be coordinated by the Chief Resident and, if the number of absences is substantial, it will be reported to the Program Director. Attendance at less than the expected minimum percentage of conferences should be addressed by the Chief Resident and/or the Program Director. Trainees may be asked to account for absences from conferences regardless of the percentage of conferences that they have attended. Disciplinary actions may be instituted for unwarranted absences. [Adopted by the GMEC on September 17, 2004 as a replacement for the policy of June 27, 1996, approved April 20, 2012. Reviewed December 19, 2014, March 2018]. 13. DRESS CODE The professionalism of the trainee is often projected by his/her appearance, including apparel, hairstyle and grooming, and cleanliness. Trainees will maintain an appearance acceptable to their residency programs and to the facilities in which they are assigned. [Adopted by the GMEC in March 2018 as a replacement for the policy of December 19, 2014]. 14. DUTY HOURS, ON-CALL ACTIVITIES, PATIENT LOADS AND SERVICE OBLIGATIONS Residencies and fellowships must comply with the current ACGME policies on Duty Hours and On-Call Activities. The relevant policies are excerpted in Appendix IV.


Residents and fellows should be apprised of these policies at least annually. Training must document this compliance. Statements by resident that they adhere to the policy are no longer sufficient. All residency and fellowship programs must monitor compliance to these policies at least quarterly. A report on compliance and actions taken to remedy recurring episodes of non-compliance must be submitted to the Graduate Medical Education Committee at least semi-annually. Residencies and fellowships must maintain a policy specifying the maximum number of admissions, inpatients and outpatients for rotations and clinics in which an excessive number of patients may reasonably compromise the educational process or working environment. [Adopted by the GMEC on September 17, 2004, approved April 20, 2012 as a replacement for the policy of the same title of September 11, 2003. Reviewed on December 19, 2014, March 2018]. 15. ANCILLARY SUPPORT Each residency program will ensure that on-call residents are provided adequate sleeping quarters and food services. The program will also ensure that its residents are provided sufficient radiology, medical records, library, phlebotomy, transport and laboratory services to assure that the trainees’ time can be appropriately focused on education and patient care. [Adopted by the GMEC on November 22, 1996, approved April 20, 2012. Reviewed on December 19, 2014, March 2018]. 16. LEARNING AND WORKING ENVIRONMENT Each residency program will ensure that residents have access to:

a. a physician or resident lounge, b. a locker for personal belongings, c. a mailbox, and d. parking facilities with adequate security.

[Adopted by the GMEC on September 17, 2004, approved April 20, 2012, as a replacement for the policy of June 27, 1997. Reviewed December 19, 2014, March 2018]. 17. QUALITY ASSURANCE, PATIENT SAFETY, PRACTICE FEEDBACK, AND ADMINISTRATIVE

ACTIVITIES Residents should be informed of the quality assurance activities of the affiliated medical centers to which they are assigned to and must actively participate in patient safety systems and contribute to a culture of safety. Residents must know their responsibilities in reporting patient safety events at the clinical site; know how to report patient safety events, including near misses, at the clinical site, be provided with summary information of their institution’s patient safety reports. All residents must receive training in how to disclose adverse events to patients and families.


Residents and faculty members must receive data on quality metrics and benchmarks related to their patient populations. Residents must have the opportunity to participate in interprofessional quality improvement activities which include activities aimed at reducing health care disparities. Residents may be asked to participate on School committees, e.g. the Graduate Medical Education Committee (GMEC) and the Faculty Executive Council. They may also be appointed to University committees, departmental committees and committees of the affiliated medical centers. [Adopted by the GMEC on September 17, 2004, approved April 20, 2012, as a replacement for the policy of January 25, 2002. Reviewed December 19, 2014, March 2018]. 18. WELL BEING Residency education must occur in the context of a learning and working environment that emphasizes a commitment to the well-being of students, residents, faculty members, and all members of the health care team. Psychological, emotional, and physical well-being are critical in the development of the competent, caring, and resilient physician. Self-care is an important component of professionalism and is a skill that must be learned and nurtured in the context of other aspects of residency training. CMS/RFUMS is committed to providing a safe environment and to protecting the health and welfare of patients, students, faculty, as well as residents. Residents are expected to report to their clinical sites fit for duty, which means they are able to perform their clinical duties in a safe, appropriate and effective manner showing concern, respect, care and cooperation with faculty, staff, patients and visitors. CMS/RFUMS encourages residents to seek assistance voluntarily before clinical, educational and professional performance is affected. Resident responsibilities:

• Residents are responsible for reporting to their sites fit for duty and able to perform their clinical duties in a safe, appropriate and effective manner free from the adverse effects of physical, mental, emotional and personal problems including impairment due to fatigue. Residents have a professional responsibility to appear for duty appropriately rested and must manage their time before, during and after clinical assignments to prevent excessive fatigue.

• Residents are responsible for assessing and recognizing impairment, including illness and fatigue, in themselves and in their peers.

• If a resident is experiencing problems, he/she is encouraged to voluntarily seek assistance before clinical, educational and professional performance; interpersonal relationships or behavior are adversely affected. Residents, who voluntarily seek assistance for physical, mental, emotional and/or personal problems, including drug and alcohol dependency, before their performance is adversely affected, will not jeopardize their status as a resident by seeking assistance.

• Residents must maintain their health through routine medical and dental care and if needed mental health care. Non-urgent appointments may be scheduled in advance with appropriate permission and coverage arrangements including during regular work hours.

• At no time will residents be denied visits for acute care for illnesses (physical or mental) or dental emergencies during work hours.


Program Responsibility

• It is the responsibility of each program director and all faculty members to be aware of resident behavior and conduct.

• If a program director or faculty member observes physical, mental, or emotional problems affecting the performance of a resident, including impairment due to excessive fatigue, the member must take steps to verify the impairment and take appropriate actions.

• Program directors in conjunction with the GME Office will implement mental health screening tools that screen for burnout and/or depression.

• It is the responsibility of the Program to provide reasonable accommodations (i.e. duty assignments, on-call schedules), to enable the resident to participate in mandated counseling.

• It is the responsibility of the Program to provide opportunities for excessively fatigued residents to take therapeutic naps and to provide facilities for residents to sleep if too tired to return to their homes following clinical duties and/or transportation home if unduly fatigued and and ensure that there are no negative consequences and/or stigma for using fatigue mitigation strategies.

• The program along with the Sponsoring Institution will educate faculty members and residents in identification of the symptoms of burnout, depression, and substance abuse, including means to assist those who experience these conditions. Residents and faculty members will also be educated to recognize those symptoms in themselves and how to seek appropriate care.

• The program along with the sponsoring institution will provide access to both medical care and confidential, affordable mental health counseling and treatment, including access to urgent and emergent care 24 hours a day, seven days a week.

• The Program will put in place a mechanism to ensure coverage of patient care in the event that a resident may be unable to perform their patient care responsibilities without negative consequences.

Available Resources: (Need to fill in contact info)

• Graduate Medical Education (GME) Office 847-578-3341 • Human Resources (HR) 847-578-3266 • University Health System 847-578-8846 • National Suicide Prevention Lifeline: 1-800-273-8255 • RFU Office of Diversity and Inclusion 847-578-8351 or 8355 • Academic Learning Environment (ALE) 847-578-8741 or 8715 • Mutual of Omaha Employee Assistance Program 24/7 confidential assistance for

employees and eligible dependents 800-316-2796 (Addendum V Brochure) • RFU Fitness Center 847-578-8352 • Site specific resources (FHCC, Centegra, Sinai) • Healthy U 847-578-8352 • Other programs (see each Program’s Handbook for available resources)

[Adopted and Approved March 2018]

19. COMPETENCY-BASED CURRICULA AND EDUCATIONAL GOALS Each program will maintain an ACGME competency-based curriculum with appropriate curricular and educational goals as well as administrative structures for implementing the curriculum and assessing the achievement of these goals. The curricular and educational goals should be approved


by the program's education committee, or an equivalent body, at least annually. Changes in the curriculum, educational goals or relevant administrative structures will be submitted for approval by the GMEC at least annually through an Annual Program Evaluation. The competency-based curricula should comply with current programmatic accreditation requirements, to include the competencies of “Patient Care,” “Medical Knowledge,” “Practice-Based Learning and Improvement,” “Interpersonal and Communication Skills,” “Professionalism,” and “Systems-Based Practice and be guided by the appropriate Milestones” [Adopted by the GMEC on March 26, 2010, approved April 20, 2012, as a replacement for the policy of September 17, 2004. Reviewed on December 19, 2014, March 2018]. 20. PROVISIONS FOR PROGRAM CLOSURE OR REDUCTION / DISASTER POLICY CLOSURE OR REDUCTION: All decisions regarding reduction of size in an ACGME-accredited training program(s), closure of such a program(s), or the intention of RFUMS to cease being a Sponsoring Institution must be communicated to the ACGME Designated Institutional Official, the Graduate Medical Education Committee, affected Program Directors, and affected house officers as soon as possible after such decisions are made. If an ACGME-accredited training program at RFUMS reduces its size or ceases to exist, the house officers in that program will be notified as soon as possible by the Program Director of that program. In the event of closure or reduction, every reasonable effort will be made to allow resident(s) currently in the program(s) affected to complete their education if satisfactory progression of the resident(s) has been demonstrated. If house officers are displaced because of reduction or closure, the appropriate Program Director(s) will make every effort to assist the house officers in enrolling in an ACGME accredited program(s) in which they can continue their education. DISASTER: For the purposes of this policy, a disaster is an event or set of events causing significant alteration to the residency experience at one or more residency programs. Policy In the event of a disaster, Rosalind Franklin University of Medicine and Science will continue to provide administrative support for its GME programs through the disaster. In the event that such a disaster or its aftereffects warrant reduction or closure of a program(s), then the Training Program Reduction/Closure Policy will take effect. If, because of a disaster, an adequate educational experience cannot be provided for each resident/clinical fellow the sponsoring institution will: 1. Arrange temporary transfers to other programs/institutions until such time as the residency/fellowship program can provide an adequate educational experience for each of its house officers/fellows.


2. Cooperate in and facilitate permanent transfers to other programs/institutions. Programs/institutions will make the keep/transfer decision expeditiously so as to maximize the likelihood that each resident will complete the resident year on schedule. 3. Inform each transferred resident of the minimum duration of his/her temporary transfer, and continue to keep each resident informed of the minimum duration. If and when a program decides that a temporary transfer will continue to and/or through the end of a residency year, it must so inform each such transferred resident. The Designated Institutional Official (DIO) will call or email the ACGME Institutional Review Committee Executive Director with information and/or requests for information. When appropriate, the DIO will contact executive directors of specific residency review committees (RRCs). House officers should call or email the appropriate Review Committee Executive Director with information and/or requests for information, and copies of these requests should be sent to RFUMS’s DIO. Within ten days after the declaration of a disaster, the DIO will contact the ACGME to discuss due dates that the ACGME will establish for the programs . 1. To submit program reconfigurations to the ACGME and 2. To inform each program’s house officers of resident transfer decisions. The due dates for submission shall be no later than 30 days after the disaster unless other due dates are approved by the ACGME. [Adopted by the GMEC on November 7, 2008, approved March 2018, as a replacement for the policy of April 20, 2012]. 21. SCHOLARLY ACTIVITY Residents are expected to participate in scholarly activities which may include research projects designed to generate, assemble and/or present new medical knowledge. Residents are also expected to develop a basic capability for evaluating published research findings. [Adopted by the GMEC on November 22, 1996, approved April 20, 2012. Reviewed on December 19, 2014, March 2018]. 22. PROFESSIONALISM Programs, in partnership with the Sponsoring Institutions, must educate residents and faculty members concerning the professional responsibilities of physicians, including their obligation to be appropriately rested and fit to provide the care required by their patients, and provide a culture of professionalism that supports patient safety and personal responsibility. Residents must demonstrate and understanding of their personal role in the provision of patient- and family-centered care, safety and welfare of patients entrusted to their care, including the ability to report unsafe conditions and adverse events, assurance of their fitness for work. Residents must effectively manage their time before, during, and after clinical assignments and recognize impairment, including from illness, fatigue, and substance use, in themselves, their peers, and other members of the health care team.


Residents must commit to lifelong learning including monitoring of their patient care performance improvement indicators, and accurate reporting of clinical and educational work hours, patient outcomes, and clinical experience data. Programs must provide a professional, respectful, and civil environment that is free from mistreatment, abuse, or coercion of students, residents, faculty, and staff. [Adopted by the GMEC on November 22, 1996, approved April 20, 2012. Reviewed December 19, 2014, Revised and adopted March 2018] 23. INFECTION CONTROL The infection prevention and control programs at the affiliated medical centers provide a system for the collection and analysis of data needed to determine areas of risk of infectious disease and opportunities for improvements. Residents will be apprised of the existence and nature of infection control programs and at times may be asked to participate in these programs. [Adopted by the GMEC on November 22, 1996, approved April 20, 2012. Reviewed December 19, 2014, March 2018] 24. IMMUNIZATION RECOMMENDATIONS Residents are at risk for developing infectious diseases from the patients they treat. Residents with infectious diseases are conversely a potential hazard to their patients and co-workers. It is the policy of the Medical School and its affiliated medical centers to provide the residents with the same immunization panel offered to other employees at similar risk. The following measures are recommended:

a. Hepatitis B vaccine is recommended for any resident who has not developed immunity to Hepatitis B. Since there is evidence to suggest that anti-Hepatitis B titers begin to wane approximately five years after immunization, previously immunized individuals should obtain a Hepatitis B antibody titer and a booster injection if indicated.

b. Tetanus/Diphtheria (TD) vaccine should be provided to any resident who has not been

vaccinated or who has not received a booster vaccination within the last 10 years. c. Influenza vaccination is recommended annually in the fall and mandatory based on site

requirements. d. Mumps-Measles-Rubella vaccination (MMR) is recommended. A history of having

previously received 2 MMR injections should be sought. If documentation is not available, appropriate antibody titers should be obtained on female residents. The vaccine should be administered, if indicated, following screening for pregnancy. Male residents may be offered the vaccine without a titer, at the discretion of the resident or his primary care physician.

e. Varicella vaccination is recommended and should be offered to any resident without a

known history of chicken pox. Female residents should be screened for pregnancy before vaccination.

f. Hepatitis A vaccine should be made available for those at risk of exposure to Hepatitis

A.


g. TB testing should be performed for all residents unless the resident has documentation

of TB testing within the past one year or documentation of significant reactivity to tubercular antigen in the past. Routine annual testing should be done in those without significant reactivity. Chest x-rays may be required by the medical centers at which the residents rotate.

The affiliated medical centers at which residents rotate may not require all of the above immunizations, in which case residents may obtain any non-required immunizations at their own expense. Likewise, one or more affiliated medical centers may require immunizations or tests not specified above. These requirements are ordinarily provided by the affiliated medical center. [Adopted by the GMEC on November 17, 2005, approved April 20, 2012, and replaces the policy of the same title of October 25, 1996. Reviewed on December 19, 2014, Mach 2018]. 25. LEAVE POLICIES Leave for any reason may require that additional time in training be invested for successful completion of the residency program and/or for board eligibility. The need for additional time in training depends upon multiple factors that include the type of leave, its status as authorized or unauthorized, and whether it can be incorporated into annual or sick leave. Types of leave include the following:

a. Educational Leave: Residents may be granted educational leave, which may be paid or

unpaid, if and as approved by their Program Director and in accordance with the policies and procedures of the residency program, of the Medical School, and of the affiliated medical centers at which they are assigned and by which they are salaried.

[Adopted by the GMEC on March 7, 2008, approved April 20, 2012, as a replacement for

policy of the same title, approved November 16, 2005. Reviewed on March 2018]. b. Annual Leave: Residents receive up to 30 days of annual leave per academic year (July 1

through June 30), depending upon (a) the residency program, (b) the methods of counting annual leave days used by the Medical School and its affiliated medical centers, and (c) the methods of calculation of accrued annual leave used by the Medical School and its affiliated medical centers.

Accrued annual leave is pro-rated to the amount of the academic year served (or

projected to be served) (i.e. worked days, approved days-off and holidays, annual leave days, but not sick leave days) by the resident. Paid Annual leave cannot be carried over to other academic years except in extraordinary circumstances, with the agreement of the program, the employer, and the medical center on whose time the leave would be taken, and with the written permission of the Program Director and the Associate Dean for GME. If annual leave time is not used in the academic year in which it was accrued, it is subject to forfeiture.

Requests for a specific time for annual leave will be considered but approval remains at

the discretion of the Program Director. Requests should be submitted to the Program Director as long in advance as is reasonably possible and in accordance with protocol established by the residency program.


[Adopted by the GMEC on March 26, 2010, approved November 24, 2015, as a replacement for the policy of same title of March 7, 2008. Reviewed on March 2018,].

c. Parental/Maternity/Paternity/Adoption Leave: Maternity/Paternity/Adoption leave

(paid, unpaid, or a combination thereof) may be granted upon formal request and in accordance with the policies of the organization directly employing the resident (e.g. an affiliated medical center or the Medical School). When the Family and Medical Leave Act (“FMLA”) is applicable, its provisions will be observed.

Annual and/or sick leave may be used in whichever order is specified by the employer to continue salary and benefits during Maternity/Paternity/Adoption Leave. Maternity/Paternity/Adoption Leave may also be taken in an approved leave-without-pay status. The use of annual leave and leave-without-pay are subject to the FMLA, if applicable, and may require the approval of the Program Director. Sick leave may only be used for illness or as pregnancy leave. It is not equivalent to annual leave and is not to be used as “personal holidays.” Sick leave does not carry over to other academic years. A doctor's certificate verifying the status of the resident may be requested by the Program Director. Planning for maternity leave should begin months in advance of the anticipated leave in order to determine the most favorable structuring of leaves (e.g. annual leave, paid sick leave, Short-Term Disability, RFU Parental Leave). Relevant considerations include receipt of salary during leave, amount of academic “make-up” time incurred, and preservation of annual leave and paid sick leave for later use. These considerations should be discussed with the Program, the GME Office, and the University’s Human Resources Department.

Absence from training greater than that acceptable to the residency program and/or to

the program’s specialty board may require compensatory training time for the resident to be eligible for graduation and/or board eligibility. Except for FMLA leaves, retention in the program after prolonged absence requires the approval of the Program Director. Compensatory training time depends upon the availability of funding and residency positions. The resident should discuss the anticipated need for compensatory training time with his/her Program Director.

Programs are encouraged to arrange minimum night call duty around the expected

time of the birth of the resident’s child. [Adopted by the GMEC on March 2018, as a replacement for the policy of the same title

of December 2014.]. d. Sick leave: If a resident calls in sick, it is the prerogative of the Program Director to ask

for verbal or written corroboration by the resident’s physician or by an independent consultant. Residents must be aware that each specialty board allows only a certain amount of excusable absence from training. Absence beyond that amount will ordinarily require compensatory time in training in order to secure board eligibility. Except for FMLA leaves, retention in the program after prolonged absence requires the approval of the Program Director. Salary and benefits for compensatory training time depend upon the availability of funding and residency positions. The resident should discuss the anticipated need for compensatory training time with his/her Program Director.

The amount of paid and unpaid sick leave is determined by the policies and practices of the Medical School and of the medical centers at which the resident has been rotating


and/or by which he/she is salaried. Paid sick leave may be up to a maximum of 15 days per academic year and is pro-rated to the number of days served in the academic year (i.e. worked days, approved days-off and holidays, annual leave days, but not sick leave days).

[Adopted by the GMEC on March 2018, as a replacement for the policy of the same

title, approved November 24, 2015,]. e. Bereavement Leave: Bereavement leave (paid, unpaid, or a combination thereof) may

be granted for deaths in the immediate family. The amount of paid and unpaid bereavement leave is determined by the policies and practices of the medical school and of the medical centers at which the resident has been rotating and/or by which he is salaried. If additional time is required, available vacation time may be used. For purposes of Bereavement leave, the immediate family is defined as the resident's or spouse’s grandparents, parents, siblings, children and grandchildren.

[Adopted by the GMEC on November 16, 2005, approved April 20, 2012, as a

replacement for the policy of the same title, approved December 20, 1996. Reviewed March 2018].

f. Military Leave: Residents who are members of the U.S. Armed Forces, including

reserves, and who are required to undergo training or are called to active duty, may be granted a paid leave of absence for a specified period of time in accordance with the policies of the Medical School and of the medical centers at which the resident is salaried and at which he/she is rotating. Ordinarily, the salary paid to the resident will be the difference between the resident’s regular salary and the salary received from the military service. The resident may use accumulated vacation time to extend the period of salaried absence. Local drills or training assemblies might not qualify for short-term military leave, with or without pay. All legal obligations pertaining to the use of military leave will be honored.

If a resident enters the Armed Forces of the United States while an employee of the

Medical School, or of its affiliated medical centers, he/she may have certain re-employment rights, as specified by Federal or State laws, applicable upon completion of the military service.

[Adopted by the GMEC on March 7, 2008, approved April 20, 2012, as a replacement

for the policy of the same title, approved November 16, 2005. Reviewed March 2018. g. Leave of absence: A leave of absence (paid, unpaid, or a combination thereof) may be

granted only with the written permission of the Program Director and in accordance with the policies of the Medical School and of the affiliated medical centers at which the resident is salaried and at which he/she is rotating. Such leave may prolong the duration of the residency training period required to complete graduation and/or board eligibility requirements.

[Adopted by the GMEC on March 7, 2008, approved April 20, 2012, as a replacement

for the policy of the same title, approved January 27, 2007. Reviewed March 2018].

h. The Family and Medical Leave Act: The above policies are subject to revision to maintain compliance with the Family and Medical Leave Act and other applicable Federal and State laws.


i. RFU Parental Leave: RFU Parental Leave, as opposed to the Parental Leave policy of the

VA, allows a maximum of 28 calendar days of paid leave at the resident’s usual salary level. This leave requires day-for-day “make-up” of academic time. When on RFU Parental Leave, the resident is placed on Leave-Without-Pay with regard to the training sites. RFU Parental Leave cannot be used concurrently with Short- or Long-Term Disability, Annual Leave, Sick Leave, Holidays or “days-off,” e.g. weekend or other days intended to limit a string of “work days.”

If a resident is on Short-Term Disability, RFU Parental Leave can be initiated only after

the Short-Term Disability leave is completed. No “elimination” period, as is required at the start of Short-Term Disability, is required at the start of RFU Parental Leave.

Placement in the status of RFU Parental Leave requires the approval of RFU Human Resources, the GME Office and the training program.

[Adopted by the GMEC on March 23, 2018]. j. Short-Term Disability: The RFU Short-Term Disability policy allows for a maximum leave

of 12 weeks, which includes the initial 7 day “elimination” period, at full-salary. It may be used for Maternity Leave, to a maximum of 6 weeks for an uncomplicated vaginal delivery and to a maximum of 8 weeks for an uncomplicated caesarian delivery.

Short-Term Disability is initiated after 7 contiguous days out of work (“elimination”

week) during which the resident receives no funding at the cost of the University. The resident may, however, receive salary at his/her usual rate associated with Annual Leave, Sick Leave and/or training site-approved Holiday concurrent with the “elimination” week and reimbursed by an affiliated training site. After the “elimination” week is completed, earlier if Annual Leave and/or paid Sick Leave are not being utilized, the resident is placed on Leave-Without-Pay status with respect to affiliated training sites.

Time spent on Short-Term Disability or Sick Leave (but not Annual Leave) requires

“make-up” of lost academic time. Placement in the status of Short-Term Disability requires the approval of RFU Human

Resources, the GME Office and the training program. [Adopted by the GMEC on March 23, 2018]. k. Long-Term Disability: RFU The Long-Term Disability policy is paid at 60% of base salary

or as modified by other terms of the policy in effect between the University and Mutual of Omaha. Long-Term Disability begins at the time Short-Term Disability ends. When on Long-Term Disability, the resident is placed on Leave-Without-Pay status and the academic time lost needs to be made up. Refer to the plan document with the University’s Human Resources Department for further details.

Approval to enter Long-Term Disability status must be obtained from the Program, the

GME Office, the University’s Human Resources Department, and Mutual of Omaha. Additional details may be obtained from the University’s website at: https://insite.rosalindfranklin.edu/Working@RFU/HR/Benefits/Life.STD.LTD.Vol/Long%

20Term%20Disability%20-%20Residents%205.31.17.pdf and from Mutual of Omaha at United of Omaha Life Insurance Company, Mutual of

Omaha Plaza, Omaha, Nebraska 68175 Call Toll-Free: 1-800-877-5176

https://insite.rosalindfranklin.edu/Working@RFU/HR/Benefits/Life.STD.LTD.Vol/Long%20Term%20Disability%20-%20Residents%205.31.17.pdf

https://insite.rosalindfranklin.edu/Working@RFU/HR/Benefits/Life.STD.LTD.Vol/Long%20Term%20Disability%20-%20Residents%205.31.17.pdf


www.mutualofomaha.com [Adopted by the GMEC on March 23, 2018].

26. SALARY AND BENEFITS

a. Salary: Each resident is assigned to the payroll of the Medical School or of an affiliated medical center. The salary and benefits package is competitive with the regional hospitals and is adjusted annually with the approval of the School’s GME Committee. Recent salary scales are found in Appendix II. Salaries and Benefits may be updated before publication of the next version of this manual.

b. Health Insurance: Subject to eligibility requirements of the plan and enrollment by the

resident, health insurance is available through the Medical School or medical center that employs the resident. Details of the available insurance plans are presented and discussed with each resident at the time of appointment.

c. Disability Insurance: Subject to eligibility requirements of the plan and enrollment by

the resident, disability insurance is available through the Medical School or medical center that employs the resident. Details of the insurance plan, including when it goes into effect, are presented and discussed with each resident at the time of appointment.

d. Extension of Training into a subsequent academic year: Residents who are late in

beginning their training, or who must make up for time lost due to illness, unsatisfactory performance in one or more rotations, leave of absence, etc., may be allowed to extend their training into a subsequent academic year at the discretion of the residency program director. The salary and benefits for training extended into the subsequent academic year, however, will be subject to the availability of residency positions and funds in excess of those funds required for new and routinely continuing residents.

[Adopted by the GMEC on March 23, 2018, as a replacement for the policy of the same title of December 19, 2014]. 27. MALPRACTICE INSURANCE Professional liability insurance is provided by the School or by the affiliated medical center to which the resident is assigned. Each insurance plan provides at least $1,000,000 per occurrence and $3,000,000 in annual aggregate. [Adopted by the GMEC on September 17, 2004, approved April 20, 2012, as a replacement for the policy of December 20, 1996. Reviewed March 23, 2018]. 28. MEDICAL RECORDS Complete and available medical records are a necessity for good patient care. Discharge summaries, procedural reports, etc., must therefore be completed accurately and in a timely manner. The original or official copies of the medical records or patient charts are not to be taken from the hospital under any circumstances other than as required by law. Residents are expected to comply with the policies and procedures of the affiliated medical centers regarding medical records. Residents who do not comply with these policies and procedures may be disciplined or discharged from the residency program.

http://www.mutualofomaha.com/


[Adopted by the GMEC on September 17, 2004, approved April 20, 2012, as a replacement for the policy of December 20, 1996. Reviewed March 23, 2018]. 29. “MOONLIGHTING” POLICIES Residency and fellowship programs generally require substantial time commitments from the residents, allowing little if any time for outside employment, i.e. "moonlighting". The Program Director may prohibit “moonlighting” for all residents in the program or may allow it on an individual basis within specified limits depending upon the nature of the outside employment and the academic standing of the resident. Residents will not be required to “moonlight.” Residents without permanent Illinois licenses may not engage in "moonlighting". Residents holding J-1 visas are not permitted to "moonlight". Other types of immigration status may similarly restrict employment outside of the residency program. The resident who wishes to "moonlight" must request the privilege from the Program Director and provide the following information: site of "moonlighting", amount of time involved, schedule of the outside employment, and nature of the employment. A sample "Moonlighting" Request Form is provided in Appendix III. Completed “Moonlighting” Request Forms should be included in the resident’s file. It is the resident's responsibility to obtain approval from the Program Director of any significant increases in "moonlighting” hours. The Program Director may prohibit or rescind approval of any "moonlighting" commitment if he believes that the resident's performance or learning capability in the program has been, is, or would possibly be compromised. The resident may challenge the decision in accordance with the appeal processes of their department and of the School. The performance of “moonlighting” residents will be monitored by the Program Director and, if the performance of the resident appears to be compromised, permission to “moonlight” may be modified or withdrawn. The professional liability insurance provided by the School or an affiliated medical center covers only the activities of the residency program and does not cover "moonlighting" activities. The resident is therefore responsible for securing adequate professional liability insurance coverage and may be required by the Program Director to provide written evidence of such insurance. [Adopted by the GMEC on September 17, 2004, approved April 20, 2012, as a replacement for the policy of September 11, 2003. Reviewed March 23, 2018]. 30. COMPLAINTS AND GRIEVANCES RIGHTS AND PROCEDURES. 1. Scope. These grievance procedures apply to all complaints and grievances regarding the resident are academic, clinical, or research learning and working environment, except decisions of the Program Director that are cognizable under Section 30a of this Manual. 2. Timing and Submission Procedures. Any complaint or grievance cognizable under this Section of the Manual:

a. Shall be submitted to the Program Director (or, if the complaint or grievance is against the Program Director, then it shall be submitted to the Associate Dean for GME of the Chicago Medical School).

b. Should be submitted in a prompt manner in order to enable a prompt and fair resolution (any undue delay in submitting a complaint or grievance could adversely impact its resolution).


c. Shall be submitted in writing and include (i) the relevant facts and circumstances giving rise to the complaint or grievance and (ii) the desired action to be taken on the complaint or grievance. 3. Inquiry into the Complaint or Grievance. Upon receipt of a complaint or grievance cognizable under this Section of this Manual, the Program Director shall take steps to gather the relevant information in a fair and reasonable manner (i.e. by using methods deemed reasonably efficient in time and resources and that are reasonably likely to result in reliable information within this learning and working environment); however, the fact-gathering efforts shall not be subject to any formal investigative or other criminal procedure requirements that are applicable to government law enforcement officials. The Program Director may do this by personally gathering information and/or by receiving information from another who has conducted an inquiry into the matter. If the complaint or grievance is against the Program Director, then these steps shall be taken by the Associate Dean for GME of the Chicago Medical School, in lieu of the Program Director, and the Associate Dean for GME shall consult with the GMEC during the inquiry. 4. Resolution. The Program Director shall take steps to resolve the complaint or grievance in a prompt and fair manner and such resolution shall be consistent with University policies and the ACGME standards and requirements that are applicable to the specific residency program. The Program Director shall notify the resident making the complaint or grievance of its resolution, subject to the privacy rights of others and other applicable University policies. If the complaint or grievance is against the Program Director, then these steps shall be taken by the Associate Dean for GME of the Chicago Medical School, in lieu of the Program Director, and the Associate Dean for GME shall consult with the GMEC prior to making the resolution decision. 5. Appeal of Resolution Decision Made by Program Director. The resident may appeal the resolution made by the Program Director. This appeal must be submitted in writing to the Associate Dean for GME of the Chicago Medical School within 14 days of receiving the written resolution from the Program Director. The written appeal must describe the complaint or grievance, the resolution decision of the Program Director, and the desired action to be taken. The Associate Dean for GME shall take steps to gather additional information in a fair and efficient manner and shall consult with the GMEC in this effort. The Associate Dean for GME shall take steps to decide the appeal in a prompt and fair manner and shall consult with the GMEC prior to making the decision on the appeal. Such decision shall be consistent with University policies and the ACGME standards and requirements that are applicable to the specific residency program. The Associate Dean for GME shall notify the resident making the complaint or grievance of its resolution, subject to the privacy rights of others and other applicable University policies. There is no appeal of any decision made by the Associate Dean for GME described in any paragraph of this Section 30 of this Manual. 30a. APPEAL RIGHTS AND PROCEDURES 1. Scope. These appeal procedures apply to actions of a Program Director to (i) not promote a resident to the next formal level of education within a residency program, (ii) not renew a residency contact, (iii) dismiss a resident from the residency program, or (iv) any action that would lengthen the duration required to complete the residency program. 2. Timing and Appeal Authority. An appeal submitted under this Section of the Manual must be submitted and received by the Dean of the Chicago Medical School of Rosalind Franklin University of Medicine and Science no later than the expiration of fourteen (14) calendar days from the resident receiving the written letter of the Program Director announcing the action taken. In situations where date of receipt by the resident has not been acknowledged by the resident or has not otherwise documented, then an appeal submitted under this Section of the Manual must be


submitted and received by the Dean of the Chicago Medical School of Rosalind Franklin University of Medicine and Science by the expiration of twenty-one (21) calendar days from the date that written letter was sent by mail to the last known address of the resident. 3. Grounds For Appeal. An appeal submitted under this Section of the Manual may be made on any of the following grounds:

a. There was a violation of the procedures in this Manual relating to the Program Director’s decision;

b. The Program Director’s decision clearly exceeded the bounds of discretion associated with

the proper exercise of academic judgment; or c. The Program Director had a conflict of interest such that the Program Director should have

been recused. 4. Format and Content. An appeal submitted under this Section of the Manual must be submitted in writing and clearly state (a) the grounds of appeal; (b) the facts and circumstances that support the grounds for appeal; and (c) the desired action to be taken by the Dean. 5. Decision of Dean. The Dean shall consider the appeal submitted by the resident, consider the resident’s entire file, and consult with the GMEC prior to making a decision on the grievance. The Dean shall determine (a) whether or not any of the grounds for grievance exist and (b) the final resolution of the appeal. The final resolution of the appeal shall be consistent with University policies and the ACGME standards and requirements that are applicable to the specific residency program. 31. IMPAIRED PHYSICIANS: POLICIES AND PROCEDURES The Impaired Physician policy is intended to assist in the identification and treatment of the impaired resident in order to reduce any compromise of patient care and to restore the resident to health and effective practice. Procedure:

a. An impaired resident is a resident or fellow, involved in training or research, licensed to practice medicine in the State of Illinois, who is unable to practice medicine with reasonable skill and safety to patients because of mental or physical illness or shortcoming.

b. Whenever a resident, fellow or staff member observes behavior in a resident that indicates

that the resident may be impaired, the Program Director should be notified immediately. c. Upon notification, the Program Director will conduct a preliminary investigation. If he

concurs that there is a reasonable belief that such impairment exists, he will report such information to the appropriate departmental chairman and to the Associate Dean for GME.

d. The resident may be placed on paid or unpaid leave [including annual leave, sick leave or

leave of absence] at the discretion of the Program Director until evaluation of the situation is complete. During these proceedings, the resident will have access to the current grievance procedures of the School.

e. In conjunction with the leave, the Program Director, at his discretion, may notify the

Impaired Physicians Program of the Illinois State Medical Society.


f. If a resident is placed on leave because of drug or alcohol abuse, the resident will be

required, at a minimum, to complete successfully an appropriate rehabilitation program approved by the Program Director. Such programs may include those approved by the Impaired Physicians Program of the Illinois State Medical Society, programs under the auspices of affiliated medical centers, programs utilized by the University, and programs specifically arranged by the Program Director in consultation with appropriate health care professionals. The resident must document his compliance to the rehabilitation program.

g. If the resident fails to comply with the rehabilitation program, he will be terminated from

the residency program and a notice to that effect will be placed in his permanent record. Appropriate state and national agencies will be notified in accordance with state and federal laws. Termination for this reason is not eligible for appeal.

h. Upon completion of a rehabilitation program, the resident may be required by the Program

Director to enter an aftercare program. The resident must document compliance to the aftercare program to the satisfaction of the Program Director. Failure to comply or to adequately document compliance will result in termination. Termination for this reason is not eligible for appeal.

i. The Associate Dean for GME and the departmental chairman will be notified when the

resident is eligible for resumption of training pursuant to the recommendation of the resident’s physician or therapist. If the resident is participating in an aftercare program, the resident must provide the Program Director, the departmental chairman, and the Associate Dean for GME acceptable documentation of compliance to the aftercare program.

j. The Program Director will notify the departmental chairman and the Associate Dean for

GME when a resident has completed the aftercare program. Training time lost to accommodate participation in rehabilitation and aftercare programs may require the completion of additional compensatory training to secure satisfactory completion of the residency program and board eligibility requirements.

k. If, after successful completion of the aftercare program, the resident subsequently

relapses, termination from the program may be recommended unless there are extenuating circumstances. Retention of the resident will require the concurrence of the Program Director, the departmental chairman and the Associate Dean for GME. If the resident claims that he/she has a mental or physical disability accounting for the impairment or for the failure of rehabilitation, adequately documented substantiation of the claims by one or more qualified health care professionals acceptable to the University may be required by the Medical School or University.

l. The participation of the resident in a rehabilitation program will be acknowledged as

requested by state licensing agencies, hospital credentialing bodies, and any other organizations or individuals authorized to be so informed.

m. Health and disability insurance benefits will remain in effect according to the terms and

limitations of the policy. [Adopted by the GMEC on January 27, 2007, approved April 20, 2012, as a replacement for the policy of September 17, 2004. Reviewed March 23, 2018]


32. SEXUAL HARASSMENT Federal law (Title VII of the Civil Rights Act of 1964) provides that it shall be an unlawful discriminatory practice for any employer, because of the sex of any person, to discharge without just cause, to refuse to hire, or otherwise discriminate against that person in any matter directly or indirectly related to employment. Harassment of an employee on the basis of sex violates the federal regulations implementing this law. In accordance with the federal Equal Employment Opportunity Commission, sexual harassment consists of repeated, unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature which is unlawful when:

a. submission to sexual conduct is an explicit or implicit term or condition of an individual's employment,

b. submission to or rejection of sexual conduct by an individual is the basis for any employment decision affecting the individual, or

c. sexual advances, requests for sexual favors or other verbal or physical conduct of a sexual nature have the purpose or effect of unreasonably interfering with an individual's work performance or creating an intimidating, hostile or offensive working environment.

The University does not tolerate sexual harassment and will pursue appropriate disciplinary action against any member of the faculty of the University found to have engaged in sexual harassment. At the same time, it is recognized that, because of cultural and social variances which exist among members of a heterogeneous community, there may be differing views of what constitutes sexual harassment. It is suggested, consequently, that anyone who is distressed by the perceived sexual attentions of another person seek, in the first instance, to have an open and direct discussion of the behavior with the person involved. Allegations of sexual harassment are taken seriously. If you believe that you are the victim of sexual harassment, you should do the following:

a. Document each incident of alleged sexual harassment, including date, time, place, what was said or done, and the surrounding circumstances.

b. If possible, clearly communicate to the offending individual that his or her conduct is unwelcome, and request that the offensive behavior stop.

c. At the same time, you should file a complaint in accordance with Section 30 of this Manual

All such matters will be treated with the utmost discretion. The University will actively investigate all sexual harassment complaints and, if it is determined that sexual harassment has occurred, the University will take appropriate disciplinary action against the offending party, up to and including discharge. The Program Director will make available counseling for persons who have concerns related to sexual harassment and will investigate complaints where such investigations are warranted. Individuals who feel that they are targets of sexual harassment should understand that they may also utilize a variety of other resources on campus for seeking informal counseling or an informal resolution of the perceived problem. The resources of the affiliated medical centers and their specific policies and procedures will be coordinated with those of the University when appropriate. The Office of GME is available to assist the resident with the processing of any complaints.


[Adopted by the GMEC on December 20, 1996, approved April 20, 2012. Reviewed March 2018]. 33. COUNSELING AND SUPPORT SERVICES Confidential counseling and support services may be available through the University Clinic, the University Counseling Center or the departments of Psychology and Psychiatry. If preferred, a referral to an outside provider can be made. In general, the cost of these services is the responsibility of the resident. The cost of some intramural services, however, may be deferred by the University. [Adopted by the GMEC on January 27, 2007, approved April 20, 2012, as a replacement for the policy of the same title, approved January 25, 2002. Reviewed March 23, 2018]. 34. ORIENTATION PROGRAMS Residents will be oriented to the relevant policies and procedures of each medical center at which they train. Orientation to their residency program in general and to specific rotations within their residency program will also be provided in accordance with residency program policy. The curriculum, objectives and goals of each rotation, when appropriate, will likewise be provided to the residents during the course of their residency program. [Adopted by the GMEC on June 27, 1997, approved April 20, 2012. Reviewed on March 23, 2018]. 35. RESIDENT FORUM Residency programs of sufficient size shall encourage and support “residents’ forum” or similar organizations (Council, Town hall), administered and attended exclusively by residents, to which residents may voice their concerns anonymously or in the absence of members of the faculty or administration. “Residents’ Forum” leaders shall have the opportunity to bring concerns of the Council to the administration of the program, of the department or of the institution. In addition, Quarterly meetings of residents and fellows in all programs (Resident/Fellow Forums) will take place during which residents and fellows from all programs may voice their concerns anonymously or in the absence of members of the faculty or administration. [Adopted by the GMEC on January 29, 1999, approved April 20, 2012. Revised December 19, 2014, Reviewed on March 23, 2018] 36. RESTRICTIVE COVENANTS Residents and fellows will not be required to agree to practice outside of a specified locale after completion of training. Likewise, other forms of restrictive covenants intended to reduce or eliminate competition by former residents will not be required. [Adopted by the GMEC on April 23, 1999, approved April 20, 2012. Reviewed on March 23, 2018]. 37. MONITORING FOR FATIGUE A list of the major signs and features of excess fatigue in residents and fellows will be distributed annually to the residents, fellows and principal teaching faculty of the residencies and fellowships. The residents, fellows and faculty will be advised to be aware of these indicators of fatigue and, if a resident or fellow exhibits findings suggestive of excess fatigue, they should notify the resident’s Program Director. The Program Directors will evaluate such


reports to assess if a significant problem with fatigue does exist. If so, the Program Directors will take appropriate actions to remedy the problem. The Program Directors will report to the GMEC on their monitoring programs on a semi-annual basis. See also Section 18 (WELL BEING) [Adopted by the GMEC on September 11, 2003, approved April 20, 2012. Reviewed on March 23, 2018]. 38. EXTENSION OF PERMISSIBLE DUTY HOURS The 80-hour maximum for duty hours may be extended by up to 10% (8 hours) if the extension is approved by the GMEC and, subsequently, by the program’s RRC. A department seeking an extension must submit a written request for the extension, and the reasons justifying the extension, to the GMEC. If approved by the GMEC, the request will be forwarded to the RRC over the signatures of the Program Director, the Chairman of the GMEC, and the Designated Institutional Official. [Adopted by the GMEC on September 17, 2004, approved April 20, 2012. Reviewed on March 23, 2018]. 39. ACTIONS REQUIRING THE APPROVALS OF THE GME COMMITTEE AND OF THE DEAN OR

ASSOCIATE DEAN FOR GME The following actions require review and approval by the GME Committee and by the Dean or Associate Dean for GME before the actions can be implemented: (a) Additions or deletions of training sites. (b) Increases, decreases, or redistribution among training sites of 3 or more Psychiatry or Internal

Medicine residents. (c) Increases, decreases, or redistribution among training sites of 1 or more Internal Medicine

subspecialty fellows. (d) Application to establish a new residency program or to reinstate an inactive residency program. (e) Application to voluntarily withdraw a residency program or reduce an active residency program

to an inactive residency program. (f) Appointment or change of Residency Program Director. (g) Submission of a progress report or a response to a proposed adverse action to a Residency

Review Committee (RRC). (h) Submission of a request for appeal, or presentation of a written or verbal appeal, to the ACGME. (i) Submission of a request to the ACGME for increases in permissible Duty Hours [qv. Policy 38 in

the “Manual of Policies & Procedures for Graduate Medical Programs.”] (j) Significant increases in the stringency of programmatic policies or practices for resident

promotion, graduation, suspension, dismissal or threshold for allowing resident grievances, to greater than that established in Medical School policy. Relaxation of stringency to less than that established in Medical School policy is not permitted.

(k) Modification of the official residency program’s [not individual resident’s] start date (July 1) or completion date (6/30). Residents may present prior to July 1 on non-pay status for orientation or administrative processing, without prior GME Committee approval.

(l) Modification of the salaries of Chief Residents. Modification of the salaries of non-Chief Residents are not acceptable except in unusual circumstances, e.g. reductions of salary


associated with the completion of additional training time beyond the initially anticipated graduation date.

(m) Major changes in program structure or length of training. The above list is not intended to indicate that no other actions require approval of the GME Committee and/or of the Dean or Associate Dean for GME. If there is any question that a considered action should appropriately require GME Committee approval and/or Dean’s Office approval, the question should be addressed to the Chairman of the GME Committee or to the Associate Dean for GME. [Adopted by the GMEC on November 7, 2008, approved April 20, 2012, as a replacement for the policy of the same title of November 7, 2005. Reviewed on March 23, 2018]. 40. ACTIONS REQUIRING DIO COUNTERSIGNATURE The following actions require the countersignature of the DIO (Designated Institutional Official): (a) Submission of information or requests to the ACGME unless the requests are programmatically

innocuous, e.g. requests for clarification of ACGME requirements or policies, inquiries about dates of site visits or deadlines, inquiries about completion of documents or on-line surveys or databases.

(b) Submission of a Program Information Form (PIF), progress report, response to a proposed adverse action, request for appeal or written appeal, to the ACGME.

(c) Notification of the ACGME of an appointment or change of Program Director. (d) Notification of the ACGME of the addition or deletion of a training site. (e) Notification of the ACGME of changes in the numbers or distributions of residents among

training sites. The above list is not intended to indicate that no other correspondence with the ACGME requires DIO countersignature. If there is any question that considered communication with the ACGME may require DIO countersignature, the question should be addressed to the DIO before submission. [Adopted by the GMEC on November 7, 2005, approved April 20, 2012. Reviewed on March 23, 2018]. 41. TECHNICAL STANDARDS FOR GRADUATE MEDICAL EDUCATION The Americans with Disabilities Act (ADA), enacted in July of 1990, protects any individual with a physical or mental impairment that substantially limits that person in some major life activity and any individual who has a history of, or is regarded as having, such an impairment. Under the ADA, as with Section 504 of the Vocational Rehabilitation Act, universities and colleges are prohibited from discriminating against an otherwise qualified person with a disability in all aspects of academic life. Schools must make reasonable accommodations to accommodate the known physical or mental disabilities of otherwise qualified individuals. The University need not make an accommodation that would cause an undue burden. The philosophical basis of the ADA, that of judging persons on their abilities and achievements rather than their potential disabilities runs parallel to the traditional philosophy of this University.

In order to define the "essential requirements" of its graduate medical curriculum, the Chicago Medical School has developed a list of Technical Standards of physical, mental, and behavioral skills and capabilities essential for training and functioning in a residency or subspecialty fellowship program (Appendix VI). In decisions on admission, evaluation, promotion, and graduation


of any person, and especially an applicant or resident with a disability, it is the obligation of the individual to meet these technical standards, with or without reasonable accommodation. For further information on these Technical Standards and the procedures for their implementation, interested persons are encouraged to contact Ms. Rebecca Durkin, ADA Coordinator (at [847] 578-8351 or [email protected]), or Michael Zdon, MD, , Associate Dean for GME (at [847] 578-8714 or [email protected]) [Adopted by the GMEC on November 7, 2008, approved April 20, 2012. Reviewed on March 23, 2018].




Appendix I

STATEMENT OF COMMITMENT TO GRADUATE MEDICAL EDUCATION

March 23, 2018 Chicago Medical School is committed to supporting Graduate Medical Education (GME) programs of the highest caliber. The goal of these programs, consistent with the strategic goals of Chicago Medical School and Rosalind Franklin University of Medicine & Science, is the training of highly skilled, scholarly physicians whose practices will engender the highest ideals of compassion and professionalism.

To this end, the Medical School commits to:

I. Support an Office of GME headed by an Associate Dean serving as the ACGME’s Designated Institutional Official and charged with the administrative oversight and management of the School’s GME programs,

II. Support a Graduate Medical Education Committee, composed of the Associate Dean for GME /Designated Institutional Official, selected faculty, residents and administrators, which has responsibility for monitoring, advising and establishing policies as defined by the Accreditation Council for Graduate Medical Education,

III. Establish an effective, competency-based curriculum, the efficacy of which is continually monitored and improved through the use of outcomes-based methodology,

IV. Establish partnerships with medical centers sharing the same goals and offering academic, educational environments for residents, and

V.

Provide the monetary, space, material and human resources to support the GME programs and their administrative infrastructure in collaboration with the affiliated medical centers.


Approvals: _______________________________________________________ Michael J. Zdon, MD Date Designated Institutional Official (DIO) Associate Dean for GME _______________________________________________________ James M. Record, MD, JD, FACP Date Interim Dean, Chicago Medical School _______________________________________________________ Chair of the Board of Directors Date [Adopted by the GMEC on August 28, 2009; by the Faculty Executive Council on September 4, 2009; and by the Academic Assembly on October 23, 2009, approved April 20, 2012. Reviewed and approved on December 19, 2014 and December 18, 2015, March 23, 2018].


Appendix II

Basic Salary Scale for Residents 2018-19 Academic Year

PGY 1: $ 53,545.73

PGY 2: $ 55,475.37

PGY 3: $ 57,737.87

PGY 4: $ 59,978.31

Basic Salary Scale for Fellows

2018-19 Academic Year

PGY 4: $ 59,685.73

PGY 5: $ 61,230.85

PGY 6: $ 63,261.58

PGY-7: $64,828.77

PGY-8: $66,132.82


Appendix III

Request for Permission to “Moonlight” Name: _____________________________________________ Date: _________________________ Training Program: ___________________________________________________________________ I understand the following conditions of “moonlighting”: 1. I do not expect that my “moonlighting” activities will interfere with or compromise either my

performance as a resident or as a physician. 2. I understand that if my academic standing, clinical performance or learning capacity is felt to

be compromised by “moonlighting”, or reasonably expected to be compromised, permission to “moonlight” may be withdrawn.

3. I understand that the professional liability insurance provided by the Medical School and its

affiliated medical centers does not provide coverage for activities outside of the training program, for example “moonlighting.” I must therefore obtain my own professional liability insurance or assure that my outside employer will provide adequate insurance coverage for me.

4. I understand that it is unlawful for non-U.S. citizens in several types of visa status, including J-1

visa status, to engage in employment activities outside of their training programs. 5. I understand that the permission to “moonlight” applies only to the activities, facilities and

amounts of time described below. I will seek permission from my Program Director to engage in other types of “moonlighting” activities, or at other facilities or in significantly greater amounts.

____________________________________________________________________________________ I am requesting permission to “moonlight” in the following capacities: Facility: _____________________________________________________________________________ Location: ____________________________________________________________________________ Nature of the Outside Employment: ______________________________________________________ ____________________________________________________________________________________ Usual Employment Commitment (Days of the week; Time of the day; Hours/shift; Total hours/week): ____________________________________________________________________________________ ____________________________________________________________________________________ Facility: _____________________________________________________________________________ Location: ____________________________________________________________________________


Nature of the Outside Employment: ______________________________________________________ ____________________________________________________________________________________ Usual Employment Commitment (Days of the week; Time of the day; Hours/shift; Total hours/week): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Facility: _____________________________________________________________________________ Location: ____________________________________________________________________________ Nature of the Outside Employment: ______________________________________________________ ____________________________________________________________________________________ Usual Employment Commitment (Days of the week; Time of the day; Hours/shift; Total hours/week): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (Attach additional sheets if necessary) ____________________________________________________________________________________ I understand the conditions of “moonlighting” described above and attest that there are no prohibitions against my engagement in “moonlighting.” _______________________________________________ Date: _______________________________ Signature (Resident/Fellow) APPROVAL _______________________________________________ Date: _______________________________ Signature (Program Director)


Appendix IV

ACGME REQUIREMENTS FOR DUTY HOURS AND ON-CALL ACTIVITIES Effective July 1, 2017

The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.

Clinical Experience and Education in the Learning and Working Environment

Professionalism, Personal Responsibility, and Patient Safety 1. Programs and sponsoring institutions must educate residents and faculty members concerning the professional responsibilities of physicians to appear for duty appropriately rested and fit to provide the services required by their patients. 2. The program must be committed to and responsible for promoting patient safety and resident well-being in a supportive educational environment. 3. The program director must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs. 4. The learning objectives of the program must: 4. a) be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events; and, 4. b) not be compromised by excessive reliance on residents to fulfill non-physician service obligations. 5. The program director and institution must ensure a culture of professionalism that supports patient safety and personal responsibility. Residents and faculty members must demonstrate an understanding and acceptance of their personal role in the following: 5. a) assurance of the safety and welfare of patients entrusted to their care; 5. b) provision of patient- and family-centered care; 5. c) assurance of their fitness for duty; 5. d) management of their time before, during, and after clinical assignments; 5. e) recognition of impairment, including illness and fatigue, in selves and peers; 5. f) attention to lifelong learning; 5. g) the monitoring of their patient care performance improvement indicators; 5. h) honest and accurate reporting of duty hours, patient outcomes, and clinical experience data. 6. All residents and faculty members must demonstrate responsiveness to patient needs that supersedes self-interest. Physicians must recognize that under certain circumstances, the best interests of the patient may be served by transitioning that patient’s care to another qualified and rested provider.

Transitions of Care Programs must design clinical assignments to optimize transitions in patient care, including their safety, frequency, and structure.


Programs, in partnership with their Sponsoring Institutions, must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety. Programs must ensure that residents are competent in communicating with team members in the hand-over process. Programs and clinical sites must maintain and communicate schedules of attending physicians and residents currently responsible for care. Each program must ensure continuity of patient care, consistent with the program’s policies and procedures in the event that a resident may be unable to perform their patient care responsibilities due to excessive fatigue or illness, or family emergency.

Alertness Management/Fatigue Mitigation 1. The program must:

1. a) educate all faculty members and residents to recognize the signs of fatigue and sleep deprivation; 1. b) educate all faculty members and residents in alertness management and fatigue mitigation processes; and, 1. c) adopts fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, such as naps or back-up call schedules.

2. Each program must have a process to ensure continuity of patient care in the event that a resident may be unable to perform his/her patient care duties. 3. The sponsoring institution must provide adequate sleep facilities and/or safe transportation options for residents who may be too fatigued to safely return home.

Supervision of Residents 1. In the clinical learning environment, each patient must have an identifiable, appropriately-credentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient’s care.

1. a) This information should be available to residents, faculty members, and patients. 1. b) Residents and faculty members should inform patients of their respective roles in each patient’s care.

2. The program must demonstrate that the appropriate level of supervision is in place for all residents who care for patients. Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervising faculty member. For many aspects of patient care, the supervising physician may be a more advanced resident or fellow. Other portions of care provided by the resident can be adequately supervised by the immediate availability of the supervising faculty member or resident physician, either in the institution, or by means of telephonic and/or electronic modalities. In some circumstances, supervision may include post-hoc review of resident delivered care with feedback as to the appropriateness of that care. 3. Levels of Supervision - To ensure oversight of resident supervision and graded authority and responsibility, the program must use the following classification of supervision:

3. a) Direct Supervision: the supervising physician is physically present with the resident and patient.

3. b) Indirect Supervision: 3.b).(1) with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.


3.b).(2) with direct supervision available: the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision. 3. c) Oversight: the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered

4. The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members.

4. a) The program director must evaluate each resident’s abilities based on specific criteria. When available, evaluation should be guided by specific national standards-based criteria. 4. b) Faculty members functioning as supervising physicians should delegate portions of care to residents, based on the needs of the patient and the skills of the residents.

4. c) Senior residents or fellows should serve in a supervisory role of junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow.

5. Programs must set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members, such as the transfer of a patient to an intensive care unit, or end-of-life decisions.

5. a) Each resident must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence.

5. a). (1) In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. [Each Review Committee will describe the achieved competencies under which PGY-1 residents’ progress to be supervised indirectly, with direct supervision available.]

6. Faculty supervision assignments should be of sufficient duration to assess the knowledge and

skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility.

Clinical Responsibilities The clinical responsibilities for each resident must be based on PGY-level, patient safety, resident education, severity and complexity of patient illness/condition and available support services. [Optimal clinical workload will be further specified by each Review Committee.]

Teamwork Residents must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty. [Each Review Committee will define the elements that must be present in each specialty.]

Resident Duty Hours Maximum Hours of Work per Week Clinical and educational work hours must be limited to no more than 80 hours per week,

averaged over a four-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting.


The program must design an effective program structure that is configured to provide residents with educational opportunities, as well as reasonable opportunities for rest and personal well-being.

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

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

Residents must have at least 14 hours free of clinical work and education after 24 hours of in-

house call. Residents must be scheduled for a minimum of one day in seven free of clinical work and

required education (when averaged over four weeks). At-home call cannot be assigned on these free days

Clinical and educational work periods for residents must not exceed 24 hours of continuous

scheduled clinical assignments. Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or resident education.

Night float must occur within the context of the 80-hour and one-day-off in-seven requirements Residents must be scheduled for in-house call no more frequently than every third night (when

averaged over a four-week period). Time spent on patient care activities by residents on at-home call must count toward the 80-

hour maximum weekly limit. Residents are permitted to return to the hospital while on at-home call to provide direct care for

new or established patients. Duty Hour Exceptions In rare circumstances, after handing off all other responsibilities, a resident, on their own

initiative, may elect to remain or return to the clinical site in the following circumstances: to continue to provide care to a single severely ill or unstable patient; to attend unique educational events

2. Moonlighting

2. a) Moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program. 2. b) Time spent by residents in Internal and External Moonlighting (as defined in the ACGME Glossary of Terms) must be counted towards the 80-hour Maximum Weekly Hour Limit. 2. c) PGY-1 residents are not permitted to moonlight.

3. Mandatory Time Free of Duty - Residents 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. Common Program Requirements 17. 4. Maximum Duty Period Length


4. a) Duty periods of PGY-1 residents must not exceed 16 hours in duration. 4. b) Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested. 4. b). (1) It is essential for patient safety and resident education that effective transitions in care occur. Residents 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. 4. b). (2) Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty. 4. b). (3) In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. 4. b). (3). (a) Under those circumstances, the resident must: 4. b). (3). (a). (i) appropriately hand over the care of all other patients to the team responsible for their continuing care; and, 4. b). (3). (a). (ii) document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director. 4. b). (3). (b) The program director must review each submission of additional service, and

track both individual resident and program-wide episodes of additional duty. 5. Minimum Time Off between Scheduled Duty Periods

5. a) PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods. 5. b) Intermediate-level residents [as defined by the Review Committee] 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. 5. c) Residents in the final years of education [as defined by the Review Committee] must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods. 5. c). (1) This preparation must occur within the context of the 80- hour, maximum duty period length, and one-day-off-in seven standards. While it is desirable that residents in their final years of education have eight hours free of duty between scheduled duty periods, there may be circumstances [as defined by the Review Committee] when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty. 5.c).(1).(a) 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 program director.

6. Maximum Frequency of In-House Night Float - Residents must not be scheduled for more than six consecutive nights of night float. [The maximum number of consecutive weeks of night float, and maximum number of months of night float per year may be further specified by the Review Committee.] 7. Maximum In-House On-Call Frequency - PGY-2 residents and above must be scheduled for in-house call no more frequently than every-third-night (when averaged over a four-week period). 8. At-Home Call


8. a) Time spent in the hospital by residents 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. 8. a). (1) At-home call must not be as frequent or taxing as to preclude rest or reasonable personal time for each resident. 8. b) Residents 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”.

Innovative Projects Requests for innovative projects that may deviate from the institutional, common and/or specialty specific program requirements must be approved in advance by the Review Committee. In preparing requests, the program director must follow Procedures for Approving Proposals for Innovative Projects located in the ACGME Manual on Policies and Procedures. Once a Review Committee approves a project, the sponsoring institution and program are jointly responsible for the quality of education offered to residents for the duration of such a project.

[ACGME-approved]


Appendix V

Chicago Medical School at

Residency and Fellowship Agreement

«FIRSTNAME» «LASTNAME», M.D. (hereinafter, "RESIDENT/FELLOW") and Rosalind Franklin University of Medicine and Science, through its Chicago Medical School, (hereinafter, "SCHOOL") hereby enter into this AGREEMENT as of «DATE» and hereby agree as follows: 1. The term of this AGREEMENT shall be from «TERM» unless terminated or modified for good cause or by mutual agreement between the parties to the agreement. This Agreement is contingent upon the RESIDENT/FELLOW receiving satisfactory results from a background check and, if RESIDENT/FELLOW is permitted to begin pending completion of such background check, then this Agreement shall be terminated in the event the background check results are unsatisfactory. 2. The RESIDENT/FELLOW shall participate as a postgraduate year «PGY» trainee in the «Year» year of the «Residency» Training PROGRAM. 3. During the term of this AGREEMENT, the RESIDENT/FELLOW shall be paid at the annual rate of $«Annual_Salary_Rate» with provisions for a benefits package that includes up to 30 days of annual leave per academic year, up to 15 days of paid sick leave per academic year, professional liability (malpractice) insurance, medical insurance, life insurance, and disability insurance. 4. It is the responsibility of the RESIDENT/FELLOW to take all necessary steps to complete new hire paperwork, provide appropriate proof of identity and eligibility to work in the United States, enroll in the insurance programs and to so inform the Human Resources Department. The annual leave and paid sick leave during an academic year (July 1 through June 30) are based upon the amount of time worked, on annual leave, and on approved days-off and holidays (excluding sick leave) during the same academic year and cannot be carried over to other academic years. If annual leave and paid sick leave are not used during the academic year in which they were accrued, they are subject to forfeiture. Paid sick leave is reserved for illness or pregnancy and does not accrue academic credit. 4a. Your employment is contingent upon you providing appropriate proof of your identity and eligibility to work in the United States. We ask that you provide us this proof on your first day of employment because under federal law, we must verify your identity and authorization to work in the United States within the first three days of employment.


5. The professional liability insurance coverage is limited to activities that occur during, and are components of, the training PROGRAM. Protection for covered activities occurring during the training PROGRAM extends beyond the completion of the PROGRAM. The liability insurance provides coverage of at least one million dollars per occurrence and three million dollars in annual aggregate. In the event of a claim, the RESIDENT/FELLOW agrees to cooperate fully with the professional liability insurance carrier. 6. Living quarters, meals and laundry are not offered in this agreement although at times and under certain circumstances, e.g. nights on call, one or more of these benefits may be offered by an affiliated medical center. 7. Promotion and reappointment within the tenure of this AGREEMENT is contingent upon multiple factors, including (a) satisfactory completion of the expected educational and other training requirements of the PROGRAM, (b) adequate attitudinal and professional growth and behavior, (c) demonstrated ability to function at a level appropriate for the level to which he/she would be promoted or reappointed, and (d) compliance with the rules and regulations of the PROGRAM, the SCHOOL, the University, the affiliated medical centers, and with the terms of this AGREEMENT. 8. In the event of significant alterations of salary and/or benefits, e.g. associated with a promotion or other change of status, the alterations will be specified in an updated AGREEMENT or in an amendment to this AGREEMENT. 9. The SCHOOL, in conjunction with its affiliated medical centers, shall strive to provide the RESIDENT/FELLOW a training program that meets the standards of the Accreditation Council for Graduate Medical Education. 10. The RESIDENT/FELLOW agrees to perform all appropriate duties and assignments to the best of his/her ability. He/she further agrees to complete all assigned rotations, to devote clearly sufficient time to the PROGRAM, and to abide by all the rules and regulations of the PROGRAM, the SCHOOL, the University, the affiliated medical centers, and with the terms of this AGREEMENT. 11. The RESIDENT/FELLOW may be subject to disciplinary action for the pursuit of any unauthorized outside employment ("moonlighting"). This specifically includes, but is not limited to, (a) outside employment that interferes with his/her learning, teaching, patient care or other programmatic commitments, (b) outside employment conducted without a permanent Illinois medical license or in violation of his/her visa regulations (e.g. "moonlighting" on a J-1 visa), (c) outside employment without adequate professional liability insurance, or (d) outside employment that jeopardizes the reputation of the SCHOOL or its affiliated medical centers. The professional liability insurance provided by the SCHOOL or its affiliated medical centers does not cover the RESIDENT/FELLOW during "moonlighting." 12. The RESIDENT/FELLOW agrees to comply with the DUTY HOUR regulations of the PROGRAM, the SCHOOL, and the ACGME, and to cooperate with the mechanisms for implementing and monitoring compliance to the DUTY HOUR regulations. 13. Non-competition agreements (restricted covenants) are not required of, or permitted for, RESIDENTS/FELLOWS. 14. The RESIDENT/FELLOW, by signing below, acknowledges receipt of the current copy of the "Manual of Policies and Procedures for Graduate Medical Education Programs," (MANUAL) with this AGREEMENT. The MANUAL contains the most relevant policies and procedures common to the SCHOOL's graduate medical programs, including those for leaves (including leaves of absence,


annual leave, sick leave, maternity/paternity/adoption leave, military leave, bereavement leave, and leaves covered under the Family & Medical Leave Act); counseling/medical/psychological support services; physician impairment; promotion; dress code; notification and consequences of unacceptable performance, skills, knowledge, professional and personal conduct or attitude; dismissal; suspension; remedial training; fatigue monitoring and duty hour policies; patient loads; service obligations; working environment; attendance at conferences; graded supervision plans; evaluations of and by trainees; immunization recommendations; “moonlighting” policy; residents' councils; sexual and other forms of harassment; residency closure policy; restrictive covenants; gifts from industry; grievance resolution procedures; Technical Standards and compliance to the Americans with Disabilities Act; and the potential effects of leave on delaying graduation and board eligibility. The RESIDENT/FELLOW agrees to comply with the policies described in this AGREEMENT and in the accompanying and subsequent editions of the MANUAL. 15. The RESIDENT/FELLOW acknowledges that subsequent MANUALs and contracts may contain revisions, and that the current MANUAL, and its subsequent revisions, will be posted on the University’s website at www.rosalindfranklin.edu. The RESIDENT/FELLOW also agrees that his/her retention in the program depends upon his/her compliance to the rules and regulations of his specific training program, the SCHOOL, the University, and the medical centers or organizations that will employ and train him/her. The RESIDENT/FELLOW acknowledges that he/she has read the MANUAL and this AGREEMENT and will read subsequent editions as they become available, and that he/she is bound thereby. 16. The RESIDENT/FELLOW attests that he/she has completed, as stated, all of the training and administrative requirements claimed in the application process and grants permission to the SCHOOL to seek verification of any or all documents and claims attending the application process. Likewise, the RESIDENT/FELLOW grants the SCHOOL access to all information related to determining eligibility for specialty board examinations. He/she acknowledges that any false or misleading statements presented verbally or in the application or board eligibility-related materials or in other supporting documents, are sufficient cause for termination of this AGREEMENT. 17. This AGREEMENT may also be terminated by the SCHOOL if the RESIDENT/FELLOW (a) does not obtain and keep current an Illinois Medical License or (b) (if not a U.S. citizen) does not obtain and keep current appropriate visa or resident alien status, enabling him/her to work in the United States, or (c) is not or would not be successful in obtaining clearance to work in an affiliated medical center essential for the successful completion of the training program (e.g. successfully passing background checks or drug tests as required by a medical center or non-compliance to Selective Service regulations as required by a medical center) or (d) becomes incapacitated or otherwise cannot or will not perform satisfactorily the essential functions of a RESIDENT/FELLOW. 18. This agreement will not take effect until and unless signed by all of the designated signatories, or their delegates, within two months of the date of the agreement (indicated in the first sentence). If the agreement is not signed by all signatories, or their delegates, within this interval, the offer of a training position is considered withdrawn. This time restriction may be waived only by the Associate Dean for GME or by the Dean of the Medical School or by their delegates. 19. The RESIDENT/FELLOW must be ready to start his/her training by August 31st of the academic year or this agreement will be terminated. This time restriction can be waived only by the Associate Dean for Graduate Medical Education or by the Dean for the Medical School or his designee.

http://www.rosalindfranklin.edu/


SIGNATURES ____________________________________________ «FIRSTNAME» «LASTNAME», MD Date Resident/Fellow ____________________________________________ Michael J. Zdon, MD, FACS Date Designated Institutional Official (DIO) Associate Dean for GME ____________________________________________ James M. Record, MD, JD, FACP Date Dean of the Chicago Medical School


Appendix VI

TECHNICAL STANDARDS FOR GRADUATE MEDICAL EDUCATION

The Americans with Disabilities Act

The Americans with Disabilities Act (ADA), enacted in July of 1990, protects any individual with a physical or mental impairment that substantially limits that person in some major life activity and any individual who has a history of, or is regarded as having, such an impairment. Under the ADA, as with Section 504 of the Vocational Rehabilitation Act, universities and colleges are prohibited from discriminating against an otherwise qualified person with a disability in all aspects of academic life. Schools must make reasonable accommodations to accommodate the known physical or mental disabilities of otherwise qualified individuals. The University need not make an accommodation that would cause an undue burden. The philosophical basis of the ADA, that of judging persons on their abilities and achievements rather than their potential disabilities runs parallel to the traditional philosophy of this University.

In order to define the "essential requirements" of its graduate medical curriculum, the Chicago Medical School has developed a list of Technical Standards of physical, mental, and behavioral skills and capabilities essential for training and functioning in a residency or subspecialty fellowship program. In decisions on admission, evaluation, promotion, and graduation of any person, and especially an applicant or trainee with a disability, it is the obligation of the individual to meet these technical standards, with or without reasonable accommodation.

For further information on these Technical Standards and the procedures for their implementation, interested persons are encouraged to contact Ms. Rebecca Durkin, ADA Coordinator (at [847] 578-8351 or [email protected]), or Michael J. Zdon, MD, Associate Dean for GME (at [847] 578-8714 or [email protected] ).

An applicant for a position in a residency or subspecialty fellowship position, or a trainee already in such a position, must possess abilities and skills which include those that are observational, communicational, motor, intellectual-conceptual (integrative and quantitative), and behavioral and social. The use of a trained intermediary is not acceptable in many clinical situations in that it implies that the applicant’s or trainee’s judgment must be mediated by someone else's power of selection and observation, or implemented through someone else’s physical, mental or other relevant skill sets. The applicant or trainee must also be able to utilize these abilities and skills effectively over frequent and long periods of duty, e.g. up to 30 continuous hours of duty, up to 88 hours duty per week, in-house call as often as every third day, potentially no more than 10 hours between shifts, and on average up to 6 workdays per week, in accordance with accepted duty hour limitations. I. Observation:

The applicant or trainee must be able to acquire appropriate information as presented through didactic group or individual teaching methods, self-learning, and experience with patients. Furthermore, the applicant or trainee must be able to:

observe a patient accurately, at a distance and close at hand, with or without standard medical instrumentation, to acquire information from written documents, and to visualize




information as presented in images from computer and telemetry monitors, projections, paper, films, slides or video.

interpret x-ray and other graphic images, and digital or analog representations of physiologic phenomenon (such as EKGs) with or without the use of assistive devices.

Such observation and information acquisition necessitates the functional use of visual, auditory and somatic sensation while being enhanced by the functional use of other sensory modalities. In any case where a candidate's ability to observe or acquire information through these sensory modalities is compromised, the applicant or trainee must demonstrate alternate means and/or abilities to acquire and demonstrate the appropriate information in a realistic clinical setting and within a time interval sufficient for proper patient care. If the alternatives are acceptable, it is expected that obtaining and using such alternate means and/or abilities shall be the responsibility of the student. Costs of necessary accommodations should be reasonable and will be properly borne by the University or affiliated medical center(s) when not the responsibility of the student or otherwise funded.

II. Communication:

An applicant or trainee must be able to speak, to hear, and to observe patients by sight in order to elicit information, describe changes in mood, activity and posture, and perceive nonverbal communications. An applicant or trainee must be able to communicate effectively and sensitively with patients and their families. Communication includes speech and writing. The applicant or trainee must be able to communicate effectively and efficiently in oral and written form with all members of the health care team. If the applicant’s or trainee’s ability to communicate is compromised, the applicant or trainee must demonstrate satisfactory alternate means and/or abilities to communicate the appropriate information within a realistic clinical setting and within a time interval sufficient for proper patient care.

III. Motor:

It is required that an applicant or trainee possess the motor skills necessary to directly perform palpation, percussion, auscultation and other diagnostic and therapeutic maneuvers, basic laboratory tests and diagnostic and therapeutic procedures. The applicant or trainee must be able to execute motor movements reasonably required to provide general and emergency medical care such as airway management, placement of intravenous catheters, cardiopulmonary resuscitation, application of pressure to control bleeding, suturing of wounds and the performance of simple obstetrical maneuvers. Such actions require coordination of both gross and fine muscular movements, equilibrium and functional use of the senses of touch and vision. If the applicant’s or trainee’s ability to perform motor skills is compromised, the applicant or trainee must demonstrate satisfactory alternate means and/or abilities to accomplish the same tasks within a realistic clinical setting and within a time interval sufficient for proper patient care.

IV. Intellectual-Conceptual (Integrative and Quantitative) Abilities:

The applicant or trainee must be able to measure, calculate, reason, analyze, integrate and synthesize. In addition, the applicant or trainee must be able to comprehend three-dimensional relationships and to understand the spatial relationships of structures. Problem solving, the critical skill demanded of physicians, requires all of these intellectual abilities. The applicant or trainee must be able to perform these problem-solving skills within a realistic clinical setting and within a time interval sufficient for proper patient care.


V. Behavioral and Social Attributes:

The applicant or trainee must possess the emotional health required for full utilization of his/her intellectual abilities, the exercise of good judgment, the prompt completion of all responsibilities attendant to the diagnosis and care of patients, the development of mature, sensitive, and effective relationships with patients, their families, peers and other healthcare personnel. He/she must also have the skills to effectively lead a healthcare team consisting of residents, fellows, students, nurses and other healthcare personnel. The applicant or trainee must be able to tolerate physically and mentally taxing workloads and to function effectively under stress. He/she must be able to adapt to changing environments, to display flexibility, and to learn to function in the face of uncertainties inherent in the clinical problems of patients. Compassion, integrity, concern for others, interpersonal skills, interest and motivation are all personal qualities that will be assessed during the admissions and educational processes.


DISTRIBUTION AND REVIEW I acknowledge that I have received the “Manual of Policies and Procedures for Graduate Medical Programs, dated March 23, 2018 in printed or electronic format, and, as required, I will review it within the next two weeks. ________________________________________________ Name (Printed) ________________________________________________ Signature ________________________________________________ ________________________________ Training Program Date

Documents

Manual of Policies & Procedures for Graduate Medical Education …€¦ · The Medical School endorses the “Essentials of Accredited Residencies in Graduate Medical Education: Institutional