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TULANEUNIVERSITYSCHOOLOFMEDICINE

RESIDENTANDSTAFFGRADUATEMEDICAL

EDUCATIONPOLICIESANDPROCEDURES

2018-2019

AllGraduateStudentsareboundbytheUniversity’spolicies,whichcanbe

foundathttp://tulane.edu/administration/policies/

TABLEOFCONTENTS

..........................................................................................................................................

PurposeofGraduateMedicalEducation

.......................................................................................................................3

SECTION1:POLICIESONPROGRAMSIZE&COMPLEMENT

I.PolicyonResidentEligibilityandSelection

...........................................................................................................5

II.PolicyonEqual-Opportunity,AffirmativeAction,&Disabilities

..........................................................11

III.PolicyonProgramClosure,Reduction,orExpansion

.................................................................................14

IV.PolicyonDisaster/InterruptionofResidentTraining

..................................................................................16

SECTION2:POLICIESONRESIDENTSUPPORT&CURRICULUM

V.PolicyonFinancial&ResourceSupportofResidents

.................................................................................23

VI.PolicyonMoonlighting

.............................................................................................................................................

VII.PolicyonInteractingwithVendors

....................................................................................................................27

VIII.PolicyonResidents’DutyHours

.......................................................................................................................28

IX.Residents’ParticipationonInstitutionalCommittees

..................................................................................29

X.PolicyonCoreCurriculumandtheCoreCompetencies

..............................................................................31

XI.PolicyonVacationandLeave

................................................................................................................................

XII.PolicyonImmunizationandOccupationalHazards

...................................................................................38

SECTION3:SUPERVISION,EVALUATION,&REMEDIATIONOF

RESIDENTS

XIII.PolicyonSupervisionof

Residents...................................................................................................................

XIV.PolicyonEvaluationof

Residents.....................................................................................................................

XV.PolicyonRemediation,Suspension,TerminationandGrievance

.......................................................51

XVI.Residents’AssistanceProgramandResidentWellness

..........................................................................57

XVII.PolicyonSubstanceAbuse

.................................................................................................................................

XVIII.PolicyonArrest

......................................................................................................................................................

XIX.PolicyonSexualHarassment

..............................................................................................................................

XX.PolicyonElectronicCommunicationandSocialMedia

......................................................71

SECTION4:INSTITUTIONALPOLICIESANDORGANIZATIONSASIT

RELATESTO

GME

XXI.TheGMEC:Composition,Mission,&Responsibilities

.........................................................................73

XXII.PolicyonProgramEvaluation,ImprovementandAnnualProgram

Reports.....................73

XXIII.PolicyonInternalReviews

...............................................................................................................................

APPENDICIES

AppendixA.TheResidencyCongress

.......................................................................................................................83

AppendixB:WrittenStatementofInstitutionalCommitment

........................................................................91

AppendixC:SampleContract

........................................................................................................................................

AppendixD:Organizational

Charts..........................................................................................101

AppendixE:CodeCloudandCodeGreyPersonnelassignments

................................................96

AppendixF:Listofaffiliatedsitesand

accreditation...................................................96

AppendixG:AnnualEvaluationandSelf-StudyTemplate

..........................................................96

PURPOSEOFGRADUATEMEDICALEDUCATION

WelcometoGraduateMedicalEducationattheTulaneUniversitySchoolof

Medicine,the15tholdestmedicalschoolintheU.S.Afternearlytwocenturies

ofmedicaleducation,Tulaneremainsdedicatedtothedevelopmentofresidents

intheirprogressiontobecomeexceptionalphysiciansandscholars,

encompassingexcellenceineachofthecorecompetencies.

TheGMEofficeassumesstewardshipincreatingasupportiveandsafeclinical

environmentthatfacilitatesresidents’professional,ethical,andpersonal

development.TheGMEofficeensuresthateachprogram,throughcurricula,

evaluation,andresidentsupervision,ensuresaresidencytrainingthatenables

safeandappropriatepatientcare.

Tulane’sparticipatinghospitalshavebeenchosenbasedupontheireducational

merits,permittingadiverseclinicalexposure.Tulane’sfacultyhavebeenchosen

basedupontheireducational,clinicalandscientificprowess,enablingresidents

toadvancetheirpersonalandprofessionalcareers.Thereare32ACGME-

accreditedtrainingprogramsatTulaneUniversity.Theinstitutionprovides

supportforeachtrainingprogram,aswellastheeducationalinfrastructure

necessaryfortrainingineachoftheseprograms.Residentsprogressively

advanceintheirclinicalresponsibilitiesbaseduponassessedcompetency,with

closesupervisionbyTulane’sfacultyateachstageoftheirdevelopment.

Dr.JeffWiese,theAssociateDeanforGraduateMedicalEducationand

DesignatedInstitutionalOfficial(DIO)overseesallGMEactivities.Eachofthe

institution’sprogramdirectorsanswerdirectlytoDr.Wiese,andallmajor

decisionsregardinggraduatemedicaleducationarebroughtbeforetheGraduate

MedicalEducationCommittee(GMEC).Inparalleltothiscommitteeisthe

ResidentandFellowCongress,composedofrepresentativesfromeachprogram

electedbytheirpeers.TheCongressinturnelectsresidentrepresentativesto

serveontheGMEC.

IfIcanassistyouinanywayduringyouryearsoftrainingatTulanepleasedo

nothesitatetocontactme(504388-7771)oranyoneintheGraduateMedical

EducationOffice(504-988-5464).

JeffWiese,MD,FACP,MHM

AssociateDean,GraduateMedicalEducation

jwiese@tulane.edu

SECTION1:

POLICIESONPROGRAMSIZEAND

COMPLEMENT

I.POLICYONRESIDENTELIGIBILITYANDSELECTION

ThroughouttheGMEPoliciesandProcedures,theterm“resident”collectively

referstobothresidentsandfellows;“residencyprogram”collectivelyrefersto

residencyprogramsandfellowshipprograms.

A.ResidentEligibility.TobeeligibleforappointmenttotheTulaneUniversity

residencyprograms,applicantsmustmeetoneofthefollowingqualifications:

1.BeagraduateingoodstandingfromanallopathicmedicalschoolintheU.S.

orCanadathatisaccreditedbytheLiaisonCommitteeonMedicalEducation

(LCME).

2.BeagraduateingoodstandingfromanosteopathicmedicalschoolintheU.S.

orCanadathatisaccreditedbytheAmericanOsteopathicAssociation(AOA).

3.BeagraduateingoodstandingfromaofmedicalschoolsoutsideoftheU.S.

orCanadawhomeetsoneofthefollowingqualifications:

a.HavereceivedacurrentlyvalidJ-1VisasponsoredbytheEducational

CommissionforForeignMedicalGraduates(ECFMG),orbeaUSCitizen,and

haveaGraduateEducationTemporaryPermit(GETP);or

b.Haveafullandunrestrictedlicensetopracticemedicineinthestateof

Louisiana,asissuedbytheLouisianaStateMedicalBoard,or

c.BeagraduateingoodstandingfromamedicalschooloutsidetheU.S.who

hascompletedaFifthPathwayprogramprovidedbyanLCME-accredited

medicalschool.

4.TulaneUniversitydoesnotsponsorworkvisas(H1)forgraduatemedical

education.

B.ResidentSelection

1.TulaneUniversityGraduateMedicalEducationProgramsselectfromamong

eligibleapplicantsonthebasisoftheirpreparednessandabilitytobenefitfrom

theprogramtowhichtheyareappointed.Aptitude,academiccredentials,

personalcharacteristics,andabilitytocommunicateareconsideredinthe

selection.ThesecharacteristicsareaccessedbythecomponentsoftheERAS

application,ortheequivalent,includingthefollowing:theapplicant’sDean’s

letterofrecommendation,theapplicant’slettersofrecommendationfrom

faculty,theapplicant’smedicalschooltranscriptandgrades,theapplicant’s

NBMEorCOMPLEXscores,theapplicant’sscholarlyandcommunityservice

record,andtheapplicant’sevaluationfromthosewhointerviewhimorheron

thedateofhisinterviewwiththeprogram.TulaneUniversityhasasitspolicyto

considerallcandidatesforgraduatemedicaleducationregardlessofrace,sex,

creed,nationality,orsexualorientation.Performanceinmedicalschool,personal

lettersofrecommendation,officiallettersofrecommendation,achievements,

humanisticqualities,andqualitiesthoughtimportanttothedesiredspecialtywill

beusedintheselectionprocess.

2.AllTulaneUniversityGraduateMedicalEducationresidencyprograms

participateintheNationalResidencyMatchingProgram(NRMP)inselecting

residentswiththeexceptionoftheUrologyandOphthalmologyprogram,which

selectsresidentsthroughtheSanFranciscoMatchingProgram,andthe

hematopathology,cytopathology,dermatopathologyandpreventivemedicine

fellowships,whichhavenonationally-organizedmatch.

3.Allprogramsmustensurethatasamplecopyoftheresident’scontractis

availabletoallapplicantsduringtheinterviewprocess,andallprogramsmust

makeasamplecontractavailableontheirwebsite.

a.Thiscontractshouldoutlinetheterms,conditions,andbenefitsofappointment

tothetrainingprogram,eitherineffectatthetimeoftheintervieworthatwillbe

ineffectatthetimeofhisorhereventualappointment.(SeeAppendixC)

b.Informationthatisprovidedmustinclude:financialsupport;vacations;

parental,sick,andotherleavesofabsence;andprofessionalliability,

hospitalization,health,disabilityandotherinsuranceaccessibleto

residents/fellowsandtheireligibledependents.(SeeAppendixC)

C.Recruitingresidentsoutsideofthematch

1.Programsthatparticipateinanorganizedmatchareboundbytheconditions

oftheagreementwiththatentity.Noapplicantwhoisalsoapartofthe

organizedmatchcanbeacceptedintoaresidencyprogramatTulaneoutsideof

thetermsofthatmatchprocess.

2.Programdirectorswhowishtoaddadditionalresidentstotheirprogram

duringthetimeoftheyearwhenthematchisnotineffect(i.e.,off-cycle)must

sendaformalrequesttotheDIO,includingtheinformationoutlinedinChapter

III:PolicyonProgramClosure,Reduction,orExpansion.

3.Noresidentorfellowmaybeenrolledinatrainingprogramoutsideofthe

abovenotedmatchprocedureswithoutpriorapprovaloftheDIO.Aresidentor

fellowenrolledoutsideofthematchorwithoutthepriorapprovaloftheDIO,

willbethefinancialresponsibilityoftheenrollingDepartmentthroughoutthe

resident/fellow’straining,andmayresultinareductionintheprogram’smatch

numberforsubsequentyears.

4.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.

D.RecruitmentofresidentsbetweentrainingprogramsatTulane.

1.Whenapositioninatrainingprogramis,orbecomes,vacant,theprogram

mayadvertisethevacancyanditsintenttofillthepositionafterreceiving

approvalfromtheDIO.

2.Aresidentwhoisinterested,butwhoiscurrentlyundercontractinanother

Tulanetrainingprogram,mayapplyfortheopenposition.

3.Theresidentapplicantmustdisclosetotherecruitingprogramdirectorany

contractualobligationthatcurrentlyexiststohisorhercurrentprogram.The

residentmustalsodisclosetohisorhercurrentprogramdirectortheintentionto

pursuetheopenposition,4.Theprogramdirectorandfacultyfromtherecruiting

programmustrefrainfromactivelyinitiating,enticingornegotiatingwiththe

candidateuntiltheresident’scurrentprogramdirectorhasgivenapprovalforthis

communication.

5.Aletterofintenttoreleasetheresidentfromhisorhercontractualobligation

andaletterofrecommendationoutlininghisorherperformancewithrespectto

eachofthecorecompetenciesmustbeobtainedfromthecurrentprogram

directorbeforeacontractcanbeofferedtotheresidentbytherecruiting

program.

6.Thestartdatefortheresidentinthenewprogrammustbeapprovedbythe

resident’scurrentprogramdirector.

7.TheDIOwillserveasthemediatorinanysituationinwhichthetwoprogram

directorscannotreachanamicableresolutiontotheresidentwishingtoswitch

programs.

8.Failuretoabidebytherulessetforthinthissectionmayresultinareduction

intheprogram’scomplementforthefollowingyear.

E.ExtensionofContracts

1.AllresidentswhomatchtoaGMEpositionatTulanewillbesentawritten

contractoutliningthetermsandconditionsofemploymentasaresidentat

Tulane.Thiscontractwillbemailedtotheapplicantwithintwoweeksofthe

matchresults.Residentsemployedoutsideofthematchoroffcyclewillreceive

asimilarcontractwithintwoweeksofextendingtheofferforemployment.

2.Thecontractmustcomplywiththeinstitutionalrequirementsforemployment.

AlistingofthecorecomponentsoftheTulaneUniversitystandardGME

contractisprovidedbelow.Withtheexceptionofthestartandfinishdate,the

standardinstitutionalGMEcontractcannotbemodifiedwithouttheexpress

permissionoftheDIO.Thecontractshallcontainorprovideadirectlinkto:a.

Residents’responsibilities

b.Durationofappointment

c.Financialsupport

d.Conditionsforreappointment,includingcriteriafornon-renewalandnon-

promotione.Grievanceproceduresanddueprocess

f.Professionalliabilityinsurance

g.Healthanddisabilityinsurance

h.Vacation,parental,sick,andotherleave(s),includingtheeffectofleaveonthe

abilityofresidentstosatisfyrequirementsforprogramcompletion

i.DutyHourspolicies

j.Moonlightingpolicies

k.Accesstocounselingservices

l.Physicianimpairmentpolicies

m.Harassmentpolicies

n.Accommodationfordisabilities

o.Accesstoinformationrelatedtoeligibilityforspecialtyboardexaminations3.

Eachresidentcontractrequiresthesignatureoftheresident,theprogram

director,thedepartmentalchair,andtheDIO.Payrollwillnotauthorizesalary

paymentunlesstheDIOhasapprovedthecontractbysignature.

4.Contractsforallresidentsareextendedonayearlybasis.Acontractmustbe

initiatedeachyear.

5.NeithertheSponsoringInstitutionnoranyofitsACGME-accredited

programswillrequirearesident/fellowtosignanon-competitionguaranteeor

restrictivecovenant.

6.AsamplecontractisincludedinAppendixC

7.ThePGYstatuslistedinthecontractistobeassignedbaseduponthePGY

levelroutinelyheldforthatpositionintheprogram(i.e.,afirstyearresidentwill

bepaidasaPGY-1status;afirstyearcardiologyfellowwillbepaidasaPGY-4

status)regardlessoftheresident’syearsofpasttraining.

F.PolicyonCompletionofUSMLEStepExaminations

1.TheUnitedStatesMedicalLicensingExam(USMLE)STEPIICKandCS

mustbepassedpriortomatriculationintoanyTulanetrainingprogram.

2.AnapplicantwhohasfailedStepIIorStepIIIoftheUSMLEmorethanthree

times,eveniftheexaminationissubsequentlypassed,isineligiblefor

enrollmentinaTulaneUniversityresidencytrainingprogram.

3.TheUnitedStatesMedicalLicensingExam(USMLE)STEPIIImustbetaken

withinthePGY1yearofresidencytraining.Thisrequirementalsoappliesto

residentstransferringintoTulaneUniversityprogramsduringthePGY-2yearof

training;theseresidentsmusthavetakenStepIIIinordertobeeligiblefor

enrollment.

4.AnyresidentwhofailstotakeSTEPIIIbyJune30thofthePGY1yearof

trainingwillbeplacedonimmediateprobation,forwhichtheremediationwill

requireanon-paidleaveofabsence(LOA)asoutlinedwithinChapterXIV.Such

LeaveofAbsencewillremainineffectuntilSTEPIIIhasbeentakenand

supportingdocumentationisobtained.TheDepartmentalChairand/orthe

ProgramDirectorwilldeterminethemaximaldurationforwhichtheLOAwill

bepermitted;afterthatpoint,theresidentistheninviolationofhisorher

probationandimmediateterminationwillbeenacted.

5.STEPIIImustbepassedbyDecember31stofthePGY2yearofresidency

training.FailuretopassSTEPIIIbyDecember31stmayresultinaformalletter

ofnon-renewalofcontractfortheupcomingacademicyear.

6.AllresidentsmusthavepassedSTEPIIIpriortomatriculationintothePGY-3

yearoftraining.

G.ResidentsTransferringtoAnotherProgramOutsideofTulaneUniversity.

IntheeventthataresidentenrolledinaTulanetrainingprogramtransfersto

anothertrainingprogramoutsideofTulaneUniversity,theTulaneprogram

directormustprovidetotheacceptingtrainingprogramtimelyverificationofthe

resident’seducationwhileatTulane,andasummativeperformanceevaluationof

theresidentineachofthesixcorecompetencies,asoutlinedinChapterXIV.

PolicyonEvaluationofResidents..

H.ResidentsRotatingtoAnotherProgramOutsideofTulaneUniversityand

TulaneUniversity’saffiliatedinstitutions.

1.Tofulfillorexpandcurricularrequirements,Tulaneresidentsmayonoccasion

beallowedtorotatetoexternaltraininglocations.

2.Allexternalrotationsmustbeapprovedbytheresident’sprogramdirector.

3.Tomaintaintrainingcredit,thelocationmustbeanACGME-approved

traininglocation,andtherotationmustbeunderthesupervisionofanACGME-

accreditedtrainingprogram.

4.BecauseTulaneresidentsalariesandbenefits(includingmalpractice

insurance)arepaidbythehospitalatwhichheorsherotates,salaryandbenefits

arenottransferrableforrotationsoutsideofTulaneUniversity’saffiliated

institutions.

5.Residentsseekingtodorotationsatexternaltraininglocationsmustbe

responsibleforensuringthattheirsalaryandbenefits,includingmalpractice

insurance,arepaidbythereceivingtraininglocationoranotherexternalsource

forthetimetheyarerotatingawayfromTulaneUniversity.

Residentsmaychoosetoforgosalary/benefitsduringthistime,orusevacation

timetosupportthisrotation,buttheyarestillresponsibleforensuring

malpracticeinsuranceiscoveredinorderthattheymayparticipateclinicallyat

theexternalrotation.

6.TulaneUniversitywillnotauthorizethetransferofCMScapstosupport

externalrotations.

I.AuxiliaryLearners

1.Thepresenceofotherlearners(including,butnotlimitedto,residentsfrom

otherspecialties,subspecialtyfellows,PhDstudents,pharmacologystudentsand

nursepractitioners)mustnotinterferewiththeappointedresidents’education.

2.Theprogramdirectormustapprovethepresenceofallauxiliarylearners.If,in

theprogramdirector’sdiscretion,thepresenceofauxiliarylearnersdilutesor

impairsthetrainingoftheTulaneresidents,theprogramdirectorisauthorizedto

removeandprohibitsaidauxiliarylearnersfromthetrainingenvironment.

J.ExternalResidentandFellowRotators

1.ExternalRotatorsaredefinedastraineescurrentlyenrolledinanACGME-

accreditedresidencytrainingprogramwhoarenotenrolledinTulane

University’strainingprograms.

2.Thereceivingprogramdirectormustfirstapprovetheexternalrotationto

ensurethatitdoesnotdisruptordiminishtheeducationalexperienceofthe

TulaneUniversityresidents.

3.Uponreceiptoftheprogramdirector’sapproval,theDIOmustthenapprove

therotation.

4.Financialsupportofexternalrotators.

a.Theexternalrotator’ssponsoringinstitutionmustagreetofinanciallysupport

theexternalrotator,includingsalary,benefitsandmalpracticeinsurance.

b.Iftheexternalrotator’ssponsoringinstitutionisseekingCMSreimbursement

fortheexternalrotator,therespectiveGMEOfficemustarrangeaCMScap

transferwiththehospitalatwhichtherotatorwillspendhis/hertime.This

arrangementisbetweentheexternalrotator’ssponsoringinstitutionandthe

hospital;thefinancialfundsflowwillbebetweenthehospitalandtheexternal

rotator’ssponsoringinstitution.Theroleofthe8

TulaneUniversityGMEOfficeistoapprovetherotation,butnottofacilitatethe

contractbetweentherotator’ssponsoringinstitutionandthehospital.

c.Iftheexternalrotator’ssponsoringinstitutionisnotseekingCMS

reimbursementfortheexternalrotator,theexternalrotator’ssponsoring

institutionmustassumeallfinancialresponsibilityfortherotator,including

salary,benefitsandmalpracticeinsurance.

5.Theprocedureforanexternalrotatorisasfollows

a.Thereceivingprogramdirectormustapprovetherotation,asoutlinedabove.

b.TheDIOmustbeinformedofhowtheexternalrotatorwillbefunded.

c.TheDIOmustthenapprovetherotation,asoutlinedabove.

d.Thereceivingprogramcoordinatorwillberesponsiblefortheappropriate

credentialingoftherotatorfortherespectiverotation(s).Thiswillinclude:i.

Verificationofapprovalfromtherotator’ssponsoringinstitutionii.Verification

ofmalpracticeinsurance

iii.Assuringtheappropriateorientationforthehospital/clinicrotationsatwhich

he/shewillrotate.

iv.Completingappropriateforms(TBtesting,etc.)asrequiredbythehospitalat

whichhe/shewillrotate

v.ObtainingahospitalIDcard

vi.Arrangingforparking/beeperandotherrequiredamenities

vii.EnsuringtherotatorhasbeentrainedinallapplicableTulaneUniversity,and

affiliatedhospitalpolicies,including,butnotlimitedto,HIPPAtrainingand

compliance,andhasreceivedappropriateEMRtrainingfortherotationatwhich

heorshewillattend.

viii.Ensuringappropriateevaluationformsarereturnedtohis/hersponsoring

institution.

ix.Communicatingwiththehospitalatwhichtherotatorwillattendthatthe

rotatorhaswilltemporarilybeapartoftheTulaneresidencyprogramduringthis

rotation,andensuringthatthehospitalhasallnecessaryforms/credentialsas

notedabove.

e.Oncetheaboveprocedurehasbeenfulfilled,forthepurposesofhospital

credentialing,theexternalrotatorwillbeconsideredapartoftheTulanetraining

programduringthetimethathe/sherotatesatTulaneaffiliatedhospitals.All

policiesandproceduresapplyingtoTulaneresidentsincluding,butnotlimited

to,grievanceandsupervisionpolicies,willapplytotherotatorduringhis/her

timeatTulane.

f.TheTulaneGMEOfficewillnotberesponsibleforthecredentialingprocess

oftherotatorasoutlinedabove;thereceivingprogramcoordinatoranddirector

mustassumethisresponsibility.

K.ResidentsnotinACGME-accreditedprograms

1.Non-accreditedtraineesaredefinedastraineeswhohavecompletedtheir

residencyinanACGME-accreditedprogramwhoarenowseekingtoengagein

additionalclinicaltrainingforwhichthereisnoACGME-accreditedprogram

(e.g.,fellowsseekingadditionalclinicaltrainingoutsideofACGME-accredited

trainingprograms).

2.Non-accreditedtrainingmaybeextendedtotraineeswiththefollowing

provisions:a.Theapprovaloftherespectiveprogramdirectormustbeobtained

priortothenon-accreditedtrainee’spresenceontheteachingservice.The

programdirectorisresponsibleforensuringthatthenon-accreditedtrainee’s

presencedoesnotdisruptordiminishtheeducationalexperienceoftheresidents

inthetrainingprogram.

b.TheapprovaloftheDIOmustbeobtainedpriortothenon-accreditedtrainee’s

presenceontheteachingservice.

c.Credentialingofnon-accreditedtraineesistheresponsibilityofthehospital

credentialingcommittee,andnottheresponsibilityoftheGMEOffice.The

GMEofficewillprovidenoverificationoftrainingfornon-accreditedtrainees.

d.Therespectivedepartmentchairmanisresponsibleforensuringthatthenon-

accreditedtraineecomplieswithallapplicableTulaneUniversity,andaffiliated

hospitalpolicies,including,butnotlimitedto,HIPAAtrainingandcompliance.

e.Non-accreditedtraineesaretheresponsibilityofthesponsoringdepartment,

andnotoftheTulaneUniversityGraduateMedicalEducationOfficeorofanyof

TulaneUniversity’sACGME-accreditedprograms.Non-accreditedtraineeswill

notbeprovidedfinancialcompensationorbenefits,includingmalpracticeand

healthinsurance,bytheTulaneGMEoffice.

f.Therightsaffordedtotraineesinaccreditedprogramsarenottobeextendedto

non-accreditedtrainees,including,butnotlimitedto,dueprocessandgrievance.

Applicablerightsaretheresponsibilityofthesponsoringdepartment.Non-

accreditedtraineesmayberemovedfromateachingserviceatanytime,atthe

discretionoftheprogramdirectorortheDIO,iftheirpresenceisfoundto

disruptordiminishtheeducationalexperienceoftraineesinanaccredited

program.

L.Observerships

1.Observersaredefinedastraineeswhohavenotcompleted,norarethey

enrolledin,anACGME-accreditedtrainingprogram.

2.Observershipsmaybeextendedwiththefollowingprovisions:a.The

approvaloftherespectiveprogramdirectormustbeobtainedbeforeinitiationof

theobservership.Theprogramdirectorisresponsibleforensuringthatthe

observer’spresencedoesnotdisruptordiminishtheeducationalexperienceof

theresidentsinthetrainingprogram.

b.ATulaneUniversityfacultyphysicianmustagreetosponsortheobserver.He

orsheisresponsibleforensuringthattheobserverisincompliancewithTulane

GMEandotherUniversitypoliciesandprocedures.

c.TheapprovaloftheDIOmustbeobtainedbeforeinitiationofthe

observership.

d.Observersmaynotparticipateinclinicaldecision-makingorprovisionof

care.

Theobserver’sroleisaswouldbeaffordedtoamedicalstudent.

e.Therespectivesponsoringfacultyisresponsibleforensuringthattheobserver

complieswithallTulaneUniversity,andaffiliatedhospitalpolicies,including,

butnotlimitedto,HIPPAtrainingandcompliance.

f.ObserversarenotemployeesortraineesofTulaneUniversity.

i.TulaneUniversitywillnotprovidefinancialcompensationorbenefits,

includingmalpracticeinsurance,toobservingresidents.

ii.TherightsaffordedtoTulaneemployeesandtrainees,includingbutnot

limitedto,dueprocessandgrievance,arenotextendedtoobservers.

iii.Observershipsareaprivilege,andmayberevokedwithoutcauseforany

reason,includingbutnolimitedto,failuretocomplywiththestandardsnoted

above.

g.Observingresidentswillbeofferednocredittowardstrainingrequirements.

3.Programsmaynotchargeobserversforservices.

ApprovedbytheGMEC;December17th,2015

II.POLICYONEQUALOPPORTUNITY,AFFIRMATIVEACTION,AND

DISABILITYACCOMODATIONS

EQUALEMPLOYMENTOPPORTUNITYSTATEMENT

TulaneUniversityiscommittedtoprovidingequalemploymentopportunityto

qualifiedpersonswithoutregardtorace,color,sex,religion,nationalorigin,age,

disability,geneticinformation,sexualorientation,genderidentity,gender

expression,pregnancy,maritalstatus,militarystatus,veteranstatus,oranyother

statusorclassificationprotectedbyfederal,stateorlocallaw.Thiscommitment

toequalityextendstoallpersonnelactions,includingrecruitment,advertising

foremployment,selectionforemployment,compensation,performance

evaluation,andselectionfortrainingoreducation,treatmentduring

employment,promotion,transfer,demotion,discipline,layoffandtermination.

Discriminationonthebasisofanyprotectedclassificationwillnotbetolerated.

TulanemaintainsawrittenAffirmativeActionPolicy.Tulaneinvitesqualified

individualswithdisabilities,specialdisabledveterans,Vietnam-eraveterans,

ArmedForcesservicemedalveterans,recentlyseparatedveteransfromallwars,

andotherprotectedveteranswhoservedduringawarorinacampaignor

expeditionforwhichacampaignbadgehasbeenauthorizedtoidentify

themselvesiftheywishtodoso.QuestionsregardingTulane’sEqual

EmploymentOpportunityPoliciesoritsAffirmativeActionPoliciesshouldbe

directedtotheOfficeofInstitutionalEquity.Furthermore,Tulanetakes

affirmativeactiontorecruitandemployspecialdisabledveterans,disabled

veterans,recentlyseparatedveterans,otherprotectedveterans,ArmedForces

ServiceMedalveterans,inaccordancewithTheVietnamEraVeterans

ReadjustmentAssistanceActof1974,asamended,38

U.S.C.4212.

Complaintsofdiscrimination,harassmentand/orretaliationmustbefiledin

accordancewiththepoliciessetforthbelow.Individualsmustpromptlyreport

discrimination,harassmentandretaliationsothatpromptandappropriateaction

canbetaken.

ANTI-DISCRIMINATIONSTATEMENT

Tulaneiscommittedtoandencouragesadiverseandinclusivecommunitythat

respectsandvaluesindividualdifferences.Insupportofthiscommitment,

TulaneUniversityprohibitsdiscriminationinitsemploymentpracticesor

educationalprograms/activitiesonthebasisofrace,color,sex,religion,national

origin,age,disability,geneticinformation,sexualorientation,genderidentity,

genderexpression,pregnancy,maritalstatus,militarystatus,veteranstatus,or

anyotherstatusorclassificationprotectedbyfederal,stateorlocallaw.Tulane

Universitycomplieswithapplicablefederalandstatelawsaddressing

discrimination,harassmentandretaliation.Discriminationorharassmentonthe

basisofanyprotectedclassificationwillnotbetolerated.

Complaintsofdiscriminationmustbefiledinaccordancewiththepoliciesset

forthbelow.Individualsmustpromptlyreportdiscriminationsothatpromptand

appropriateactioncanbetaken.

DeborahLove,Vice-PresidentfortheOfficeofInstitutionalEquity,isTulane’s

designatedinvestigationcoordinatorfortheAmericanswithDisabilitiesAct,and

Section504oftheRehabilitationActof1973.

DeborahLoveandWendyStark,DirectorofOIE,alsoserveasDeputyTitleIX

CoordinatorsforTulane.

TheymaybecontactedattheOfficeforInstitutionalEquity,200Broadway

Street,Suite105-A,NewOrleans,LA,70118orreachedbytelephoneat(504)

862-8083.OIE’semailaddressisoie@tulane.edu.

MeredithM.SmithhasbeendesignatedastheUniversity’sTitleIXCoordinator.

Anyallegedviolationsofthesepoliciesorquestionswithrespecttosexual

misconductorsexualharassmentshouldbedirectedtoMeredithM.Smith,

OfficeofAcademicAffairs&Provost;Lavin-BernickCenterforUniversity

Life,SuiteG02,TulaneUniversity,NewOrleans,LA70118;(504)314-2160;

msmith76@tulane.edu;titleix.tulane.edu.

ApersonmayalsofileacomplaintwiththeDepartmentofEducation’sOffice

forCivilRightsregardinganallegedviolationofTitleIXbycalling(800)421-

3481orvisiting:www2.ed.gov/about/offices/list/ocr/complaintintro.html.

C.TheAmericanswithDisabilitiesAct(ADA)

TheUniversityiscommittedtoequalemploymentandeducationalopportunity

andnondiscriminationofqualifiedfaculty,students,andstaffwithphysicaland

mentaldisabilitiesinaccordancewiththeAmericanswithDisabilitiesAct

(ADA),Section504oftheRehabilitationActof1973,asamended,andstateand

locallawsandordinances.Anindividualisconsideredtohaveadisabilityifthey

haveaphysicalormentalimpairmentthatsubstantiallylimitsoneormoremajor

lifeactivities,hasarecordofsuchimpairment,orisregardedashavingsuch

impairment.

TheADAprohibitsdiscriminationagainstaqualifiedindividualwithadisability

inemploymentpracticessuchasjobapplicationprocedures,hiring,promotion,

discharge,compensation,training,benefitsandotherconditionsofemployment.

Aqualifiedindividualisonewhocanperformtheessentialfunctionsofhisor

herjobwithorwithoutareasonableaccommodation.TheADAalsorequires

thatemployersprovidereasonableaccommodationstoqualifiedindividualswith

knowndisabilities.Areasonableaccommodationisdesignedtoassistan

employeeintheperformanceofhisorherjobwithoutplacinganunduehardship

onTulaneorposingadirectthreattotheemployeeortootherindividuals.

Inaddition,Section504oftheRehabilitationActof1973statesthatno

otherwisequalifiedindividualwithadisabilityshall,solelybyreasonofhisor

herdisability,beexcludedfromparticipationin,bedeniedthebenefitsof,orbe

subjectedtodiscriminationunderanyprogramoractivityreceivingfederal

financialassistancefromtheU.S.DepartmentofEducation.

TheGoldmanCenterforStudentAccessibility(Goldman)iscommittedto

providingequalaccessandafriendlyenvironmentforallwhostudyandworkat

TulaneUniversity.Goldmanoffersaccommodationsandmodificationsofthe

academicorworkenvironmenttoqualifiedstudentsandemployeeswith

psychological,medical/physical,andlearning/developmentaldisabilities.

Goldmanhasbeendesignatedtocoordinatestudentandemployeerequestsfor

accommodations.Studentsandemployeesshouldmakeaccommodationrequests

directlytoGoldman.Itisyourresponsibilitytorequestanaccommodation.

Tulanemayrequirewrittendocumentationfromyourhealthcareproviderwith

knowledgeofyourlimitations.

Concerningemployees,ifGoldmannotifiestheOfficeofHumanResource

(OHR)thatanaccommodationhasbeenapproved,implementationofthe

accommodationwillbehandledbytheemployee’sdepartment.

Ifyourequestedandweregrantedanaccommodation,youmustreportchanges

inyourongoingneedforaccommodation.Goldmanstaffmaybecontactedat

http://www2.tulane.edu/studentaffairs/support/accessibility/index.cfm.

TheUniversityhasadoptedaninternalgrievanceprocedureprovidingfor

promptresolutionofcomplaintsallegingviolationoftheUniversity’sADA

policy.Ifyouhaveconcernsregardingdenialofareasonableaccommodationor

thespecificaccommodationselectedbytheUniversity,youareencouragedto

reviewtheprocesswithGoldman.Intheeventyoudisagreewiththe

determinationorproposedaccommodationorbelieveyouhavebeen

discriminatedagainstbasedonadisability,youshouldcontacttheOfficeof

InstitutionalEquityat(504)862-8083,locatedat200BroadwayStreet,Suite

105-A,NewOrleans,LA,70118,orfileareportonlineat:

www.Tulane.edu/concerns.

D.IndividualswithdisabilitiesmayapplytoTulaneresidencytrainingprograms.

Eachprogramisrequiredtohaveajobdescription,outliningtheminimum

mentalandphysicalrequirementsofthetrainingprogram.Applicantswith

disabilitieswillnotbediscriminatedagainstprovidedtheymeettheminimum

jobrequirementsoutlinedintheprogram’sjobdescription.

TITLEIX

ItisthepolicyofTulaneUniversitytocomplywithTitleIXoftheEducation

Amendmentsof1972,whichprohibitsdiscrimination(includingsexual

harassmentandsexualmisconduct)basedonsexintheUniversity'seducational

programsandactivities.TitleIXalsoprohibitsretaliationforassertingclaimsor

sexdiscrimination.TulanehasadesignatedTitleIXCoordinator.TheTitleIX

CoordinatoroverseestheUniversity’scentralizedreview,investigation,and

resolutionofreportsofsexdiscrimination,includingsexualharassmentand

violence.

MeredithM.Smith,TitleIXCoordinator

TulaneUniversityTitleIXOffice

Lavin-BernickCenter,SuiteG03NewOrleans,LA70118

msmith76@tulane.edu(504)865-5615

Faculty,StafforStudentsmaycontactthefollowingforinformation:Deborah

Love,DeputyTitleIXCoordinatorTulaneUniversity

OfficeofInstitutionalEquity200Broadway,Suite105ANewOrleans,LA

70118dlove1@tulane.edu(504)862-8083

WendyStark,DeputyTitleIXCoordinatorTulaneUniversity

OfficeofInstitutionalEquity200Broadway,Suite105ANewOrleans,LA

70118wstark@tulane.edu(504)862-8083

EricaWoodley,DeputyTitleIXCoordinatorforStudentAffairsTulane

UniversityDivisionofStudentAffairs6823St.CharlesAvenue

Lavin-BernickCenterforUniversityLife,RoomG03NewOrleans,LA70118

ewoodley@tulane.edu(504)314-2188

ApprovedbytheGMEC;November29th,2017

III.POLICYONPROGRAMCLOSURE,REDUCTIONOREXPANSION

A.ProgramReduction:

1.Shouldanaffiliatedtraininglocationcloseorreducethefundingofresidency

positions,anattemptwillbemadetorelocateaffectedresidentstoother

affiliatedtraininglocationsthatmeettheeducationalrequirementsforthe

resident’straining.

2.Shouldappropriateeducationalopportunitiesorfundingnotbeavailable

amongTulaneaffiliates,anditthusbecomesnecessarytoreducethenumberof

residencypositionsintheaffectedprogram,theresidentsoftheaffectedprogram

willbeinformedassoonaspossible.

a.Ifeducationalopportunitiesaresufficientforareducedcomplementof

residents,butnotforthecurrentcomplementofresidents,theprogramwillfirst

attempttoreducetheprogram’ssizebysequentiallydecreasingtheincoming

matchclasstotheprogram.

b.Ifthisisstillinsufficienttobringtheprogramtoaright-sizeforthe

educationalopportunitiesthatdoexist,theDIOwillworkwiththeprogram

directorinassistingcurrentresidentsinfindingatrainingpositionatanother

ACGME-accreditedprogramsuchthattheirtrainingmaycontinue.

c.Noresidentwillbereleasedfromemploymentduetofinancialexigencyuntil

anothertrainingpositionatanotherACGME-accreditedprogramisascertained.

B.ProgramClosure

1.Ifitbecomesnecessarytocloseaprogram,theresidentsalreadyinthe

affectedprogramwillbeinformedassoonaspossible.

2.Theresidentsintheaffectedprogramwillbeallowedtocompletetheir

educationatTulaneaslongaseducationalopportunitiesconsistentwith

accreditationcontinuetoexist.

3.Ifsucheducationalopportunitiesdonotexist,theDIOandtherespective

programdirectorwillassisttheresidentsinenrollinginanotherACGME-

accreditedprograminwhichtheycancontinuetheireducation.

4.Noresidentwillbereleasedfromemploymentduetofinancialexigencyuntil

anothertrainingpositionatanotherACGME-accreditedprogramisascertained.

5.Programclosureduetoaninstitutional-leveldisasterisaddressedinChapter

IV.PolicyonDisaster/InterruptionofResidentTraining.

C.ProgramExpansion

1.Expansionofaresidency’scomplementisbaseduponapprovalbythe

ACGME,andupontheeducationalopportunitiesaffordedbytheresidency

program.Thefollowingrequirementsmustbemetinordertorequestexpansion

ofaresidencyprogram.

2.ArequestmustbemadeinwritingtotheDesignatedInstitutionalOfficial.The

requestmustincludethefollowing:

a.Thecurrentresidentcomplementintheprogram,theACGMEresidency

complementcapfortheprogram,therequestednumberofexpansionpositions,

andaprospectusoftheprogram’ssizeforeachofthefuture“x”numberof

years.“X”isdefinedasthedurationoftheresidencyprogram.

b.Cleardelineationofeducationalrationaleforanincreaseincomplement.

Include:i.Theeducationalopportunities(patientvolume)thatnowexistthatdid

notpreviouslyexistfortheresidentsinthetrainingprogram.

ii.Thefacultysupervisionthatnowexiststhatdidnotpreviouslyexistforthe

residentsinthetrainingprogram.Includeacurrentfacultylistfromthe

program’sWebADS.

iii.Theimpacttheexpansion,orfailuretoexpand,willhaveuponcurrent

residents’education.Thisshouldincludecommentaryonhowtheexpansionwill

orwillnotdilutetheeducationalexperienceofotherresidentscurrentlyinthe

program,andincludetheimpactexpansionmayhaveonworkhoursregulations

asitregardscurrentresidents.

iv.Thisshouldincludeacurrentrotationschedulefortheresidents,anda

prospectusofhowthisrotationschedulewouldchangewithadditionalresidents.

c.CaseLogsandProcedures.IftheprogramisrequiredbytheRRC/ACGMEto

submitcaselogsforboardcertification,includethefollowing:

i.Currentresidentscaselogs.

ii.Thelastsetofgraduatingresidentscaselogs

iii.Institutionaldataforfacultyprocedures(fromparticipatingsites)iv.

Commentaryonhowsufficientcaselogswillbefulfilledforallresidentsinthe

programwiththeproposedexpansion

d.ThemostrecentACGMEaccreditationletter,includingcitationsandthe

program’sresponsetothesecitations.Includeastatementofhowtheresident

expansionwillaffectthesecitations.

e.ThemostrecentACGMEresidentsurvey.

f.Aprospectusonhowtheadditionalresident(s)willbefunded.

3.CompletedapplicationswillbebroughtbeforetheGMECwitha

recommendationfromtheDIOforeitherexpansionordenialofexpansion.The

GMECwillvoteupontheproposal4.Theprogramdirectormaynotappoint

moreresidentsthanapprovedbytheACGMEReviewCommittee.The

program’seducationalresourcesmustbeadequatetosupportthenumberof

residentsappointedtotheprogram.Programdirectorsmaysubmittheabove

informationtotheDIO’sofficeasaproposedrequesttopetitiontheACGMEfor

anexpansionintheirresidencycap.IftheaboveisapprovedbytheDIOandthe

GMEC,theDIOwillendorsethepetitioninconcertwiththeprogramdirectorto

theACGME.IftheACGMEsubsequentlyapprovestheincreaseincap,theDIO

andtheGMECwillconsidertheproposalprovidedthatadequatefinancial

resourcesareavailable.

ApprovedbytheGMEC;August17th,2011

IV.POLICYONDISASTER/INTERRUPTIONOFRESIDENCYTRAINING

A.SubjecttoTulaneUniversitySchoolofMedicine’spolicyregardingclosures

andreductionsoftrainingprograms,intheeventofadisasteroraneventthat

causestheinterruptionofresidenttraining,,theTulaneUniversitySchoolof

Medicinehasadoptedthefollowingpolicyrelatedtoitsresidents.

1.TheOfficeofGraduateSchoolMedicalEducationwillannually

collect/updateemergencycontactinformationfromallHouseOfficerseach

spring.

2.TheGMEofficewillannuallysendoutemailstoresidentswithemergency

information.

3.Tulanewillcontinuetoprovideadministrativesupportthatmayinclude

continuedpaymentofsalaryandbenefitsdependingontheoverall

circumstances,scopeanddurationoftheEmergency,subjecttoTulane’sPolicy

onResidencyTrainingProgramClosureorReduction.

4.IntheeventofanEmergency,TulanewillworkcloselywiththeACGMEand

otheraccreditingbodiestoensurethatminimalinterruptionoccursinaHouse

Officer’strainingexperienceandthatHouseOfficersaretransferred(ifneeded)

temporarilyorpermanently,tonewsites.

5.IntheeventofanEmergency,Tulanewillassess,inconsultationwiththe

appropriateaccreditingbodies,whethercertainprogramsmayneedtobe

temporarilyorpermanentlywithdrawninordertoensureaqualitytraining

experience.

B.Hurricane-specificPolicies

1.HurricaneWatch-

a.UponaHurricaneWatch,theGMEofficewillensurethatallfilesrelatedto

currentresidentsareportableviaelectronicstorage.Thiswillinclude

informationvitalforresidentandfellowcredentialing,licensingandtransfer.

b.TheGMEofficewillcontacteachresidencyprogramadministrator.Theoffice

willensurethateachprogramcoordinatorhasaportableelectronicversionofall

resident/fellowfilescontaininginformationvitalforresidentandfellow

credentialing,licensingandtransfer.Theofficewillensurethattheprogram

administratorhasup-to-dateemergencycontactinformationforeachresident,

includinganon-universityemailaccountthroughwhichtheresident/fellowcan

becontactedintheeventofanemergency.

c.TheDIOwillcontacteachprogramdirectorandconfirmthattheprogram

directorhascommunicatedthewarningtohisorherresidents.Forapplicable

programs,theDIOwillensurethattheprogramdirectorispreparedtoactivate

hisorherprogram’sCodeGreyorCodeCloudplan.

2.CodeCloud(TropicalStormorHurricaneCategory1or2)

a.ACodeCloudwillbecalledforanimpendingTropicalStorm,orCategory1

or2

Hurricane.

b.UponactivationofaCodeCloud,thehospitaladministrationswillnotifythe

DeanandtheDIO.

c.TheDIOwillthencontacteachprogramdirectorandthedepartmentchairand

instructhimorhertoprovidethenamesoftheindividuals,asspecifiedbelow,

whowillbeprovidingcoverageonthedayoftheCodeCloudactivation,andthe

dayfollowingtheCodeCloudactivation.

d.TheDIOwilltheninformthehospitalsofthepersonnelwhowillbeproviding

coverage.

e.PrinciplesoftheCodeCloud

i.ThegoaloftheCodeCloudCoverageistoensuretheon-goingoperationof

thehospitalfortwodayssurroundingthestorm,withoutburdeningthehospital

withexcessivestafforresidents.

ii.ThepresumptionunderlyingtheCodeCloudisthataccesstothehospital

immediatelyfollowingthestormmaybeimpaired;ensuringthenextday’s

clinicalserviceswillbeaddressedproactivelybyhousingthenextday’steamsin

thehospitalpriortothestorm.

iii.AsopposedtoaCodeGrey,aCodeCloudassumesthatthedamagefromthe

stormwillnotbesufficientlyseveretowarrantmandatorycityevacuations,nor

prolongedhospitalstaysforthefacultyandstaff.Assuch,thereisagreater

degreeofcomfortinselectingresidentsandfacultywhoarealreadyonthecall

schedule.

iv.Stayingwiththecallscheduleensuresalessdisruptiveandmoreeffect“re-

entry”

followingthestorm’sabatement(i.e,residents’callcyclefrequencyandduty

hoursarenotdisrupted).

f.WhiletheCodeCloudCoverageoperatesonpre-existingcallschedule

coverage,programdirectorsandchairsshouldmakesuitablesubstitutionsfor

personnelwho,duetolifeissues(i.e.,childcare,etc.),cannotaffordtobeinthe

hospitalfor48hours.

g.Essentialservices

i.Residentson-callforessentialservices(asdefinedbelow)willreportonthe

dayoftheactivationoftheCodeCloud(astheyordinarilywould),andwillbe

providedhousingonthedayofcall,andthedayfollowingcallintheeventthat

theycannotreturnhomefollowingthestorm.

ii.Residentsthatarepre-callforessentialservices(asdefinedbelow)willalso

reportonthedayoftheactivationoftheCodeCloud(theirpre-callday),and

willbeprovidedhousingonthedaypriortotheircallday,andthedayoftheir

callday.

iii.Essentialserviceswillincludethefollowing.Personnelfortheseserviceswill

consistofthepreviouslyscheduledon-callteam,thepre-callteam,andfaculty

forthesetwoteams.AlistingofCodeClouddepartmentalassignmentsisin

AppendixE

a.Generalinternalmedicine

b.Intensivecaremedicine

c.Generalsurgery

d.Generalpediatrics(Lakesideonly)

e.PediatricICU(Lakesideonly)

f.OB/Gyn(Lakesideonly)

h.PrecautionaryServices.Servicesforwhichthehospitalmusthaveaccess,but

arenotimminentlynecessary,willbeprovidedbyfaculty(atthenumberslisted

below)butnotresidents.Theseservicesincludethefollowing.AlistingofCode

ClouddepartmentalassignmentsisinAppendixE

i.Ophthalmology(willsign-outtheirpatientstotheGeneralSurgeryService)(1

facultyatTulane;1facultyatUMC/VA)

ii.Urology(willsign-outtheirpatientstotheGeneralSurgeryService)(1

facultyatTulane;1facultyatUMC/VA)

iii.Orthopaedics(willsign-outtheirpatientstotheGeneralSurgeryService)(1

facultyatTulane;1facultyatUMC/VA)

iv.Otolaryngology(willsign-outtheirpatientstotheGeneralSurgeryService)

facultyatTulane;1facultyatUMC/VA)

v.Neurosurgery(willsign-outtheirpatientstotheGeneralSurgeryService)(1

facultyatTulane)

vi.Nephrology(1facultyatTulane;1facultyatUMC/VA)

vii.Gastroenterology(1facultyatTulane;1facultyatUMC/VA)viii.

Interventionalcardiology(CCUteamswillsignouttheirpatientstothemedical

ICUService.(1facultyatTulane;1facultyatUMC/VA)

ix.InterventionalRadiology(1facultyatTulane)

x.DiagnosticRadiology(1facultyatTulane)

xi.Anesthesia(2facultyatTulane)

i.Non-essentialserviceswillnothaveresidentsorfacultypresent,butfaculty

willbeavailablefortelephoneconsultation.Theseinclude:

i.PathologyandPathologyFellowships

ii.Psychiatry

iii.Allergy/Immunology

iv.Endocrinology

v.InfectiousDiseases

vi.ChildPsychiatry

vii.PreventiveMedicine

viii.Neurology(willsign-outtheirpatientstotheGeneralMedicineService)ix.

Hematology/Oncology(willsign-outtheirpatientstotheGeneralMedicine

Service)

x.Dermatology

xi.Hepatology(willsign-outtheirpatientstotheGeneralSurgeryService)j.

Callroomswillforallin-housepersonnelwillbeassignedproactivelyaheadof

theCodeCloudactivation,andwillbeon-filewiththeDIO.

k.Oncethestormhaspassedandaccesstothehospitalisassuredtobesafe,the

CodeCloudwillbelifted.HospitalleadershipwillinformtheDIO,whowill

theninformtheresidentsandfaculty.Accesstothehospitalswillbeallowedfor

allpersonnelasitisdeemedtobesafe.

3.CodeGreyArmy(HurricaneCategory3orabove)

a.ACodeGreywillbecalledforanimpendingHurricaneCategory3orabove.

b.UponactivationofaCodeGrey,thehospitaladministrationswillnotifythe

DeanandtheDIO.

c.TheDIOwillthencontacteachprogramdirectorandthedepartmentchairto

ensurethatthepreviouslyprovidednamesfortheCodeGreyArmy(asprovided

onJuly1stofeachacademicyear)areaccurate.

d.TheDIOwilltheninformthehospitalsofthepersonnelwhowillbeproviding

coverage.

e.PrinciplesoftheCodeGreyArmy

i.ThegoaloftheCodeGreyArmyistoensuretheon-goingoperationofthe

hospitalforthreetofourdayssurroundingthestorm.

ii.LikeaCodeCloud,thegoalistoprovidenecessarypersonwithoutburdening

thehospitalwithexcessivestafforresidents.UnlikeaCodeCloud,itispossible

thatallpersonnelwillrequireevacuation,andwillconsumemoreresources

(food,water)becauseofaprolongedhospitalstay.Assuch,itisimperativethat

thenecessarynumberofpeoplearepresent,butnotmorethanthat.

iii.ThepresumptionunderlyingtheCodeGreyisthataprolongedhospitalstay

istobeexpected.Assuch,CodeGreypersonnelshouldbeproactivelyselected

suchthattherightpersonnelcapableofhandlingtheassignmentarechosen.

EachprogramistochoosepersonnelfortheCodeGreyArmybyJuly1stof

eachacademicyear.

iv.AsopposedtoaCodeCloud,aCodeGreyassumesthatthedamagefromthe

stormwillbesufficientlyseveretowarrantmandatorycityevacuations.Because

allpersonnelontheCodeGreyArmyhavebeenproactivelychosen(asofJuly

1stofeachacademicyear),residentsnotontheCodeGreyArmythereforehave

theluxuryoftimelyandsafeevacuationfromthecity.

v.BecauseaCodeGreyArmyassignmenthasareasonableprobabilityof

executingpatientevacuations,theCodeGreyArmyshouldbeselectedin

sufficientadvancetobecometrainedinthehospitalpoliciesregardingpatient

evacuationpoliciesandprocedures.

f.ThegoaloftheCodeGreyArmyistoensuretheemergentoperationofthe

hospitalforupto4dayssurroundingthestorm.Becausethiswillbeanextended

tourofduty,programsanddepartmentsmustproactivelychoosepersonnelfor

thisassignment(i.e.,personnelshouldnotbeassignedarbitrarilybywhoison

serviceforthatmonth,orwhoisoncallforthosedays).

Directorsandchairsshouldfollowthefollowingprinciplesinselecting

personneli.Noresidentmaybeconscriptedintoservice.Onlyresidents

volunteeringfordutyshouldbeselected.

ii.Itispreferabletonotchooseresidentsandfacultywithdependentchildrenor

adultswhosehospitalserviceduringtheCodeGreywouldthusbecompromised

becauseofconcernsfortheirfamily.

iii.Itispreferabletonotchooseresidentsandfacultywithmedicalissuesthat

couldbecompromisedbyanextendedstayinthehospital

iii.TheGMEofficerecognizesthatnoteveryresidentisequallypreparedto

enduretheresponsibilitiesrequiredofdisasterduty.Fromthepoolofvolunteers,

thedirectorandchairshouldchoosepersonnelwhotheybelievewillhavethe

mentalstaminatoendureuptofourdaysinthehospital.

iv.InternsshouldnotbechosenforCodeGreyassignments;bydefinitionofthe

hurricaneseason(July-November),theywilllacksufficientfamiliaritywiththe

hospitalsystem,andcannotprovidethenecessaryproceduresthatupper-level

residentscanperform.

v.Programsshouldanticipatethatthoseselectedtobeonthedisasterteammight

notbeavailableduringthedisaster(duetovacations,etc.).Programsshould

selectandtraintwopeopleforeachpositiontowhichtheyareassigned.Those

notassignedduringanemergencysituationwillconstitutethe“ReliefTeam”as

outlinedbelow.ProgramsarerequiredtosubmittheirCodeGreyrostertothe

GMEOfficepriortotheonsetofhurricaneseason(July1st).

g.Essentialservices.Essentialserviceswillincludethefollowing.Personnelfor

theseserviceswillconsistofthepreviouslyscheduledon-callteam,thepre-call

team,andfacultyforthesetwoteams.AlistingofCodeGreyArmy

departmentalassignmentsisinAppendixE.

a.Generalinternalmedicine

b.Intensivecaremedicine

c.Generalsurgery

d.Generalpediatrics(Lakesideonly)

e.PediatricICU(Lakesideonly)

f.OB/Gyn(Lakesideonly)

h.PrecautionaryServices.Theseareservicesforwhichthehospitalmusthave

access,butarenotimminentlynecessary.Asageneralrule,surgicalserviceswill

consolidatetheirpatientsontothegeneralsurgeryserviceforon-going

managementthroughthehurricane;neurologyandmedicalsubspecialtyservices

willconsolidatetheirpatientsontothegeneralmedicineserviceforon-going

managementthroughthehurricane.AlistingofCodeGreyArmydepartmental

assignmentsisinAppendixE

i.Ophthalmology(willsign-outtheirpatientstotheGeneralSurgeryService)ii.

Urology(willsign-outtheirpatientstotheGeneralSurgeryService)iii.

Orthopaedics(willsign-outtheirpatientstotheGeneralSurgeryService)iv.

Otolaryngology(willsign-outtheirpatientstotheGeneralSurgeryService)v.

Neurosurgery(willsign-outtheirpatientstotheGeneralSurgeryService)vi.

Nephrology

vii.Gastroenterology

viii.Interventionalcardiology(CCUteamswillsignouttheirpatientstothe

medicalICUService).

ix.InterventionalRadiology

x.DiagnosticRadiology

xi.Anesthesia

i.Non-essentialserviceswillnothaveresidentsorfacultypresent,butfaculty

willbeavailablefortelephoneconsultation.Theseinclude:

i.PathologyandPathologyFellowships

ii.Psychiatry

iii.Allergy/Immunology

iv.Endocrinology

v.InfectiousDiseases

vi.ChildPsychiatry

vii.PreventiveMedicine

viii.Neurology(willsign-outtheirpatientstotheGeneralMedicineService)ix.

Hematology/Oncology(willsign-outtheirpatientstotheGeneralMedicine

Service)

x.Dermatology

xi.Hepatology(willsign-outtheirpatientstotheGeneralSurgeryService)j.

TheActivationTeam.Onceahurricanewarninghasbeencalled,theActivation

Teamwillbedeployedtotheirrespectivestations.Allotherresidentswillsign-

outtheirpatientstotheactivationteamresidents,andthendepartthecity.Ifa

fullevacuationofallpatientsinthehospitalisrequired,theActivationTeam

willsequentiallyaccompanytheevacuatedpatientstoevacuationcentersper

hospitalprotocol.

k.TheReliefTeam.Eachprogramwillbeaskedtoproactivelyassignresidents

andfacultytoaReliefTeam.Forsimplicity,thecompositionofthereliefteam

shouldmatchtheactivationteam.

Internsmaybeusedforthereliefteam.OnceaCodeGreyhasbeencalled,the

ReliefTeamwillbeginpreparationstoevacuatetoJackson.Mississippi.Hotelor

dormatoryroomswillbeprovidedbytheUniversityfordesignatedReliefTeam

members.

i.ReliefteammemberswillremaininJackson,MS,untiltheyareactivatedto

returntoNewOrleans.Atwhichtime,thereliefteamwillconvoytoNew

Orleans.

ii.TheActivationTeamwillsubsequentlyberelievedoftheirduties.The

ActivationTeamwillconvoytoJackson,MS,unlessthecityhasbeendeemed

safeforinhabitation,inwhichcasetheywillbefreetoreturntotheirhomes.

iiiIfafullevacuationofallpatientsinthehospitalisrequired,theReliefTeam

willbedirectedtoevacuationcenterstoproviderelieffortheactivationteam.

l.AswithaCodeCloud,programdirectorsandchairswillinstructallstudents,

residents,andfacultywhohavenotbeendesignatedastheCodeCloudArmyto

stayawayfromthehospitalfacilitiesuntiltheCodeGreyhasbeenlifted.

4.Allprogramsarerequiredtoprovideemergencycontactinformation(cell

phonenumbers,secondaryemailaddresses,andpreferredrelocation

destinations)forallresidents.

ApprovedbytheGMEC;July17th,2012

SECTION2:POLICIESONRESIDENT

SUPPORT&CURRICULUM

V.POLICYONFINANCIAL&RESOURCESUPPORTOFRESIDENTS

A.ParkingisprovidedforresidentsassignedtoUMC,TMC,andSLVHCS

(VANO)atthedowntownmedicalcampus,andthroughindividualaffiliated

traininglocationsasspecifiedinaffiliationagreements.

1.Allresidentswillbeprovidedparkingatthedowntownmedicalcampus.

2.SelectprogramswillbeprovidedadditionalparkingforresidentsatUMCand

theSLVHCS(VANO).

a.Thesepositionsareprioritizedforprogramsthathave:

i.Prolongedshiftsinthehospital(wherebytheywouldbeleavingatoddhours

ofthenightwhentheshuttlesdonotrun),

ii.Programsthatarealreadyupagainstthe80hour/weekdutylimit,suchthat

waitingforshuttlesontheafferentandefferentsideoftransportationwouldrisk

non-compliancewiththe80hourlimit.

3.ForresidentsthatdonothaveadditionalparkingatUMCandtheVA,ashuttle

servicewillbeprovidedthatrotatesonadowntown-onlycampusloop.

a.Shuttletimescanbefoundat

http://www2.tulane.edu/universityservices/transportation/medical-loop.cfmb.

ResidentscanaccesstheSmartTraxxappforreal-timeGPSshuttlelocationsand

theTAP-RIDEapp,whichenablesaresidenttorequestashuttlewhenneeded.

c.AllresidentswillbeprovidedtheRaveGuardianapp,enablingresidentsto

requestavirtualsafetyescortregardlessofmethodoftransportation.

http://www2.tulane.edu/universityservices/transportation/index.cfm4.Residents

comingintotheVAorUMCafterhours,orthoseonaservicewheretheyare

emergentlycalledovertothehospitalforanemergentprocedure/operation.can

stopbythesecuritydesknexttotheEDandgettheirparkingvalidatedforafree

exit.Andifyouareonayoucanalsohavetheparkingticketvalidated.

B.Pagersareprovidedforthedurationoftheresidencies.Eachresidentis

responsibleforreturningthepageratthecompletionorterminationoftraining;a

seventy(70)dollarchargewillbeaccessedforlostofstolenpagers.

TheGMEOfficeprovideseachprogramwithanadequatenumberofpagers;

distributionistheresponsibilityoftheprogramcoordinators.

C.TechnologyServicesSupport.TulaneUniversityhasadedicatedofficefor

freeinformationalandtechsupportforallresident/facultycomputer

questions/assistance,availablethroughtheTechnologyServicesHelpDesk(988-

8888).

1.Eachresidentisgivenanemailaccountandpassword,providingtwenty-four

houraccesstoeducationalmaterialsontheTulaneUniversitywebsite,including

on-linestreamingvideoofimportantlecturesandtheTulaneLibrary.Through

theTulaneLibrarywebsite,residentshave24-houraccesstoUp-to-Date,

Medline,Ovid,DynaMedProgram,andExammaster.Theseservicesprovide

accesstofull-textjournalsubscriptionsaswellasotheron-linemedical

textbooks,providingaccesstospecialty-specificandotherappropriatereference

materialinprintaswellaselectronicformat.

2.On-lineevaluationservicesareprovidedatnochargeforeachresident,

allowingfortheconvenienceofat-homeevaluationreviewandcompletion.

3.EachresidentisprovidedHIPAAtrainingasapartoftheorientation,andafter

completingthistraining,canreceiveadditionaltrainingatnocosttolearnhow

toaccesstheelectronicmedicalrecordsofthethreeprimarytraininglocationsat

Tulane:UMC(EPIC),TMC(MeditechandE-ClinicalWorks)andTheVA

(CPRS).Forresidentsenrolledoff-cycle,itistheresponsibilityofthesponsoring

trainingprogramtoensurethattheresidenthasreceivedappropriateHIPPA

trainingateachclinicalinstitutionthroughwhichheorshewillrotate.

4.Eachcallroomistocontainatelephoneandacomputer,toensure24-hour

accesstothemedicalliteratureandeducationalresourcesnecessaryforoptimal

learningandpatientcare,aswellasaccesstotheelectronicmedicalrecordofthe

hospitalinwhichtheresidentisprovidingpatientcare.

D.Eachhospitalinwhichresidentsperforminpatientandhome-callcaremust

havethefollowingcomponents:22

1.Safe,quiet,andprivatesleep/restfacilitiesforthoseresidentsoncall.Each

callroommusthaveaccesstoacomputerandatelephone.

2.Eachfacilitymustoffer24-houraccesstofoodforthoseresidentswhoareon-

dutyatthatlocation.

3.Securityandsafetymeasuresappropriatetotheparticipatingsite.

E.SimulationCenter.EachresidentisofferedaccesstoTulaneUniversity’s

simulationcenteratnoadditionalcost.

F.HealthInsurance-healthinsuranceisprovidedtoresidentsatnocost.Family

healthcoverageisavailableatanadditionalcosttotheresident.Health

insuranceeligibilityisavailabletotheresidentonthefirstdatethattheresident

istoreportforemployment,asspecifiedintheresidentcontract.

G.Optionaldentaland/orvisioninsuranceisavailabletoresidentsandtheir

familiesasanoptionalexpense.

Dentalandvisioninsuranceeligibilityisavailabletotheresidentonthefirstdate

thattheresidentistoreportforemployment,asspecifiedintheresidentcontract.

H.Life&DisabilityInsurance-A$25,000lifeinsurancepolicyisprovidedatno

costtoresidents.Supplementalinsurancemaybepurchasedbytheresident.

Disabilityinsuranceisprovidedatnocosttotheresidents.Lifeanddisability

insuranceeligibilityisavailabletotheresidentonthefirstdatethattheresident

istoreportforemployment,asspecifiedintheresidentcontract.

I.MalpracticeinsuranceisprovidedatnocosttotheresidentsthroughtheOffice

oftheGeneralCounsel.TulaneresidentsareincludedintheSelf-InsuranceTrust

Programforprofessionalliabilitycoverage(OccurrenceCoverage).Underthe

followingcircumstances,thiscoverageissecondarytocoveragethatis

otherwiseprovided.

Officialdocumentationofthedetailsofliabilitycoverageareavailabletothe

residentattherequestoftheindividual.Anyquestionsaboutthecoverage

addressedbelowcanbeaddressedtotheDirectorofRiskManagementfor

TulaneUniversity(504-865-5783)orTheOfficeofAssociateGeneralCounsel

fortheHealthSciencesCenter(504-988-5031).

1.PrivateHealthcareInstitutionsWithintheState.UndertheTulanecoverage,

thefirst$100,000iscoveredbyTulane,theremaining$400,000(uptothe

statutorylimitof$500,000)isprovidedthroughthePatient’sCompensation

Fund.Asasafetynetincasethestatutorycapisremoved,theTulaneSelf-

InsuranceTrustprogramprovidesanadditional$900,000coverageundera

separatepolicy.ThecoverageprovidedbyTulanethroughitsSelf-Insurance

TrustandthroughthePatient’sCompensationFundisanoccurrence-based

coverageandthereforewhenresidentsleaveTulane,notailcoveragewouldbe

required.

2.RotationsatState-operatedFacilities.Residentsareprovidedcoverage

throughtheStateMalpracticeProgram.Thisisstatutorycoveragethatprovides

thathealthcareproviders,includingresidents,whotreatpatientsatanyofthe

stateinstitutionsareconsideredStateemployeesandtheStateisliablefortheir

conduct.UMCisnowaprivately-operatedfacilityand,therefore,theabove

provision#1willapply.

3.VeteransAdministrationRotation.ThoseResidentsonrotationwithintheVA

systemareconsideredcoveredundertheFederalTortClaimsActandtherefore

wouldbeimmunefromanypersonalliability.Inthosesituations,thefederal

governmentisobligatedtoprovidethecostofdefenseandthesatisfactionofany

judgmentsand/orsettlements.

4.Inalloftheabovecases,insuranceisavailabletotheresidentonthefirstdate

ofemployment,asspecifiedintheresidentcontract.

5.OutofStateRotations.Theprimarycoverageisdeterminedpursuanttothe

affiliationagreementbetweenTulaneandtheaffiliateinstitution.Residents

wouldhaveprimarycoveragebytheTulaneprogram,whichincludesaSelf-

Insurancecomponentand/orcoverageunderacommercialinsurancepolicy

purchasedbytheUniversity.

6.Moonlighting.Tulanedoesnotprovideanycoverageformoonlighting

activitiesofaresident.

J.Vacations&EducationalLeave-Withtheapprovaloftheprogramdirector,

educationalleaveisallowedinsomeprogramsasoutlinedinPolicyonVacation

andLeaveEachresidentisallowednolessthanthree(3)weeksofvacationper

academicyear.Additionalweeksareatthediscretionoftheeachresidency

program.

K.Stipend-2017-2018annualsalariesforresidentsareasfollows:PGYI

$50,019

PGYII

$51,696

PGYIII

$53,465

PGYIV

$55,526

PGYV

$57,875

PGYVI

$60,382

PGYVII

$60,382

PGYVIII

$60,382

L.CounselingServicesandPhysicianImpairmentResources.

TulaneUniversityiscommittedtofosteringanenvironmentinwhichresidents

feelsafeinidentifyingandcorrectingacademicandprofessionaldeficiencies

withoutfearofreprisalorimplicationstotheircareer.

Residentsareprovidedconfidentialcounselingandbehavioralhealthservices,at

nocosttotheresident,asoutlinedinChapterXV.PolicyonRemediation,

Suspension,TerminationandGrievance,andChapterXVI.PolicyonResidents’

AssistanceProgram.ResidentsarenotreportedtolicensingagenciesorThe

TulaneAdministrationforself-referralexceptintheextenuatingcircumstances

asnotedinChapterXV.PolicyonRemediation,Suspension,Terminationand

Grievance

M.OtherProgramPersonnelandSupportServices.TheDIO,onbehalfofthe

SponsoringInstitution,therespectivechairandprogramdirectormustjointly

ensure:

1.Theavailabilityofallnecessaryprofessional,technical,andclericalpersonnel

fortheeffectiveadministrationoftheprogram.

2.Theappropriatenumberofprogramcoordinator(s)tosustaintheeffective

operationofthetrainingprogram.Programcoordinatorsmusthavesufficient

supportandtimetoeffectivelycarryouttheirresponsibilities.

3.Theavailabilityofadequateresourcesforresidenteducation,includingspace,

technology,andsupplies,areavailabletoprovideeffectivesupportforACGME-

accreditedprograms.

4.Allclinicalrotationshavesupportservicestominimizeresidents’workthatis

extraneoustotheirACGME-accreditedprograms’educationalgoalsand

objectives

5.Residents’educationalexperienceisnotcompromisedbyexcessivereliance

onresidentstofulfillnon-physicianserviceobligations.Thesesupportservices

andsystemsmustinclude:a.Peripheralintravenousaccessplacement,

phlebotomy,laboratory,pathologyandradiologyservicesandpatient

transportationservicesprovidedinamannerappropriatetoandconsistentwith

educationalobjectivesandtosupporthighqualityandsafepatientcare;b.

Medicalrecordsavailableatallparticipatingsitestosupporthighqualityand

safepatientcare,residents’education,qualityimprovementandscholarly

activities.

ApprovedbytheGMEC;January28th,2015

VI.POLICYONMOONLIGHTING

A.Residentswhowishtoengageinthepracticeofmedicineoutsideoftheir

formaltrainingprogrammusthavetheexplicitwrittenapprovaloftheirprogram

director.Theprogramdirector’swrittenpermissionmustbeincludedinthe

resident’sfile.

B.Allresidentswhoengageinmoonlightingactivitiesmustbefullylicensedto

practicemedicine;havestateandfederal(DEA)licensetoprescribe;andmust

carryindividualmalpracticeinsurancecoverage.Alllicensesandinsurance

coverageprovidedbyTulaneUniversity,SchoolofMedicineorbyitsaffiliated

teachinghospitalsforpurposesofgraduatemedicaleducationcannotbeusedfor

purposesofmoonlighting.

C.Moonlightingmaybeconductedonlywithintheestablishedinstitutional

principlesofdutyhours(ChapterVIII).Theprogramdirectorisresponsiblefor

monitoringtheeffectofmoonlightingonaresident’sperformanceinthe

educationalprogram.Hoursdevotedtomoonlightingaretobecountedtowards

thedutyhoursregulationsasoutlinedinChapterVIII.

D.Moonlightingisaprivilege.Resident’swhochoosetomoonlightwillbe

monitoredbytheirprogramdirector,andthemoonlightingprivilegemaybe

revokedbytheprogramdirector,ortheDIO,ifheorshefeelsthatthe

moonlightingisadverselyaffectingtheresident’spatientcareoreducation,oris

puttingtheresidentatriskforworkhoursviolationorexcessive

sleepiness/fatigue.

E.Violationofthispolicymayresultinimmediatesuspensionortermination.

F.Noresidentmaybeforcedtomoonlight.

ApprovedbytheGMEC;August17th,2011

VII.POLICYONINTERACTIONWITHVENDORS

A.ResidentsoftheTulaneUniversitySchoolofMedicineareprohibitedfrom

acceptinggiftsfrompharmaceuticalandmedicaldevicecompany

representativesandotherindustryrepresentativesthatareintendedtoinfluence,

ormayhavetheeffectofinfluencing,theresidents’healthcaredecisions.

Residentsshouldrefrainfromacceptinggiftsandparticipatinginactivities

offeredbyindustryrepresentatives,withtheexceptionofthegenerallypermitted

itemsandactivitiesincludedonthelistbelow:1.Receiptofmedicaltextbooks.

2.Participationinindustry-supportededucationalprograms.Attendanceat

educationalprogramsthatarenotaccreditedbyanACCMEaccreditedprovider

shouldbeapprovedinadvancedbytheProgramDirectorand/ortheAssociate

Dean,GraduateMedicalEducation,SchoolofMedicine.Registrationfeesand

othersupportforparticipationineducationalprogramsshouldnotbeaccepted

directlybyanyresidentfromanindustryrepresentative.Questionsregarding

attendanceatandsupportforeducationalprogramsshouldbeaddressedtothe

TulaneCenterforContinuingMedicalEducationinconjunctionwiththeOffice

ofGraduateMedicalEducation.

3.Individualgiftsofminimalvaluethatarerelatedtotheworkoftheresident,

suchaspensandnotepads.

B.Residentsshouldnotparticipateinactivitiesoracceptgiftsnotincludedon

thelistabovewithoutspecificpermissionfromtheDIO.Inadditiontothe

TulaneUniversitypolicy,Tulaneresidentsareexpectedtocomplywiththe

policiesonvendorinteractionsineffectateachhospitaltowhicharesident

rotates.WherethereisdiscordancebetweentheUniversity’spolicyanda

hospital’spolicy,themorestringentofthetwowillapply.

C.QuestionsregardingthispolicyshouldbedirectedtotherespectiveProgram

Director,theTulaneUniversityMedicalGroupComplianceOfficerortheOffice

ofGeneralCounsel.

ApprovedbytheGMECBoard;August17th,2011

VIII.POLICYONRESIDENTS'DUTYHOURS

A.Eachresidencyprogrammustbecommittedtoandresponsibleforpromoting

patientsafetyandresidentwell-being,andtoprovidingasupportiveandsafe

educationalenvironment.Regardlessofwhereaffiliatedrotationsareoffered,

dutyhoursandon-calltimeperiodsmustnotbeexcessivefortheresidents.Duty

hoursmustbeconsistentwiththeACGMEInstitutionalandSpecificProgram

Requirements.Inspecific:1.Thestructuringofdutyhoursandon-callschedules

mustfocusontheneedsofthepatient,continuityofcare,andtheeducational

needsoftheresident.Dutyhourassignmentsmustrecognizethatfacultyand

residentscollectivelyhaveresponsibilityforthesafetyandwelfareofpatients.

2.Didacticandclinicaleducationmusthavepriorityintheallotmentof

residents’timeandenergy.

3.Thelearningobjectivesoftheprogrammustnotbecompromisedby

excessiverelianceuponresidentstofulfillserviceobligations.

B.Dutyhoursmustcomplywiththefollowingstandards:

1.Aresidentmustnotworkmorethan80hoursperweek.

2.Theprogramdirectorisresponsibleforincluding“moonlighting”hours

towardthe80hourslimitationsnotedabove.(SeeChapterVI.Policyon

Moonlighting).

3.Aresidentmustworknolongerthan24hoursofcontinuouson-siteduty.Up

to4additionalhoursarepermittedforpatienttransferandotheractivitiesas

definedinRRCrequirements;howevernonewpatientsmaybeadmittedafter

the24hoursofcontinuousduty.

5.Aresidentmusthaveatleast8,andpreferably10,hoursoffforrestand

personalactivitiesbetweendutyperiodsandaftercall.

6.Aresidentmusthaveatleast14hoursoffaftereachcallduty.

7.Residentsmusthaveatleastonedayoffperweek.Adayoffisdefinedas24

hoursofcontinuoustimewithoutpatientcareobligations,includingnotholding

ahome-callpager.Itisdesirablethateachresidenthaveone48-hourperiodfree

ofallpatientcareobligationseachmonth.

8.In-housecallmaynotoccurmorefrequentlythaneverythirdnight.

C.HomeCall

1.Forresidentsassignedhomecall,theactualtimespentansweringcalls,or

deliveringin-housepatientcareistobecountedtowardthe80hourstandard.

2.Aresidentonhome-callwhoiscalledintothehospitalforanextensiveperiod

oftimeshouldbereleasedfromdutythefollowingday.Theprogramdirectoris

responsibleforestablishingajeopardysysteminvolvingotherresidentsor

faculty,whichensuresthattheresidentmaybereleasedfromdutythefollowing

dayifthepreviousnight’srequirementswereexcessive.

3.Residentsonhome-callmuststillhaveonedayoffinsevenwithoutholding

thepager.

D.Programdirectors&facultyareresponsibleforadoptingpoliciestoprevent,

monitorandcounteracteffectsoffatigue.

1.TheGMEOfficeisresponsibleforensuringanon-boardingsessionsforall

newresidentsandfacultytoTulaneonthesigns,risk,andmethodsof

counteractingfatigue.

2.Programdirectorsareresponsibleforensuringayearlyin-servicetoeducate

residentsandfacultyonthesigns,risk,andmethodsofcounteractingfatigue.

3.Theprogramleadershipisresponsibleforensuringthatresidentshave

alternativemeansoftransportationhomeshouldtheyfeeltoofatiguedtosafely

returnhomefollowingashift.Insuchcases,residentsshould:

a.Firstseekalternativetransportationfromcolleagues,programfaculty,or

programadministration.

b.Ifthisoptionisnotfeasible,theresidentshouldtakeataxi,andproducethe

receiptforthetriphometotheprogramleadership.Theresidentwill

subsequentlybereimbursedforthetaxiexpensestotheirhome.

E.TulaneUniversityallowsnoexceptionstothedutyhoursaslistedabove.

F.ReportingFall-OutsinDutyHours

1.Eachprogramisresponsibleformonitoringdutyhours,inclusiveof

moonlightinghours.Themethodofmonitoringmustbepresentedtoand

approvedbytheDIOaspartoftheannualreviewprocess..

2.Itistheresponsibilityofallresidentsandfacultytoreporteventsthatviolate

theprogramandinstitution’sdutyhourpolicies.Residentsandfacultyareto

reportsucheventsviaoneormoreofthefollowingmechanisms.

a.Anonymousreportingviaresident-of-rotationorResident-of-facultyE-value

evaluations.

b.Directreportingtoattendingphysiciansortheprogramdirector.

c.Anonymousreportingviatheaffiliatedinstitution’s(iehospital/clinic)near-

miss/adverseeventreportingsystem

d.ReportingtotheResidencyEducationCommittee,eitherdirectlyorviathe

resident’s/faculty’srepresentative

e.TulaneResidentandFellowsCongress,eitherdirectlyorviatheresident’s

representativef.Resident-of-Programannualevaluation

g.DirectreportingtotheDepartmentChair

g.DirectreportingtotheDIO

ApprovedbytheGMEC;August17th,2011

IX.RESIDENTS’PARTICIPATION&REPRESENTATIONON

INSTITUTIONAL

COMMITTEESANDCOUNSELS

A.Residentsmusthaveappropriaterepresentationoninstitutionalcommittees

andcounselswhoseactionseffecttheireducationandpatientcare.Residents

mustbeawareof,andparticipatein,institutionalprogramsandmedicalstaff

activities.Theymustbeknowledgeableabout,andadhereto,established

practices,procedures,andpoliciesofeachinstitutionparticipatinginthe

educationalexperiencesandactivitiesoftheirtrainingprogram.

B.TheGMEOfficeadvocatesonbehalfoftheTulaneResidencyProgramsto

ensurethatresidentshaverepresentationoneachofthefollowingcommittees.

Duringtheircourseoftraining,eachresidentwillhavetheopportunityto

participateinoneormoreofthefollowinginstitutionalcommittees:aswellas

othersimilarlyestablishedinstitutionalcommitteesastheyoccurinallaffiliated

traininginstitutions1.TulaneUniversityHospital&Clinic:

Cancer

CriticalCareAdvisory

Ethics

EmergencyServices

InfectionControl

Informationandtechnologycommittee

MedicalRecords

OperatingRoom

Pharmacy&Therapeutics

PerformanceImprovement

Transfusion

UtilizationReview

QualityImprovementCounsel,Hospital

2.TulaneUniversityMedicalSchool

CodeBlue

InfectionControl

EnvironmentofCare

UtilizationReview

PICouncil

Stroke

BloodUtilization

QDC

Pharmacy/Therapeutics

Ethics

CriticalCare

Perinatal

RadiationSafety

IRBworkgroup

QIC

ChestPain

SMAT

3.VAMedicalCenter,NewOrleansExecutiveCommitteeoftheMedicalStaff:

Cancer

PatientRights/Ethics

InfectionControl

Informationandtechnologycommittee

MedicalRecords

Operative/InvasiveProcedure

Pharmacy&Therapeutics

PerformanceImprovement

UtilizationReview

QualityofCare

4.ILH

CancerCareCommittee(Quarterly;12N)

CriticalCareCommittee(1stFridayofEvenMonths;11:30AM)

DepartmentDirectorsMeeting(3rdThursdayofeveryothermonth;9:30AM)

EnvironmentofCareCommittee(3rdTuesdayoftheMonth;10AM)Ethics

Committee(LastWednesdayofthemonth;12N)

LasersCommittee(3rdTuesdaythelastMonthofthequarter;1PM)Medicine

SurgicalUnitPICommittee(1stThursdayoftheMonth;9AM)Mortality

ReviewCommittee(2ndWednesdayoftheMonth;11AM)

NutritionCommittee(2ndTuesdayoftheMonth;12N)

PatientSafety&Satisfaction(2ndTuesdayoftheMonth;10AM)PrisonerCare

Committee(2ndWednesdayofeveryotherMonth;10:30AM)Research

Committee(FirstMondayofoddmonths;2PM)

StrokeCommittee(2ndThursdayoftheMonth;12N)

TraumaCareCommittee(EveryMondayat1PM)

TraumaPeerReviewCommittee(EveryMondayat2PM)

Anesthesia/ORCommittee(2ndWednesdayoftheMonth;7AM)

ComprehensiveQMCommittee(LastThursdayoftheeverymonth;9AM)

CredentialsCommittee(1stThursdayoftheMonth;7AM)

InfectionControlCommittee(4thThursdayoftheMonth;12N)

MedicalRecordsCommittee(2ndWednesdayoftheMonth;1PM)

PharmacyandTherapeutics(3rdTuesdayoftheMonth;12N)

TransfusionCommittee(LastMondayoftheMonth;10AM)

5.ExternalOrganizations:OrleansParishMedicalSociety,LocalandNational

SpecialtyandSubspecialtyOrganizations

ApprovedbytheGMEC;March19th,2014

X.POLICYONCORECURRICULUMANDTHECORECOMPETENCIES

A.GeneralCompetencies:Forthepurposesofpromotionandgraduation,all

Tulaneresidentsmustdemonstrateprogressivecompetencyinthefollowing

areas.Failuretodemonstratecompetenceinanyoneareaisgroundsfornon-

promotion.

1.Patientcare,

2.Medicalknowledge,

3.Practice-basedlearningandimprovement,and

4.Interpersonalandcommunicationskills,

5.Professionalism,

6.Systems-basedpractice.

B.PATIENTCARE

Residentsmustbeabletoprovidepatientcarethatiscompassionate,

appropriate,andeffectiveforthetreatmentofhealthproblemsandthepromotion

ofhealth.Residentsareexpectedto:1.Communicateeffectivelyand

demonstratecaringandrespectfulbehaviorwheninteractingwithpatientsand

theirfamilies.

2.Gatheressentialandaccurateinformationabouttheirpatients.

3.Makeinformeddecisionsaboutdiagnosticandtherapeuticinterventionsbased

onpatientinformationandpreferences,up-to-datescientificevidence,and

clinicaljudgment.

4.Developandenactpatientmanagementplans.

5.Counselandeducatepatientsandtheir

families

6.Useinformationtechnologytosupportpatientcaredecisionsandpatient

education.

7.Performcompetentlyallmedicalandinvasiveproceduresconsideredessential

fortheareaofpractice.

8.Providehealthcareservicesaimedatpreventinghealthproblemsand

maintaininghealth.

9.Workwithhealthcareprofessionals,includingthosefromotherdisciplines,to

providepatient-focusedcare.

C.MEDICALKNOWLEDGE

Residentsmustbeabletoobtainasufficientexpertiseintheirfieldofpractice,

withrequisitemedicalknowledgenecessarytopracticetheirchosenmedical

discipline.Inspecific,residentsshouldbeableto:1.Demonstrateknowledge

aboutestablishedandevolvingbiomedical,clinical,andcognitive(e.g.

epidemiologicalandsocial-behavioral)sciencesandtheapplicationofthis

knowledgetopatientcare.

2.Demonstrateaninvestigatoryandanalyticthinkingapproachtoclinical

medicine.

3.Knowandapplythebasicsciencesappropriatetotheirdiscipline.

D.PRACTICE-BASEDLEARNINGANDIMPROVEMENT

Residentsmustbeabletoinvestigateandevaluatetheirpatientcarepractices,

appraiseandassimilatescientificevidence,andimprovetheirpatientcare

practices.Residentsareexpectedto:1.Analyzepracticeexperienceandperform

practice-basedimprovementactivitiesusingasystematicmethodology

2.Locate,appraise,andassimilateevidencefromscientificstudiesrelatedto

theirpatients’healthproblems

3.Obtainanduseinformationabouttheirpopulationofpatientsandthelarger

populationfromwhichtheirpatientsaredrawn

4.Applyknowledgeofstudydesignsandstatisticalmethodstotheappraisalof

clinicalstudiesandotherinformationondiagnosticandtherapeuticeffectiveness

5.Useinformationtechnologytomanageinformation,accesson-linemedical

information;andsupporttheireducation

6.FacilitatethelearningofstudentsandotherhealthcareprofessionalsE.

INTERPERSONALANDCOMMUNICATIONSKILLS

Residentsmustbeabletodemonstrateinterpersonalandcommunicationskills

thatresultineffectiveinformationexchangeandteamingwithpatients,their

patients’families,andprofessionalassociates.Residentsareexpectedto:

1.Createandsustainatherapeuticandethicallysoundrelationshipwithpatients

2.Useeffectivelisteningskillsandelicitandprovideinformationusingeffective

nonverbal,explanatory,questioning,andwritingskills

3.Workeffectivelywithothersasamemberorleaderofahealthcareteamor

professionalgroup4.Fosterthedevelopmentoftheprofessionthrougheffective

teachingstrategies.

F.PROFESSIONALISM

Residentsmustdemonstrateacommitmenttocarryingoutprofessional

responsibilities,adherencetoethicalprinciples,andsensitivitytoadiverse

patientpopulation.Residentsareexpectedto:1.Demonstraterespect,

compassion,andintegrity;aresponsivenesstotheneedsofpatientsandsociety

thatsupersedesself-interest;accountabilitytopatients,society,andthe

profession;andacommitmenttoexcellenceandon-goingprofessional

development

2.Demonstrateacommitmenttoethicalprinciplespertainingtoprovisionor

withholdingofclinicalcare,confidentialityofpatientinformation,informed

consent,andbusinesspractices3.Demonstratesensitivityandresponsivenessto

patients’culture,age,gender,anddisabilities.

G.SYSTEMS-BASEDPRACTICE

Residentsmustdemonstrateanawarenessofandresponsivenesstothelarger

contextandsystemofhealthcareandtheabilitytoeffectivelycallonsystem

resourcestoprovidecarethatisofoptimalvalue.Residentsareexpectedto:

1.Understandhowtheirpatientcareandotherprofessionalpracticesaffectother

healthcareprofessionals,thehealthcareorganization,andthelargersocietyand

howtheseelementsofthesystemaffecttheirownpractice

2.Knowhowtypesofmedicalpracticeanddeliverysystemsdifferfromone

another,includingmethodsofcontrollinghealthcarecostsandallocating

resources.

3.Practicecost-effectivehealthcareandresourceallocationthatdoesnot

compromisequalityofcare.

4.Advocateforqualitypatientcareandassistpatientsindealingwithsystem

complexities.

5.Knowhowtopartnerwithhealthcaremanagersandhealthcareprovidersto

assess,coordinate,andimprovehealthcareandknowhowtheseactivitiescan

affectsystemperformance.

6.UnderstandandbeabletoapplythePlan-Do-Check-Act(PDCA)methodof

systemsimprovement.

H.TRANSITIONSOFCARE

Residentsmustdemonstrateknowledgeandproficiencyinthesafeandeffective

transitionofcareforpatientsundertheirstewardship.Residentsareexpectedto

1.Understandtheimportanceofin-personsign-inandsign-outofpatientswho

willrequireon-goingcareviaacolleague(i.e.,anight-floatresident).

2.Identifythecomponentsofclosed-loopcommunication,andsuccessfully

demonstrateproficiencyofthiscommunicationstrategy.

3.Identifythecomponentofthewritten(orelectronic)sign-outformthat

ensurespatientsafety.

4.Recognizetheimportanceoftimelycompletionofdocumentsessentialto

facilitatingsuccessfultransitionsofcarefromonearenatothenext(i.e.,off-

servicenotes,post-operativenotes,dischargedictations).

I.PATIENTSAFETYANDQUALITYIMPROVEMENT

Residentsmustdevelopcompetenceinthecorecomponentsofpatientsafetyand

qualityimprovement.Residentsareexpectto:

1.Developcompetency,throughactiveparticipation,inRootCauseAnalysis

andFailureModesEffectAnalysis.

2.Identifyhowtoreportactualandnear-misspatientsafetyeventsateachofthe

trainingfacilitiesatwhichtheyrotate.

3.Demonstratecompetenceintheattitudeofpatientsafetybyregularly

reportingsuchevents,including:a.Medicationerrors

b.Adversemedicationreactions

c.Falls

d.Decubitusulcers

e.Deepveinthrombosis

f.Unexpectedchangesinlevelsofcare

g.Transitionsofcarefallouts

h.Hospitalacquiredinfections(CAUTI,CLASBI,Vent-associatedpneumonia,

Surgicalsiteinfections)

i.Antibioticstewardship

j.Andothereventsspecifictotheresident’sfieldofpractice4.Identifythe

importanceofclosed-loopcommunicationandsituationalawarenessinthe

preventionofpatientsafetyevents

5.Identifycommonheuristicsthatleadtomisdiagnosisorinappropriate

assignmentoftreatmentregimens.

6.Identifytherolethehealthcaresystemplaysinaugmentingorclosingthegap

inhealthcaredisparities7.Recognizetherolethehealthcaresystemplaysin

makingpatientsafetyeventsmoreorlessprobable:8.Recognizetheimportance

ofreceivingdataonphysicianperformanceinidentifyingareasforimprovement

inthehealthcaresystem

9.IdentifythecomponentsofthePlan-Do-Act-Studyqualityimprovement

model.

20.Demonstratecompetenceintheattitudeofqualityimprovement,byregular

participationinteam-based,multidisciplinaryqualityimprovementprojects.

J.THERESIDENCYPROGRAM’SRESPONSIBILITIESFORENSURING

COMPETENCYINEACHOF

THECORECOMPETENCIES

1.Eachresidencyprogramdirectormustensurethattheresidencyprogram

curriculumaddresseseachofthesixcorecompetencies,andthatallresidentsin

theprogramaretaughtandevaluatedineachofthesixcorecompetencies.

Further,residentsmustbeprovidedtheentrustableprofessionalactivities

(EPA’s)withineachofthecorecompetencies,andtheassociatedmilestonesof

performanceineachoftheseEPA’s.

2.Residentevaluationsmustincludeanassessmentofeachofthesixcore

competencies,asoutlinedbythemilestoneperformanceineachoftheEPA’s

3.Residentevaluationsmustutilizea360°evaluationsystemtoensurean

accurateassessmentofprofessionalismandcommunication/interpersonalskills,

includingevaluationsbyfaculty,patients,nurses,students,peersandother

ancillarystaff,asapplicabletotherotation.

4.Mid-yearandend-of-yearsummaryevaluationsmustincludeanassessmentof

eachofthesixcorecompetenciesasdetailedinChapterXIV.Policyon

EvaluationofResidents.

6.Decisionsforpromotionorgraduationmustbemadebasedupon

demonstratedcompetencyineachofthesixcorecompetencies.Failureto

achievecompetenceinanyoneofthesixcorecompetencyareasisgroundsfor

non-promotion,asdetailedinChapterXIV.PolicyonEvaluationofResidents.

7.Inadditiontotheaboverequirements,procedural-basedspecialtiesmust

monitorprocedure,operative,andcaselogs,andincorporateanassessmentof

proceduralcompetencyintomid-year/end-yearevaluationsandpromotionand

graduationdecisions.

9.Programdirectorsmustensurethatallresidentsenteringatrainingprogramat

TulaneUniversityhavesuccessfullycompletedtheTeamSTEPPStraining.

10.Programdirectorsmustensurethatallresidentsreceiveformalinstructionin

theprinciplesofsafeandeffectivetransitions-of-care.

11.Programdirectors,ortheirdesignees,mustensurethatinternsaredirectly

observedintheirtransitionsofcare(i.e.,signout)untilwhichpointtheprogram

directorissatisfiedthattheinternhasdemonstratedsufficientmasteryof

transitionscommunicationtowarranttransitionsofcaredutieswithoutdirect

supervision.

12.Programdirectorsmustensurethatresidentsunderstandhowtoreport,and

regularlyreport,patientsafetyevents,includingnear-missevents.

13.Programdirectorsmustensurethatresidentsreceivetraininginconducting

RCA’sandFMEA’s,andthatresidentsregularlyparticipateinactualor

simulatedRCA’sandFMEA’s.

14.EachprogrammusthavearegularlyoccurringMorbidity/Mortalityseries

throughouttheyear,withanemphasisonhowthesystemcontributedtothe

adverseevents,andhowthesystemcouldbechangedtopreventsucheventsin

thefuture.

15.Programdirectorsmustensurethatresidentsreceivedatafromtheir

respectivehospitalsontheirpracticehabitssuchthatthereisanopportunityto

improveintheseareas.

16.Programdirectorsmustensurethateachresidentparticipatesinatleastone

team-basedqualityimprovementprojecteachyear.

17.Programdirectorsmustsubmitanannual“StateoftheProgram”document

inJuneofeachyeartotheGMEOfficeasoutlinedinChapterXXII.Policyon

ProgramEvaluation,ImprovementandAnnualProgramReports.Thisdocument

mustcontainadescriptionofhowtheresidencyprogramteachesandevaluates

thecorecompetencies,andensurescompliancewiththeresponsibilitiesoutlined

above.

K.THERESIDENCYPROGRAM’SRESPONSIBILITIESFORENSURING

COMPETENCYIN

RESIDENTS’TEACHING,EVALUATIONANDSUPERVISIONABILITIES

1.Inamedicalschool,residentsprovideanessentialroleintheinstructionand

supervisionofmedicalstudents.Further,theactofteachingprovidesinsightinto

theteacher’sownunderstandingofmedicine,enablinghimorhertoidentify

areasofweaknesses,andsubsequentlytoimprove.TulaneGraduateMedical

Education,therefore,iscommittedtothedevelopmentofresidentsasteachers.

2.Trainingprogramswhoseresidentsregularlyinteractwithmedicalstudents

arerequiredtointegratethefollowingprinciplesofmedicaleducationintotheir

curriculum:a.Identifyandunderstandthegoalsandobjectivesofthemedical

studentcurriculum,asapplicabletotheresidents’trainingprogram.

b.Developandexecutetangibleexpectationsfortheday-to-dayactivitiesofthe

clinicalteam.

c.Identifyandeffectiveutilizestrategiestooptimizelearnerengagementinthe

learningcontent(motivation)

d.Applyvisualizationtechniquessuchthatlearnerscanidentifytheutilityofthe

teachingtopicfortheircareer,andidentifyareasofweaknesstheymight

encounterinutilizingtheskill.

e.Anticipateareasofconfusion,orareaspronetoerrorsinthelearners’

applicationofthematerial,andprovidesolutionsproactivelyinpreventingthose

areas.

f.Effectivelyutilizeformativeandsummativefeedbackstrategiestoimprove

learnerperformance.

g.Identifystrategiestoensuringaneffectiveandrespectfullearning

environment.

3.Trainingprogramswhoseresidentsregularlyinteractwithmedicalstudents

arerequiredtoregularlyassessresidents’teachingandsupervisionabilitiesusing

studentevaluationsofresidents’teachingabilitiesanddirectobservationby

peersorsupervisorsofresidents’teachingandfeedbackabilities.

L.SUPPLEMENTALTRAININGINCORECOMPETENCYTRAINING

UNIVERSALTOALLTRAINING

PROGRAMS

1.TheTulaneUniversityGMEOfficeprovidesinitialtraining,aspartof

orientation,toallresidentsnewlymatriculatingtoatrainingprogramatTulane.

Thistrainingincludesthefollowingareas:a.SleepDeprivationandFatigue

Mitigation

b.IntroductionofGMEStaff/ReviewofPolicesandProcedures

c.ReviewoftheSix-CoreCompetencies

d.ClinicalCoaching:Motivation,Visualization,Anticipation,Retentione.

FeedbackStrategies

f.MedicalMalpractice,ErrorReportingandPatientApologies

g.SexualHarassment

h.TransitionsofCare

i.PatientSafety

j.QualityImprovement

2.Followingorientation,theTulaneUniversityGMEOfficeprovides

supplementaltraininginthecorecompetencies,particularlyfortrainingmodules

thatareuniversaltoalltrainingprograms.Thesemodulesarenottoprecludea

trainingprogramfromintegratingsimilarormorein-depthtrainingineacharea,

butrathertoensurethatallTulaneresidentsreceivefoundationalandon-going

traininginthesetopics.

3.Theon-linemoduleapproachisdesignedtoallowresidentstoengageinself-

directedlearningthatisconducivetotheirlifeschedule.Further,itisdesigned

suchthatresidentshavethetimetoappropriatelyaddressandreflectuponthe

subjectmatter.

4.Eachmoduleintheonlinecoursehasapost-test,courseevaluationand

certificateofcompletionforuserswhosuccessfullycompletethecourse

requirements.Therespectiveprogramdirectorisresponsibleforensuringthat

eachresidentinhisorhertrainingprogramhassuccessfullycompletedthe

requiredmodule.

5.TheDesignatedInstitutionalOfficialisresponsibleforensuringthateach

residentcompleteshisorherrequiredmodulespriortopromotiontothenext

leveloftraining,orinthecaseofthefinalyearoftraining,priortograduation.

Promotiontosubsequentyearsoftrainingorgraduationfromthetraining

programiscontingentuponeachresidentcompletingtherequiredmodules.

6.RequirementsbyPGYLevelareasfollows.

a.LEVELI(PGY-1)

1.SleepDeprivationandFatigueMitigation

2.Confidentiality

3.ResidentandStudentIntimidation

4.PatientSafety

5.BuildingthePatientPhysicianRelationship

6.WorkingEffectivelyWithinanInter-

professionalTeam

7.ThrivingThroughResidency:TheResilientResident(Burnout)b.LEVELII

(PGY-2)

1.SleepDeprivation

2.ResidentsasTeachers

3.CulturalCompetency

4.CPTCoding:CurrentProceduralTerminology(CPT)

5.PhysicianHealth:PhysiciansCaringforourselves

6.CreatingaRespectfulLearningEnvironment:AvoidingMedicalStudent

Mistreatment7.ProvidingEffectiveFeedbackforMedicalTrainees-c.LEVEL

III(PGY-3)

1.SleepDeprivation

2.EndofLifeMyths

3.PatientSafety-NationalPatientSafety

Goals

4.PatientSafety-FurtherStepstoPreventPatientHarm

5.QualityImprovementPanelandQ&A

6.HealthCareQuality:MeasuringPhysicianPerformance

7.PhysicianHealth:PhysiciansCaringforourselves

d.LEVELIV+andAbove.

SleepDeprivation

PhysicianEmploymentContracts:WhatYouNeedtoKnow

e.Anyresidentfromanon-Tulanetrainingprogramwhohasmatriculatedinto

TulaneUniversityGME

programsatthePGY4orabovelevelwillberequiredtocompleteLevelII

trainingfortheirfirstyearatTulane,andLevelIIIfortheirsecondyearat

Tulane,inadditiontotheLevelIV+trainingrequirements.

L.THEOFFICEOFGRADUATEMEDICALEDUCATION’S

RESPONSIBILITYFORENSURING

COMPETENCYINEACHOFTHECORECOMPETENCIES

1.TheOfficeofGraduateMedicalEducationmustensurethatresidency

programsarefulfillingtheirobligationtoensuringthateachresidentdevelops

competencyineachofthesixcorecompetencies,andthecomponentsofpatient

safetyandqualityimprovement.

2.TheAnnualReviewProcesswillincludespecificquestionsastohowthe

program’seducationalcurriculumteachesandassessesthesixcore

competencies.andthecomponentsofpatientsafetyandqualityimprovement.

SeeChapterXXIIPolicyonProgramEvaluation,ImprovementandAnnual

ProgramReports.

3.TheOfficeofGraduateMedicalEducationwillreceiveandreviewannual

“StateoftheProgram”

reportsfromeachprogrameachyear.

a.Programsnotincompliancewithensuringtheteachingandevaluationofthe

corecompetencieswillundergoanadditionalinternalreviewtoidentifyand

correctthedeficienciesinthecorecompetencycurriculum.

b.StateoftheProgramreportswillbecompiledintotheannualGMEreport,

thatwillbedeliveredorallyandbywritingto:TheTUHCAdministrativeBoard,

theUMCExecutiveCommittee,andtheTulaneExecutiveFaculty.Awritten

copywillbedeliveredtoeachoftheaffiliatedtraininginstitutions.

4.TheDIOorhis/herrepresentativewillmeetwitheachgroupofresidents(i.e.,

eachprogram)atleastonceperyeartoensurecompliancewiththecore

competenciesandotherRRCrequirements.

5.TheDIOorhis/herrepresentativewillmeetwitheachprogramdirectorat

leastonceperyeartoensurethattheresidencyprogram’scurriculumensures

compliancewithrespecttotheinstructionandsupervisionofthecore

competencies.

6.TheOfficeofGraduateMedicalEducationwillensurethateachincoming

residentorfellownewtotheTulaneGMEsystemreceivesformaltraininginthe

TeamSTEPPScurriculum.

7.TheOfficeofGraduateMedicalEducationwillensurethataffiliatedhospitals

provideeffectiveelectronicsign-outsystemsforthosepatientsrequiringon-

goingcareacrossresidencyshifts(i.e.,hospitalizedpatientsforwhichnightfloat

coverageisprovided).

8.TheOfficeofGraduateMedicalEducationwillfacilitatecommunication

betweenaffiliatedhospitalsandtheTulaneresidencytrainingprograms

regardingqualityandpatientsafetyinitiatives,includingensuringresidents

knowthehospital’spatientsafetypriorities.

9.TheOfficeofGraduateMedicalEducationwillfacilitatecommunication

betweenaffiliatedhospitalsandtheTulaneresidencytrainingprograms

regardinghowtoreporterrors,adverseevents,unsafeconditions,andnear

missesinaprotectedmannerthatisfreefromreprisal.

10.TheOfficeofGraduateMedicalEducationwillfacilitatecommunication

betweenaffiliatedhospitalsandtheTulaneresidencytrainingprograms

regardingreceivingappropriatedatastreamsnecessarytoprovideresidentswith

informationontheirpracticehabits,andtoenactmeaningfulqualityandpatient

safetyinitiativesdesignedtoimprovesystemsofcare,reducehealthcare

disparities,andimprovepatientoutcomes,

11.TheOfficeofGraduateMedicalEducationwillfacilitatecommunication

betweenaffiliatedhospitalsandtheTulaneresidencytrainingprogramstoensure

thatresidentshaveanopportunitytoparticipateinactualRCA’s/FMEA’s,

hospital-basedqualityimprovementprojects,andtoparticipateoncommittees

essentialforpatientsafety.SeeChapterIX.Residents’Participationon

InstitutionalCommittees12.TheDIOorhis/herrepresentativewillfacilitate

communicationbetweenhospitalleadershipandprogramdirectorleadership

regardinganyresident/felloweventthatisjudgedtobeinconsistentwithpatient

safetyandquality.

ApprovedbytheGMEC;November29th,2017

XI.POLICYONVACATIONANDLEAVE

A.LEAVEOFABSENCE.ALeaveofAbsencemaybegrantedonlywith

writtenpermissionoftheresidencyprogramdirector.Suchleavemayprolong

thedurationofresidencytrainingaccordingtoeachspecialty'sBoard

requirements,andtherequirementsuniquetoprogramsatTulaneUniversity.In

allcases,thenumberoftotalmonthsrequiredtocompleteprogramrequirements

forgraduationistobedeterminedbytheprogramdirectorandtheprogram’s

clinicalcompetencycommittee.

B.MILITARYLEAVE

EligibleemployeeswhoaremembersoftheNationalGuard,NavalMilitiaorof

areservecomponentoftheUnitedStatesmilitaryforcesandwhoarerequiredto

undergoannualfieldorperiodicweekendtrainingoractivedutytrainingshallbe

grantedaleaveofabsenceforsuchperiodasprovidedbyregulationor

emergencysituation.

Theemployeeshallbeentitledtofullpayforaperiodoftwoweeksperyear.

Thispaywillbethedifferencebetweenhis/herregularsalaryandthemoney

receivedfromNationalGuardorotherreserveunit.Anysuchhoursgrantedwill

beinadditiontotheemployee'sregularvacationhours.Anyremainingmilitary

obligationwillbegrantedwithoutpayor,iftheemployeewishes,he/shemay

useaccumulatedvacationtime.Armorydrillsormultipletrainingassembliesdo

notqualifyforshort-termmilitaryleavewithorwithoutpay.Ifyouenterthe

ArmedForcesoftheUnitedStateswhileanemployeeoftheUniversity,youwill

havecertainre-employmentrights,asrequiredbyFederallaw,aftercompleting

yourmilitaryservice.ContactthePersonnelDepartmentfordetails.

C.SICKLEAVE

Aperiodofsickleaveoftwoweeksisallowedperresidentperyear.Ifaresident

callsinsick,itistheprerogativeoftheprogramdirectortoaskforadoctor's

excusefromtheresident.Sickleaveinexcessoftwoweekswillbetakenfrom

vacationtime.Eachresidentmustbeawarethateachparticularspecialtyallows

onlyacertainamountofabsencefromtrainingperyear.Absencebeyondthat

designatedtime,beitforvacationorsickleave,mayextendtheresident’stime

intraining.Therecanbenoaccrualofsickleavefromoneyeartothenext;i.e.,

twoweekmaximumsick-leaveisallowedperyear.

D.LEAVETIMEALLOWEDBYSPECIALTYBOARDSWITHOUTMAKE

Theamountofaggregateleavetimethatcanbeallowedwithoutanextensionof

trainingtimeisatthediscretionoftheprogramdirector,asdirectedbythe

respectiveBoard’smaximumallowableleavetime.Itistheresponsibilityofthe

programdirectortocommunicatetoresidentsthemaximumamountofleave

timethatcanbetakenwithoutanextensionoftrainingtime.

E.PARENTALLEAVE(MATERNITY&PATERNITYLEAVE)

1.Parentalleavewillbegranteduponrequesttoallresidents.Alloraportionof

thesixweeksmayberequested.

2.Parentalleaveappliestobirthsoradoptionofachild.

3.Parentalleaveappliestobiologic,adoptiveanddomestic-partnerparents.

4.Parentalleaveisanun-paidleaveofabsence.

5.BenefitswillcontinueduringthesixweeksofParentalleave.Theresident

willhavetheoptionofcontinuinghisorherbenefits,attheresident’scost,for

leavethatexceedsthesixweeks.

6.Parentalleavewillbeapaidleaveofabsencefortheportionthattheresident

choosestodevoteremainingvacationand/orsickleaveforthatyear.

7.Parentalleavegreaterthansixweeksduration,exceptincasesofillnessofthe

motherorinfant,requiresapprovalbytheprogramdirector.Thistimewillbe

unfunded.

8.Wherepossible,theresidentmustnotifytheprogramdirector,providingat

leastafour-monthnoticeoftheleave,andwhenheorsheplanstoreturntowork

followingtheparentalleave.

9.Durationofleaveexceedingthatperiodoftimedefinedbytheresident's

specialtyboardasanacceptableleaveofabsencewillextendtheresident’stime

intraining.

10.Theresidentmaychoosetousehisorherparentalleaveanytimefromone

monthpriortothe37

birth/adoptionofthechildupuntilsixmonthsafterthebirth/adoptionofthe

child.

F.BEREAVEMENTLEAVE

1.Aleaveofabsencewillbegrantedforadeathinresident’sortheresident’s

significantother’simmediatefamily.

2.Theleavewillbepaidleavewithbenefitsprovidedtheresidentusesallotted

sickleaveorvacationtime.

3.Thisleaveshallnotexceedthreeworkingdaysforafuneralthatisheldwithin

a300-mileradiusofNewOrleansandshallnotexceedfiveworkingdaysfora

funeraloutsidethisradius.Forpurposesofthispolicy,immediatefamilyis

definedastheresident's,ortheresident’ssignificantother’s,mother,father,

sister,brother,children,grandparents,grandchildren,orsignificantother.

4.Leaveinexcessofremainingsickleaveorvacationtimewillbeun-paid

leave,thoughbenefitswillcontinueuptosixweeksofabsence.

5.Theprogramdirectormayrequestverificationofthedeathandlocationofthe

funeralpriortoapprovingthisleave.

I.VACATION

Theamountofvacationperacademicyearisatthediscretionoftheprogram

director,butshallnotbelessthanthreeweeksperacademicyear.Forvacation

guidelines,theresidentshouldconsulthisorherresidencyprogramdirector.

Therecanbenoaccrualofvacationtimefromoneacademicyeartothenext.

J.EDUCATIONALLEAVE

1.ItisthepolicyofTulaneUniversitySchoolofMedicinetoensurethatthe

residentsareallowedtoattendandtoparticipateineducationalandscientific

meetingsthatwouldcontributetothemedicaleducationoftheresident

physician.

2.Eachresidentmaybegranteduptofive(5)workingdaysperyearof

educationalleaveforthepurposeofparticipatingineducationalorscientific

meetingsthatcontributetothemedicaleducationoftheresidentphysician.

Permissionforandapprovaloftheleavemustbegrantedinwritingbythe

programdirectororhis/herdesignee.

3.Thispolicydoesnotaddressexpensesorreimbursementofexpensesasapart

ofeducationleave;suchreimbursementorpaymentisatthediscretionofthe

programdirector.

ApprovedbytheGMEC;January28th,2015

XII.POLICYONIMMUNIZATIONPROCEDURES&OCCUPATIONAL

HAZARDS

Residentsmaybeatriskfordevelopinginfectiousdiseasesfrompatients,and,in

somecases,beatriskforinfectingpatientsandcolleagues.

A.TuberculinTesting.

1.TulaneprovidesPPDskintestsatthetimeoforientation.AroutinePPDtest

willbeplacedoneachresidentatorientation,unlesstheresidenthasahistoryof

priorpositivetuberculinreactivity.

2.RoutineannualPPDtestingisrequiredforcontinuationinthetraining

program.

a.InMayofeachyear,residentswillreceiveaPPDhistoryformfromtheir

programcoordinator.

b.Itwillbetheirindividualresponsibilitytocompletethisformandschedulean

appointmentwiththeTravelMedicineClini.ThePPDwillbeplacedatthattime

(withnochargetotheresident).

c.Theresidentshouldreturnin48hourstothisclinicortotheResident

ConciergeClinictohavethePPDread.

d.Theresultofthetestshouldbecommunicated,viathesignedTBform,tothe

programcoordinator.

e.ResidentswithahistoryofapositivePPDmustcompletethePositivePPD

form,documentingtreatment(ifany),andassessinganysigns/symptomsthat

wouldpromptradiographicevaluation.

AbaselineradiographshouldbeobtainedonanyresidentwithapositivePPD

(orhistoryofpositivePPD).

f.Morefrequent,oralternative,testingmaybeindicatedforresidentsathigh

riskforTB

exposure.

B.HepatitisBVaccination.Anyresidentwhohasnotreceivedaseriesofthree

hepatitisBinjectionsduringmedicalschoolshouldhaveabaselinetiter.

HepatitisBvaccineshouldbeofferedtoanyresidentwithanegativetiter.There

isevidencetosuggestthattiterswaneafterfiveyearsaftertheseries;therefore,

theseindividualsshouldalsoobtainatiterandaboosterinjectionifindicated.

C.InfluenzaVaccination.Allresidentsarerequiredtoobtainanannualinfluenza

(flu)vaccination.Thoseresidentswhoarevaccinatedwillreceiveastickerfor

theirnamebadgedemonstratingtheircompliance.Thoseresidentswhorefuse,

orhavecontra-indicationstovaccination,willberequiredtowearamaskinall

clinicalareasduringthefluseason,asdefinedbytheclinicalsite.

D.OccupationalExposures.Intheeventofanoccupationalexposuretobloodor

bodyfluids(i.e.,needle-stick),theresidentshouldfollowthefollowing

procedures.Detailedinstructioncanalsobefoundat

http://www2.tulane.edu/oehs/what-do-immediately-after-a-blood-exposure.cfm

1.Scrubthewoundfor5minuteswithbetadine,hibiclensorsoap.Ifthereisa

splashofbloodorbodyfluidstotheeye,thenitshouldbeirrigatedfor5minutes

withwaterornormalsaline.

2.TheresidentshouldreportimmediatelytotheEmergencyDepartmentofthe

facilityatwhichtheexposureoccurred.IfthereisnosuchEmergency

Department,theresidentshouldreporttotheTulaneUniversityHospital

EmergencyDepartment.

3.TheresidentshouldcompletetheExposureForm.

(http://www2.tulane.edu/oehs/upload/1st-Report-of-Injury-2.pdf).

a.Thisformwillcollectinformationontheevent,theresident’ssalientmedical

history,andanyinformationknownaboutthepatientfromwhomtheexposure

occurred.

b.Thisformshouldbereturntoworkcomp@tulane.eduorfaxto504-865-6796

4.TheresidentshouldthenpagetheInfectiousDiseaseresidenton-callto

reviewtheinformationontheformanddiscusstreatmentoptions.

5.Thefollowingday,theresidentshouldscheduleanappointmentwiththe

ResidentConciergeClinictoreviewtheincidentandtherecommendations.

6.Inallcases,theresidentshouldreporttheinjurytohisorherprogramdirector

andtheBloodborne39

PathogensCoordinatorat(504)419-1391or

kmayer@tulane.edu.

7.Anoccupationalexposurecanbepsychologicallydevastating,astheeventis

oftencoloredbyfear,guiltorshame.Alloftheseemotionsfrequentlyprevent

residentsfromseekingtimelyhelpand/orcounseling.Residentsshouldnot

underestimatetheemotionassociatedwithanoccupationalexposure,andshould

erronthesideofseekingpsychologicalcounselingfollowingtheevent.Free

counselingisavailableviatheResidents’AssistanceProgramDirector,Dr.

AndrewMoroson;(504-322-3837)oremailhimatdr.morson@ibhnola.com

D.Worker’sCompensation

1.Asemployees,residentsarecoveredunderWorkers'Compensationforan

occupationalinjury.Residentsshouldinformthetreatinghealthcareproviderthat

theinjuryiswork-relatedandtobillaccordingly.EmployeesshouldNOT

showtheirpersonalinsuranceasthiscancomplicatethebillingissues.You

shouldcalltheWorkers'CompensationManagerbyphone,(504)988-2869to

verifybenefitsavailable.

2.ImportantFacts:

a.Employeeisentitledtomedicalbenefitsoncecompensableinjuryoccurs.

b.Employeeisentitledtoindemnitybenefitsafteraseven(7)daywaiting

period.Indemnitybenefitsarepaidatacalculationof66and2/3percentof

wages.

c.Allmedicalexpensesrelatedtoacompensableinjuryarepaidperfee

schedule.

d.Ifnecessary,seekmedicaltreatmentatnearesthospitalorclinic.

e.ProvideallmedicaldocumentationtoyoursupervisorandWorkers'

CompensationManager.

f.Keepcopiesofdocumentation.

ApprovedbytheGMEC;July27th,2016

SECTION3:

SUPERVISION,EVALUATION&

REMEDIATIONOFRESIDENTS

XIII.POLICYONSUPERVISIONOFRESIDENTS

A.TheProgramDirector.Eachresidencyprogrammustbesupervisedbyone

programdirectorresponsibleforthequalityoftheeducationalexperienceforthe

trainingprogram.

1.QualificationsoftheProgramDirector.Theprogramdirectormust:a.Be

boardcertifiedinthespecialtyofthetrainingprogram.

b.Haverequisiteexperienceingraduatemedicaleducationdeemedappropriate

bytheACGME.

c.Havecurrentmedicallicensureandtheappropriatemedicalstaffappointment

atTulane.

d.Engageinprofessionaldevelopmentapplicabletotheirresponsibilitiesas

educationalleaders2.ResponsibilitiesoftheProgramDirector.Theprogram

directormustadministerandmaintainaneducationalenvironmentconduciveto

educatingtheresidentsineachoftheACGMEcompetencyareas.

Inspecific,theprogramdirectormust:

a.Overseeandensurethequalityofdidacticandclinicaleducationinallsites

thatparticipateintheprogram.

b.Approvealocaldirectorateachparticipatingsitewhoisaccountablefor

residenteducationandsupervision(SeeXIII.C.),asdefinedbytheprogram

letterofaffiliationwiththatsite.

c.Approvetheselectionofprogramfacultyasappropriateforsupervisionand

educationofresidents

d.Evaluateprogramfacultyandapprovethecontinuedparticipationofprogram

facultybasedontheseevaluations

e.Monitorresidentsupervisionatallparticipatingsitesandensurecompliance

withevaluationrequirements(SeeXIII.C.).

f.Provideeachresidentwithawrittensummaryevaluationineachofthecore

competenciesonasemi-annualbasis(SeeChapterXIV.PolicyonEvaluationof

Residents).Theprogramdirectororhis/herdesignatedliaisonshouldmeetin

personwitheachresidentatleasttwiceperyeartoreviewthisevaluation.

g.ComplywithmilestonereportingtotheACGME,asdictatedbyprogram-

specificrequiredintervals,andprovideeachresidentwithawrittensummaryof

theirmilestoneprogress.

g.Provideanend-of-trainingsummarylettermeetingtherequirementsas

outlinedinChapterXIV.PolicyonEvaluationofResidents

h.PrepareandsubmitallinformationrequiredandrequestedbytheACGME

andtheGME

Office,including

i.Theprograminformationformspriortositevisits.

ii.TheannualprogramupdatesonWebADS

iii.TheTulaneannualreportasoutlinedinChapterXXII.PolicyonProgram

Evaluation,ImprovementandAnnualProgramReports

iv.Theprograminformationforanyscheduledinternalreviewsasoutlinedin

ChapterXXII.PolicyonProgramEvaluation,ImprovementandAnnual

ProgramReportsi.Ensurecompliancewithgrievanceanddueprocess

proceduresassetforthChapterXV.PolicyonRemediation,Suspension,

TerminationandGrievance.

j.Provideverificationofresidencyeducationforallresidents,includingthose

wholeavetheprogrampriortocompletion,andthosethatentertheprogramas

outlinedinChapterI.PolicyonResidentEligibilityandSelection

k.Ensurecompliancewithpoliciesandproceduresforselection,evaluationand

promotionofresidents,disciplinaryaction,andsupervisionofresidentsChapter

I.PolicyonResidentEligibilityandSelection

l.Implementandensurecompliancewithpoliciesandproceduresregardingthe

dutyhoursandtheworkingenvironment,andmoonlightingasoutlinedin

Chapter:VIII.PolicyonResidents’

DutyHours,andChapterVI.PolicyonMoonlighting.

i.Distributethesepoliciesandprocedurestotheresidentsandfaculty.

ii.Monitorresidentdutyhourswithafrequencysufficienttoensurecompliance

withACGMErequirements

iii.Adjustschedulesasnecessarytomitigateexcessiveservicedemandsand/or

fatigue42

iv.Ifapplicable,monitorthedemandsofat-homecallandadjustschedulesas

necessarytomitigateexcessiveservicedemandsand/orfatigue

m.EnsurecompliancewithChapterXXII.PolicyonProgramEvaluation,

ImprovementandAnnualProgramReports,byobtainingapprovalofthe

sponsoringinstitution’sDIObeforesubmittinginformationtotheACGME.

n.Monitorresidentstress,andtheneedforandensuretheprovisionofbackup

supportsystemswhenpatientcareresponsibilitiesareunusuallydifficultor

prolonged.

o.Maintainfamiliaritywith,andcomplywith,ACGMEandResidencyReview

CommitteepoliciesandproceduresasoutlinedintheACGMEManualof

PoliciesandProcedures.

p.Ensurethatclinicalrotationsminimizeresidents’workthatisextraneousto

theirACGME-accreditedprograms’educationalgoalsandobjectives,ensuring

thatresidents’educationalexperienceisnotcompromisedbyexcessivereliance

onresidentstofulfillnon-physicianserviceobligations.

3.ProgramDirectorSupport.

a.TheDIO,onbehalfoftheSponsoringInstitution,andtherespective

departmentalchairwillensurethateachprogramdirectorhassufficientfinancial

supportandprotectedtimetoeffectivelycarryouttheireducational,

administrative,andleadershipresponsibilitiesasdescribedintheInstitutional,

Common,andSpecialty/Subspecialty-specificProgramRequirements;B.

Faculty.

1.SupervisionofPatientCare:Propersupervisionofresidentsisexpectedinall

areasofallaffiliatedinstitutionstoassureconsistentlyhighstandardsofpatient

care.Theoverallresponsibilityforthetreatmentofeachpatientlieswiththe

facultytowhomthepatientisassignedandwhosupervisestheresident

physician.

a.Allinpatientsandoutpatientswillhaveonefacultylistedasthephysicianin

chargeofthepatient’smedicaltreatment,andthenameofthispractitionerwill

beclearlydesignatedoneachpatient'smedicalrecord.

b.Thefacultywillbeinvolvedinthecareofthepatienttotheextentnecessary

toassureconsistentlyhighstandardsofpatientcare.Thisfacultywillbe

responsiblefor,andmustbefamiliarwith,thecareprovidedtothepatient,andis

expectedtofulfillthisresponsibility,ataminimum,inthefollowingmanner:

i.Directthecareofthepatientandprovidetheappropriatelevelofsupervision

basedonthenatureofthepatient'scondition,thelikelihoodofmajorchangesin

themanagementplan,thecomplexityofcare,theexperienceandjudgmentof

theresidentbeingsupervisedandwithinthescopeoftheapprovedclinical

privilegesofthestaffpractitioner.

ii.Documentthissupervisionviaadmission,operative,procedureorprogress

notes,oranacceptablelinking-notetotheresident’sdocumentation.Thefaculty

member’sinvolvementinthepatient’scareandsupervisionoftheresident

shouldbereflectedinboththeresident’snoteandthefaculty’saddendum.

iii.Assurethatalltechnicallycomplexdiagnosticandtherapeuticprocedures

whichcarryasignificantrisktothepatientare:medicallyindicated,fully

explainedtoandunderstoodbythepatienttomeetinformedconsentcriteria,

properlyexecuted,correctlyinterpreted,andevaluatedforappropriateness,

effectivenessandrequiredfollow-up.Evidenceofthisassuranceshouldbe

documented.

iv.Directappropriatemodificationsofcareasindicatedinresponseto

significantchangesindiagnosisorpatientstatus.Evidenceofthisassurance

shouldbedocumented.

2.EducationalResponsibilities:Facultymustdevotesufficienttimetothe

educationalprogramtofulfilltheirsupervisoryandteachingresponsibilities;and

todemonstrateastronginterestintheeducationofresidents.Facultymust:

a.Activelyparticipateinattending(teachingandmanagement)roundsonadaily

basis.

b.Reviewthegoalsandobjectivesoftherotationwiththeresidentattheoutset

oftheclinicalrotation.

c.Administerandmaintainaneducationalenvironmentconducivetoeducating

residentsineachoftheACGMEcompetencyareas,asoutlinedinChapterX.

PolicyonCoreCurriculumandtheCoreCompetencies

d.Administerandmaintainaneducationalenvironmentthatiscompliantwillall

dutyhoursandworkenvironmentrequirements,asoutlinedinChapterVIII.

PolicyonResidents’DutyHours3.EvaluationResponsibilities.

a.Provideoralevaluationsoftheresident’sperformanceatthemid-pointofthe

rotationassignment.Thisevaluationshouldprovidefeedbackontheresident’s

performanceineachofthecorecompetencies.

b.Facultyareresponsibleforthetimelycompletionofallresidentevaluations,

asoutlinedintheEvaluationrequirementsbelow(ChapterXIV.Policyon

EvaluationofResidents)4.FacultyQualifications

a.Thephysicianfacultymusthavecurrentboardcertificationintheirspecialty

b.Possesscurrentmedicallicensureandappropriatemedicalstaffappointment

c.Beappointedtotheirteachingresponsibilitiesbytheprogramdirector,based

upontheireducationalabilities.

5.Non-physicianfaculty:Non-physicianfacultymayplayavaluableroleinthe

educationofresidents.

Theuseofnon-physicianfacultymustcomplywiththefollowingstandards:a.

Non-physicianfacultymusthaveappropriatequalificationsintheirfieldand

holdappropriateinstitutionalappointments.

b.Non-physicianfacultymustnotberesponsibleforthedirectsupervisionof

residentphysiciansprovidingpatientcare.

6.Facultyresponsibilitiesasawhole

a.Participateinorganizedclinicaldiscussions,rounds,journalclubs,and

conferences.

b.Establishandmaintainanenvironmentofinquiryandscholarshipwithan

activeresearchcomponent.Facultyshouldencourageandsupportresidentsin

scholarlyactivities.

c.Somemembersofthefacultyshouldalsodemonstratescholarshipbyoneor

moreofthefollowing:

i.publicationoforiginalresearchorreviewarticlesinpeer-reviewedjournals,or

chaptersintextbooks

ii.publicationorpresentationofcasereportsorclinicalseriesatlocal,regional,

ornationalprofessionalandscientificsocietymeetings

iii.participationinnationalcommitteesoreducationalorganizations.

d.Engageinprofessionaldevelopmentapplicabletotheirresponsibilitiesas

educationalleaders;7.FacultySupport.

a.TheDIO,onbehalfoftheSponsoringInstitution,andtherespective

departmentalchairwillensurethatcorefacultyreceiveadequatesupportto

ensurebotheffectivesupervisionandqualityresident/felloweducation

C.SupervisionatAffiliatedTrainingLocations.

1.AllclinicaltrainingsitesmustbecertifiedbyJCAHO,anentitygranted

“deemingauthority”forparticipationinMedicareunderfederalregulations,or

anentitycertifiedascomplyingwiththeconditionsofparticipationinMedicare

underfederalregulations.Allclinicaltrainingsitesmustbejudgedtobe

satisfactorybytheDIOandGMECinmeetingtheeducationalneedsofthe

Tulaneresident,andbeapprovedbytherespectiveACGMERRCcommittee.

2.MasterAffiliationAgreementsmustexistbetweentheUniversityandeach

affiliatedtrainingsite,andindividualprogramlettersofagreementmustexist

betweenindividualprogramsthatsendresidentstoatrainingsite.Master

AffiliationAgreementsmustbeupdatedatleasteveryfiveyears.Program

LettersofAgreementmustbeupdatedonanannualbasis,reflectingthe

ACGMEinstitutional,traininglocation,andcommonprogramrequirements.

3.Ateachparticipatingsite,theremustbeasufficientnumberoffacultywith

documentedqualificationstoinstructandsuperviseallresidentsatthatlocation,

asoutlinedinXIII.B.

4.EachclinicalsitemusthavealiaisonwiththeOfficeofGraduateMedical

Education.TheDIOis44

responsibleformeetingwitheachliaisonatleastonceperyear.Duringthese

meetings,theDIOwilltourthelearningenvironment(callrooms,meal

availability,computeraccess,patientcarevenues,conferencespace)andreview

andconfirmtheaffiliationagreementwiththetrainingsite’sliaison.TheDIO

willensurecompliancewiththeUniversityandACGMErequirementscontained

withintheMasterLettersofAffiliationandindividualprogramlettersof

agreement.

5.TheindividualprogramdirectorisresponsibleforcompliancewithallTulane

andACGMEpoliciesatallaffiliatedtraininglocationsinwhichhisorher

residentsrotate.Theprogramdirectormusthaveadesignatedliaisonwitheach

affiliatedtraininglocation.Thispersonisresponsibleforensuringcompliance

withallprogram,University,andACGMEpoliciesandprocedures,asoutlined

intheprogramletterofaffiliation.Thetrainingsiteliaisonshouldbeinregular

communicationwiththeprogramdirector,andthetwoshouldmeetinpersonat

leasttwiceperyear.Theaffiliatedtrainingsiteliaisonshouldprovidean

assessmentofthetraininglocation,asitregardscompliancewithprogram,

University,andACGMEpoliciesandprocedures,andthisinputshouldbe

documentedintheannualreportoftheprogram.

6.EachprogrammusthaveaProgramLetterofAffiliationwiththetraining

institution.ThePLAmustbeapprovedbytheDIO,andmust:

a.Identifythefacultywhowillassumebotheducationalandsupervisory

responsibilitiesforresidents;

b.Specifythefaculty’sresponsibilitiesforteaching,supervision,andformal

evaluationofresidents

c.Specifythedurationandcontentoftheeducationalexperience;and,d.State

thepoliciesandproceduresthatwillgovernresidenteducationduringthe

assignment.

D.JobDescriptionsandGraduatedLevelsofResponsibility:

1.Theprogramdirectorisresponsiblefordevelopingajobdescriptionforthe

residencyprogram.Thisjobdescriptionshouldoutlinethephysicalandmental

requirementsofthejob.Nocandidatewhoisabletoperformthephysicaland

mentalcomponentscontainedwithinthejobdescriptioncanbediscriminated

againstbaseduponadisability(SeeChapterII.PolicyonEqual-Opportunity,

AffirmativeAction,&

Disabilities).

2.Theprogramdirectormustestablishanoutlineofprogressivelevelsof

responsibilityforeachtraininglevelwithintheresidencyprogram.Residents

whoadvanceinthetrainingprogramshouldincurprogressivelygreaterlevelsof

responsibilityandindependentpracticeasoutlinedintheprogressivelinesof

responsibility.

3.Assignmentofthelevelofresponsibilitymustbecommensuratewiththe

resident’sperformanceinthecorecompetencies,andthisshouldbedocumented

intheresident’send-of-the-yearpromotionletter.

Residentswhofailtomeetexpectedcompetency,baseduponthemilestones,

shouldnotbepromoted.

E.SupervisionofResidentsPerformingInvasiveProceduresintheOperative

Suite.Theinherentrisksassociatedwithalltypesofsurgeryandinvasive

proceduresrequirethatstaffpractitionersprovideappropriatelevelsof

supervisionofallresidentsperformingsuchprocedures.

1.Facultymustbepresentforallinvasiveproceduresperformedbyresidentsin

theoperatingroomorproceduralsuite.

2.Facultysupervisingresidentswillreviewtheindicationsfortheprocedure,

andwilldocumentinthepatient’smedicalrecordtheirconcurrencewiththe

indication,risksandbenefits,theresident’sperformance,theinterpretationof

theresultsandthecomplications,ifany.

3.Facultyphysicianswillsupervisetheevaluationofpatients,schedulingof

cases,assignmentofcasepriorities,thepreoperativepreparation,andtheintra-

operativeandpostoperativecareofsurgicalpatientsandpatientsundergoing

invasiveprocedures.Thissupervisionwillbereflectedinthefaculty’sprogress

notesatappropriatetimesinthecourseofeachpatient’shospitalization.

4.Asresidentsadvanceintheireducationandtraining,theymaybegiven

progressivelyincreasinglevelsofresponsibility,asdefinedintheprogram’s

ProgressiveLinesofResponsibility.Thedegreeofresponsibilityandautonomy

willdependupontheindividual'sgeneralaptitude,demonstratedcompetence,

priorexperiencewithsimilarprocedures,thecomplexityanddegreeoftherisks

involvedin45

theanticipatedsurgical/invasiveprocedure.Programdirectorswilldocumenta

resident’sassignedlevelofresponsibilityintheresident'srecord.Thiswill

includethetypesofdiagnosticortherapeuticprocedurestheresidentmay

perform,thedegreeofautonomyaffordedtotheresidentinperformingthose

procedures,andthoseproceduresforwhichtheresidentmayactasateaching

assistant.

5.Animportantaspectofaresident’slearningexperienceistheopportunityofa

seniorresidenttosupervisemorejuniorresidents.Asageneralrule,senior

residents,whenactingintheroleofateachingassistanttolessexperienced

residents,maysupervisetheperformanceofsurgical/invasiveproceduresof

lesserormoreroutinecomplexity.This,however,doesnotreleasetheFaculty

practitioner'sresponsibilityfortheoversightofthepatient'scare.Whena

residentisactingasateachingassistant,thestaffpractitionerremains

responsibleforthequalityofcareofthepatient,providingsupervisionand

meetingmedicalrecordeddocumentationrequirementsasdefinedwithinthis

policy.

F.SupervisionofResidentsPerformingInvasiveProceduresattheBedside.

1.Facultydonotneedtobephysicallypresentforsupervisionofinvasive

proceduresperformedbyresidentsatthebedside,buttheyremainresponsible

forensuringthattheprocedureissafelyperformed.

Thisincludesreviewingwiththeresidenttheindicationsfortheprocedure;

facultywilldocumentinthepatient’smedicalrecordtheirconcurrencewiththe

indication,risksandbenefits,theresident’sperformance,theinterpretationof

theresultsandthecomplications,ifany.

2.Asresidentsadvanceintheireducationandtraining,theymaybegiven

progressivelyincreasinglevelsofresponsibility,asdefinedintheprogram’s

ProgressiveLinesofResponsibility.Thedegreeofresponsibilityandautonomy

willdependupontheindividual'sgeneralaptitude,demonstratedcompetence,

priorexperiencewithsimilarprocedures,thecomplexityanddegreeoftherisks

involvedintheanticipatedinvasiveprocedure.

3.Programdirectorswillmaintainalistofbedsideproceduresthatcanbe

performedbytheirresidentsatthebedsidewithoutdirectsupervision.

a.Programdirectorswillassigntoeachresidentwhichproceduresheorshecan

performwithoutdirectfacultyorseniorresidentsupervision.Thisassignment

shouldnotbebasedsolelyupontheresident’sPGYstatus,butratherassigned

individuallybasedupontheresident’saptitude,demonstratedcompetence,and

priorexperiencewithsimilarprocedures.

b.Residentswhohavebeendeemedcompetenttoperformaprocedurewithout

directsupervisionwillbegivenahologramsticker,specifictothatprocedure,to

beplacedonthebackoftheirID.

c.Nursesandappropriateconsultingprovidersshouldasktoseearesident’s

validationstickerpriortoallowingaresidenttoperformthebedsideprocedure.

d.Residentswithoutsuchavalidationstickermaystillperformtheprocedure,

butmusthaveaseniorresident(whohassuchavalidationsticker)orfaculty

memberpresentatallphasesoftheprocedure.

G.SupervisionofTransitionsofCare

1.Programdirectorsmustfacilitateprofessionaldevelopmentforcorefaculty

membersandresidents/fellowsregardingeffectivetransitionsofcare.This

instructionshouldinclude:a.Theprinciplesandpurposeofclose-loop

communication

b.Appropriateidentificationofillnessseverity

c.Appropriatepatientsummaries,asdefinedbythepatient’scomplexityand

tenuousnessd.Appropriateactionlists,asdefinedbythepatient’scomplexity

andtenuousnesse.Situationawarenessandcontingencyplanning

2.Programdirectors,inconcertwiththeDIO,mustensurethatparticipating

sitesengageresidents/fellowsinstandardizedtransitionsofcareconsistentwith

thesettingandtypeofpatientcare.

a.First-yearresidents(i.e.,,interns)mustbedirectlysupervisedintheir

transitionsofcare(i.e.,sign-out)byseniorresidentsorin-housefacultyuntil

whichtimetheprogramdirectorhasdeterminedthattheinterncansafely

conducttransitionsofcare.

b.Programdirectors,workingwithlocalsitedirectors,mustensurethatinterns

aredirectlyobservedintheirtransitionsofcare(i.e.,signout)untilwhichpoint

theprogramdirectorissatisfiedthattheinternhasdemonstratedsufficient

masteryoftransitionscommunicationto46

warranttransitionsofcaredutieswithoutdirectsupervision.

H.ReportingFall-OutsinSupervision

1.TheGMEOfficerecognizesthattheclinicalenvironmentcanbecomplex,

heterogeneousanddynamiconaday-to-daybasis.Nonetheless,thereshouldnot

beanoccasioninwhichresidentsareinadequatelysupervisedorinaposition

wheretheybelievetheirclinicalresponsibilitiesareabovetheirclinical

responsibilities.

2.Itistheresponsibilityofallresidentsandfaculty,regardlessofwhetherthey

weredirectlyinvolvedintheincidentornot,toreporteventsofinadequate

supervision.Residentsandfacultyaretoreporteventsinvolvinginadequate

supervisionviaoneormoreofthefollowingmechanisms.

a.Anonymousreportingviaresident-of-rotationorResident-of-facultyE-value

evaluations.

b.Directreportingtoattendingphysiciansortheprogramdirector.

c.Anonymousreportingviatheaffiliatedinstitution’s(iehospital/clinic)near-

miss/adverseeventreportingsystem

d.ReportingtotheResidencyEducationCommittee,eitherdirectlyorviathe

resident’s/faculty’srepresentative

e.TulaneResidentandFellowsCongress,eitherdirectlyorviatheresident’s

representativef.Resident-of-Programannualevaluation

g.DirectreportingtotheDepartmentChair

g.DirectreportingtotheDIO

ApprovedbytheGMEC;May26th,2015

XIV.POLICYONEVALUATION

A.Evaluations

Itistheresponsibilityoftheprogramdirector,andtheassociatedfaculty,to

ensurethat1.Residentsreceivetimely,accurateandmeaningfulevaluationsof

theirperformanceineachofthesixcorecompetencies.

2.Residentsreceiveanaccurateassessmentoftheirdevelopmentalprogress

alongthemilestonesofeachentrustableprofessionalactivities(EPA)fortheir

respectivetrainingprogram.

B.AfferentEvaluations

1.Faculty-of-ResidentEvaluations.

a.Thisevaluationmustbeconductedattheconclusionofeachrotation

assignment.Forassignmentsgreaterthanonemonth,theevaluationmustbe

conductedattheconclusionoftherotation,aswellasatthemidpointofthe

rotation,oreverytwomonths,whicheverisless.

b.Theevaluationshouldconsistofbothnumericalscores(objective)andwritten

comments.

c.Theevaluationshouldevaluateeachofthecorecompetencies(SeeChapterX.

PolicyonCoreCurriculumandtheCoreCompetencies)andthecomponentsof

thejobdescriptionfortheresident’sleveloftraining.

d.Theevaluationshouldbeconductedelectronicallysuchthatresidentshave

immediateand24

houraccesstoreviewingtheevaluation.

e.Theevaluationshouldbediscussedinpersonwiththeresidentpriortothe

conclusionoftherotation.

f.TheprogramdirectorandtheResidencyEducationCommitteewillusedata

fromtheseevaluationsinmakingthedeterminationforpromotionorgraduation.

g.Eachprogramisrequiredtousefaculty-of-residentevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

2.Resident-of-ResidentEvaluations

a.Inrotationswhereresidentsareroutinelysupervisingotherresidents(i.e.,a

residentsupervisinganintern),bothresidentsshouldbegiventheopportunityto

evaluateeachother.

b.Theevaluationshouldconsistofbothanumericalscoreandwritten

comments.

c.Theevaluationshouldevaluateeachofthecorecompetencies(SeeChapterX:

PolicyonCoreCurriculumandtheCoreCompetencies)andthecomponentsof

thejobdescriptionfortheresident’sleveloftraining(SeeXIII:Fbelow).

d.Theevaluationshouldbeconductedelectronicallysuchthatresidentshave

immediateand24

houraccesstoreviewingtheevaluation.

e.Collectively,datafromtheseevaluationsshouldbeusedbytheprogram

directorinmakingthedeterminationforpromotionorgraduation.

f.Eachprogramisrequiredtousetheresident-of-residentevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

3.Student-of-ResidentEvaluations

a.Inrotationswhereresidentsareroutinelysupervisingstudents,studentsmust

begiventheopportunitytoevaluatetheresident.

b.Theevaluationshouldconsistofbothanumericalscoreandwritten

comments.

c.Theevaluationshouldevaluateataminimumtheresident’steaching,

communication,interpersonalskills,professionalismandpatientcareskills.

d.Theevaluationshouldbeconductedelectronicallysuchthatresidentshave

immediateand24

houraccesstoreviewingtheevaluation.

e.Collectively,datafromtheseevaluationsshouldbeusedbytheprogram

directorinmakingthedeterminationforpromotionorgraduation.

f.Eachprogramisrequiredtousethestudent-of-residentevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

4.Patient-of-ResidentEvaluations

a.Inrotationswhereresidentsroutinelyprovidepatientcare,patientsmustbe

giventheopportunitytoevaluatetheresidentoverseeinghisorhercare.

b.Whilenoteverypatientneedstoevaluatetheresident,atleastonepatient

evaluationshouldbesolicitedduringeachoftheclinicalrotationsthatthe

programdirectordesignatesascoreclinicalrotations.

d..Theevaluationshouldevaluateataminimumtheresident’scommunication,

interpersonalskills,professionalismandpatientcareskills.

d.Theevaluationmaybecollectedbypaperorinpersonbyasupervisor,but

shouldeventuallybeconvertedtoanelectronicformatsuchthattheresidenthas

immediateand24houraccesstoreviewingtheevaluation.

e.Collectively,datafromtheseevaluationsshouldbeusedbytheprogram

directorinmakingthedeterminationforpromotionorgraduation.

f.Eachprogramisrequiredtousethepatient-of-residentevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

5.Nurse/AlliedHealthProvider-of-Resident

a.Inrotationswhereresidentsroutinelyprovidepatientcare,nursingand

ancillarystaff(i.e.,OR

staff,respiratorytherapy,etc.)mustbegiventheopportunitytoevaluatethe

residentwithwhomtheyhaveworkedduringtherotation.

b.Whilenoteverystaffneedstoevaluatetheresident,atleastonenurse

evaluationshouldbesolicitedduringeachoftheclinicalrotationsthatthe

programdirectordesignatesascoreclinicalrotationsappropriateandfeasiblefor

nurse-of-residentevaluations.

d.Theevaluationshouldevaluateataminimumtheresident’scommunication,

interpersonalskills,professionalismandpatientcareskills.

d.Theevaluationmaybecollectedbypaperorinpersonbyasupervisor,but

shouldeventuallybeconvertedtoanelectronicformatsuchthattheresidenthas

immediateand24houraccesstoreviewingtheevaluation.

e.Collectively,datafromtheseevaluationsshouldbeusedbytheprogram

directorinmakingthedeterminationforpromotionorgraduation.

f.Eachprogramisrequiredtousethenurse-of-residentevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

6.Resident-of-Self.

a.Thisevaluationmustbeconductedatleasttwiceperyear.

b.Theevaluationshouldconsistofbothanumericalscoreandopportunityfor

written,self-reflectioncomments.

c.Ataminimum,theevaluationshouldallowtheresidenttoevaluatethe

followingcomponentsi.Aself-evaluationineachofthesixcorecompetencies

areasii.Alistingofmedicalerrorsfromtheprevioussixmonths,andself-

reflectiononhowtheseerrorscouldhavebeenprevented.

iii.Areflectionontheresident’sprogressinprofessional/careergoalsiv.A

reflectionontheresident’sprogressinpersonalgoals.

d.Theevaluationshouldbeconductedelectronically,andinamannerthat

ensurestheresidentsanonymitytoenableeffectiveevaluationswithoutthefear

ofreprisal.

e.Eachprogramisrequiredtousetheresident-of-selfevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

B.EfferentEvaluations

1.Resident-of-ResidentEvaluations

a.Inrotationswhereresidentsareroutinelysupervisingotherresidents(i.e.,a

residentsupervisinganintern),bothresidentsshouldbegiventheopportunityto

evaluateeachother.

b.Theevaluationshouldconsistofbothanumericalscoreandwritten

comments.

c.Theevaluationshouldevaluateeachofthecorecompetencies(SeeChapterX:

PolicyonCoreCurriculumandtheCoreCompetencies)andthecomponentsof

thejobdescriptionfortheresident’sleveloftraining(SeeXIII:Fbelow).

d.Theevaluationshouldbeconductedelectronicallysuchthatresidentshave

immediateand24

houraccesstoreviewingtheevaluation.

e.Collectively,datafromtheseevaluationsshouldbeusedbytheprogram

directorinmakingthedeterminationforpromotionorgraduation.

f.Eachprogramisrequiredtousetheresident-of-residentevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

2.Resident-of-Faculty.

a.Thisevaluationmustbeconductedmonthly,or,forrotationsthatarelonger

thanonemonth,attheconclusionoftherotation,oreverythreemonths,

whicheverisless.

b.Theevaluationshouldconsistofbothanumericalscoreandwritten

comments.

c.Theevaluationshouldevaluatethefacultyonhisorhereffectivenessin

teaching,commitmenttotheeducationalprogram,clinicalknowledge,and

professionalism.

d.Theevaluationshouldbeconductedelectronically,andinamannerthat

ensurestheresidentsanonymitytoenableeffectiveevaluationswithoutthefear

ofreprisal.AllprogramsuseEVALUE’slock-outfeaturetoensurethatfaculty

cannotseetheirevaluationsuntilatleastfivelearnershaveevaluatedthefaculty;

allcommentsareaggregatedtode-linkthecommentfromthetimeperiodin

whichitwasreceive.

e.Theresultsoftheseevaluationsshouldbeusedbytheprogramdirectorin

decidingwhichfacultyareinvitedtocontinuetosuperviseresidentsonclinical

rotations.

f.Eachprogramisrequiredtousetheresident-of-facultyevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

3.Resident-of-Rotation.

a.Thisevaluationmustbeconductedmonthly,or,forrotationsthatarelonger

thanonemonth,attheconclusionoftherotation,oreverythreemonths,

whicheverisless.

b.Theevaluationshouldconsistofbothanumericalscoreandwritten

comments.

c.Ataminimum,theevaluationshouldevaluatethefollowingcomponentsi.

Thecallrooms(ifapplicable)

ii.Thenursesandancillarystaffinvolvedintheclinicalrotationiii.Thesafety

oftherotation(parking,secureplaceforpersonalbelongings)50

iv.Thecommunicationinfrastructureoftherotation(accesstomedicalrecords

andpatientdata,accesstoeducationalresources).

v.Thebalancebetweeneducationandserviceofthisrotation.

vi.Therotation’scompatibilitywithduty-hoursrequirements.

d.Theevaluationshouldbeconductedelectronically,andinamannerthat

ensurestheresidentsanonymitytoenableeffectiveevaluationswithoutthefear

ofreprisal.

e.Collectively,datafromtheseevaluationsshouldbeusedbytheprogram

directorinmakingthedeterminationforcontinuationofaclinicalrotation.

f.Eachprogramisrequiredtousetheresident-of-rotationevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

4.Resident-of-Program.

a.Thisevaluationmustbeconductedatleastonceperyear.

b.Theevaluationshouldconsistofbothanumericalscoreandopportunityfor

writtencomments.

c.Ataminimum,theevaluationshouldevaluatethefollowingcomponentsi.

Thegoalsandobjectivesofeachclinicalrotation,includingthebalancebetween

educationandserviceofeachrotation

ii.Thecurriculumandcoreeducationalconferences.

iii.Thesupervisionbythefaculty,andthefaculty’sclinicalteachingabilities,

commitmenttotheeducationalprogram,clinicalknowledge,professionalism,

andscholarlyactivities.

iv.Theeffectivenessoffacultyinprovidingmeaningfulevaluationstothe

residents.

v.Theeffectivenessoftheprogramdirector.

vi.Theprogram’scompliancewithduty-hoursrequirementsandotherprogram

policiesd.Theevaluationshouldbeconductedelectronically,andinamanner

thatensurestheresidentsanonymitytoenableeffectiveevaluationswithoutthe

fearofreprisal.

e.Collectively,datafromtheseevaluationsshouldbeusedbytheprogram

directorinmakingadjustmentsintheresidencyprogram.Theresultsofthese

evaluationsmustbeincludedintheannualreport.

f.Eachprogramisrequiredtousetheresident-of-programevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

5.Resident-of-Self.

a.Thisevaluationmustbeconductedatleasttwiceperyear.

b.Theevaluationshouldconsistofbothanumericalscoreandopportunityfor

written,self-reflectioncomments.

c.Ataminimum,theevaluationshouldallowtheresidenttoevaluatethe

followingcomponentsi.Aself-evaluationineachofthesixcorecompetencies

areasii.Alistingofmedicalerrorsfromtheprevioussixmonths,andself-

reflectiononhowtheseerrorscouldhavebeenprevented.

iii.Areflectionontheresident’sprogressinprofessional/careergoalsiv.A

reflectionontheresident’sprogressinpersonalgoals.

d.Theevaluationshouldbeconductedelectronically,andinamannerthat

ensurestheresidentsanonymitytoenableeffectiveevaluationswithoutthefear

ofreprisal.

e.Eachprogramisrequiredtousetheresident-of-selfevaluationtemplate

providedbytheGraduateMedicalEducationOffice.Tailoringoftheevaluation

questionstotheuniquefeatureofthetrainingprogramisallowed,butthe

modificationsmustnotdeviatefromtheintentofeachquestiononthe

evaluation,asitrelatestotheACGMEcommonprogramrequirements.

C.CaseLogs

Inprogramsthatrequireminimumnumbersofprocedurestoensurepromotion,

graduation,oreligibilityforcertifyingexaminations(i.e.,boardlicensure),a

caselogmustbecompiledandupdatedonasemi-annualbasis,ormore

frequentlyifspecifiedbythetrainingprogram.Thecaselogshouldbereviewed

withtheresidentateachsemi-annualmeetingwithhisorherprogramdirector.

D.AccesstoEvaluations

TheFamilyEducationalRightsandPrivacyAct,requireseducationalagencies

orinstitutionstoprovideaccesstoeducationalrecordswithcertainlimitations.

Residentandfelloweducationrecords,otherthanpubliclyavailabledirectory

information,areprivateandshallnotbedisclosedexceptasappropriatetothe

following:1.Theresidentorfellow,whomayreviewhisorherrecordwith

supervision2.TheprogramdirectorandtheAssociateDeanforGraduate

MedicalEducation3.Personsspecificallyauthorizedbytheresidentorfellowin

writingtoreceivetheinformation;4.Othereducationalinstitutionsinwhichthe

residentorfellowseekstoenrollorobtainemployment,withpermissionofthe

residentorfellow,providedthedisclosureislimitedtoofficialcopiesofresident

orfellow’stranscriptsfromtheappropriateUniversityoffice;5.Other

organizationsconductingeducationalresearchstudiesapprovedbytheir

respectiveInstitutionalReviewBoards,providedthestudiesareconductedina

mannerthatdoesnotpermitidentificationofresidentsandprovidedthe

informationwillbedestroyedwhennolongerneededforthespecifiedpurpose;

6.Personsincompliancewithacourtorderorlawfullyissuedsubpoena

providedthatareasonableattemptismadetonotifytheresidentorfellowwhere

requiredpriortorelease;7.Appropriatemembersofthecourtsystemwhenlegal

actionagainsttheUniversityisinitiatedbytheresidentorfellowandthe

disclosureispartoftheUniversity’sdefense;8.Appropriatepersonsduringan

emergency,providedtheinformationisnecessarytoprotectthehealthorsafety

oftheresidentorfelloworotherindividuals;

9.Accreditingorganizationsandstateorfederaleducationauthoritiesusing

informationforauditing,evaluating,orenforcinglegalrequirementsof

educationalprograms,providedthedataisprotectedtoprohibittheidentification

oftheresidentorfellowandallpersonallyidentifiableinformationisdestroyed

whennolongerneeded;and

10.Appropriatepersonsoragenciesinconnectionwitharesidentorfellow’s

applicationfororreceiptoffinancialaidtodetermineeligibilityamount,or

conditionsoffinancialaidandtoenforcethetermsandconditionsoftheaid.

E.PromotionandGraduation

1.Eachresidencyprogramisrequiredtocreateandmaintainacriteriafor

promotionforeachyearoftraining(SeeProgressiveLinesofResponsibility).

Thiscriteriashouldbebasedupontheentrustableprofessionalactivities(EPA’s)

fortherespectivefield,andtheeventualrequirementsforboardcertification.

Decisionsastopromotionand/orrenewalofaresident’sappointmentmustbe

madeincontextofthiscriteria.

2.Residentsmustreceiveawrittensummaryoftheirperformance,basedupon

thecorecompetencies,atleasttwiceperyear.Thesummarylettermustcontaina

descriptionoftheresident’sprogressalongeachoftheentrustableprofessional

activities(EPA)inthetrainingprogram,asbasedupontheircollectivefaculty,

patient,nurse,andpeerevaluationstothatpointintheyear.

a.Mid-YearEvaluationSummaries.Theprogramdirectororhisorherdesignee

mustmeetwitheachresidentinpersontoreviewthemid-yearevaluation.The

summarylettermustcontainanumericalassessmentoftheresident’smilestones

progressoneachentrustableprofessionalactivity(EPA),asbasedupontheir

collectivefaculty,patient,nurse,andpeerevaluationstothatpointintheyear;

thesummarymustalsoprovideanarrativecommentaryonhisorherlevelof

performance,ornotethatsuchwrittencommentsareavailabletotheresidenton

theE-Value52

summaryreport.Iftheresidentisatriskfornotbeingpromotedbaseduponthis

evaluation,thisshouldbediscussedwiththeresidentatthistime.

b.End-of-YearEvaluationSummaries.Theprogramdirectororhisorher

designeemustmeetwitheachresidentinpersontoreviewtheend-of-year

evaluation.Thesummarylettermustcontainanumericalassessmentofthe

resident’smilestonesprogressoneachentrustableprofessionalactivity(EPA),as

basedupontheircollectivefaculty,patient,nurse,andpeerevaluations

throughouttheyear;thesummarymustalsoprovideanarrativecommentaryon

hisorherlevelofperformance,ornotethatsuchwrittencommentsareavailable

totheresidentontheE-Valuesummaryreport.Ifsowarranted,thepromotion

lettertothenextyearoftrainingshouldbegiventotheresidentatthistime,and

thelettermustclearlystatethattheresidentisbeingpromotedtothenextyearof

training.Thelettermustbeaccompaniedbyadescriptionoftheprogressive

levelofresponsibilitycommensuratewiththePGYleveltowhichheorsheis

beingpromoted.

3.Adversepromotionorgraduationdecisions

a.PromotionandgraduationdecisionsmustbemadebytheClinical

CompetencyCommittee’sincorporationofaglobalassessmentoftheresident.

Decisionsforpromotioncannotbebasedsolelyonin-servicescores.

b.Iftheresidentisnottobepromoted,ortorepeatrotationsthatwouldrequire

extensionoftotaltrainingtime,theprogramshouldinformtheresident,and

followthepoliciesandproceduresasoutlinedin(ChapterXV.Policyon

Remediation,Suspension,TerminationandGrievance)..

4.End-of-TrainingEvaluationSummaries.Theprogramdirectororhisorher

designeemustmeetwitheachresidentinpersontoreviewtheend-of-training

evaluation.Thesummarylettermustcontainadescriptionoftheresident’s

milestoneprogressoneachentrustableprofessionalactivity(EPA),asbased

upontheircollectivefaculty,patient,nurse,andpeerevaluationsthroughoutthe

year;thesummarymustalsoprovidewrittencommentaryonhisorherlevelof

performance,ornotethatsuchwrittencommentsareavailabletotheresidenton

theE-Valuesummaryreport.Thisevaluationshoulddocumenttheresident’s

performanceduringthefinalperiodofeducation.

a.Ifsowarranted,thegraduationlettershouldbegiventotheresidentatthis

time,andthelettermustclearlystatethattheresidenthascompletedthetraining

programand“Theprogramdirector,inconsultationwiththeprogram’sclinical

competencycommittee,hasdeemedtheresidentsufficientlycompetenttoenter

practicein“x”independentlyandwithoutdirectsupervision.”Where“X”isthe

fieldoftheresident’strainingprogram.

b.Iftheresidentisnottobegraduated,adescriptionoftherationale,referencing

failuretomeetsatisfactorilythecorecompetencies,shouldbeincludedinthis

letter.

i.Iftheresidentisaskedtoextendtotaltrainingtime,heorshemustbegivenan

opportunitytoappealthisdecisiontotheClinicalCompetencyCommittee.If

uponappeal,theClinicalCompetencyCommitteeupholdsthedecisiontoextend

training,theresidenthasarighttogrievethisdecisionthroughtheUniversity’s

GrievanceCommittee(ChapterXV.PolicyonRemediation,Suspension,

TerminationandGrievance).

ii.Ifthedecisionistoterminatetheresidentfromthetrainingprogram,the

residentmustbegiventheopportunitytoappeal(grieve)thisdecisiontothe

University’sGrievanceCommittee,asoutlinedintheTulaneUniversityGME

policiesandprocedures(ChapterXV.PolicyonRemediation,Suspension,

TerminationandGrievance).

ApprovedbytheGMEC;May26th,2015

XV.POLICYONREMEDIATION,SUSPENSION,TERMINATIONAND

GRIEVANCE

A.DEFINITIONS

1.Personnel

a.Resident–referstoallinterns,residentsandfellowsparticipatinginaTulane

UniversitySchoolofMedicinepost-graduatetrainingprogram.

b.ResidencyProgram–referstoaresidencyorfellowshipeducationalprogram.

c.ProgramDirector-referstotheDirectoroftheResidencyProgram.

d.DIO-referstotheDesignatedInstitutionalOfficial,alsoknownasthe

AssociateDeanofGraduateMedicalEducation.

e.AdministrativePersonnel-Programdirectors,departmentalchairs,andCEO’s

ofaffiliatedtraininglocations.

2.Actions

a.Probation–aformallevelofdisciplineinwhichtheresidentmaystillengage

inhisorhertrainingprogramwithintheconfinesofaprobationaryplan.Implicit

in“probation”isthatfailuretosuccessfullycompletetheprobationplanwill

resultineitherextensionoftheprobationorterminationofthecontract,atthe

clinicalcompetencycommittee’sdiscretion.

b.Remediation-theprocessofimprovingresidentperformance.Remediation

mayoccureitherwithin,orseparatefrom,probation.

c.Suspension-aformallevelofdisciplineinwhichtheresidentwilltemporarily

nolongerengageinhisorhertrainingprogram.

d.Termination–theactofseveringemploymentpriortotheexpirationdateof

theresident’scontract.Ifaresidentisterminated,hisorherresidentcontractwill

notberenewed.

e.Non-Renewal–adecisiontonotrenewaresident’sparticipationina

residencyprogram.Intheabsenceofextenuatingcircumstances,suchadecision

shouldideallybemadenolaterthanfourmonthspriortotheinitiationofthe

resident’snextcontractstartdate.Terminationandnon-renewalafterthisdate

remainsanoption.

f.Grievance-aformalprocessofcontestingthedecisionmadebytheevaluation

andremediationprocedure.

B.GENERALPRINCIPLES

1.Residentsareexpectedtomeetandadheretoallacademic,clinicaland

professionalstandardssetforthintheinstitutional,departmental,andresidency

programrequirements.Inadequateperformanceorunprofessionalbehavioris

groundsfordisciplinaryaction,upto,andincluding,termination.

2.Unprofessionalbehaviorincludes,butisnotlimitedto,actingimproperly

towardspatients,supervisorsand/orpeers;disrespectforfaculty,patients,

supervisorsand/orpeers;dishonest,unethicaland/orillegalbehavior;failureto

meetclinicalresponsibilities;andfailuretocorrectdeficienciesinacademic

performanceinaresponsibleandtimelyfashion.

3.Inadequateperformanceshouldbeclearlycommunicatedtotheresident,

preferablyinwriting,asearlyaspossible.

C.REMEDIATIONANDPROBATION.

Probationandremediationareusedtocorrectacademicand/orprofessional

deficits,including,butnotlimitedto,deficitsinmedicalknowledge,time

management,organizationalabilities,communicationskills,andprocedural

skills.

1.Remediationistheprocessofimprovingresidentperformance.Remediation

mayoccureitherwithin,orseparatefrom,probation.

a.Whereremediationisseparatefromprobation,itisavoluntaryexerciseonthe

partoftheresidenttoengageinactivitiestoimprovehisorherperformance.As

such,remediationisnotreportable,normayaresidentbemandatedto

participateinstand-alone(i.e.,separatefromprobation)remediation.

2.Probationisaformallevelofdisciplineinwhichtheresidentmaystillengage

inhisorhertrainingprogramwithintheconfinesofaprobationaryplan.Implicit

in“probation”isthatfailuretosuccessfullycompletetheprobationplanwill

resultineitherextensionoftheprobationorterminationofthecontract,atthe

clinicalcompetencycommittee’sdiscretion.

TheOfficeofGraduateMedicalEducation,inconcertwiththeresident’s

programdirector,overseesallprobationsasoutlinedabove.

a.Thedecisionforprobationshouldbemadebytherespectiveprogram’s

ClinicalCompetencyCommittee,afterthiscommitteehasreviewedthe

resident’sperformanceevaluations.

b.Ifafterreviewingtheresident’sperformanceevaluations,theCCCagreesthat

probationisappropriate,theresidentwillbesonotified,andhe/shewillbe

informedthatheorshehastherighttoaddresstheCCCtocontestthedecision.

Thedecisionforprobationisotherwisenotgrievable.

c.Theresidentwillbegivenaprobationagreementthatwilloutlinetheterms

andtimeframeoftheprobation.

d.Shouldtheresidentrefusetheprobationagreement,hisorhercontractwith

theUniversitywillbeterminated.He/shewillthenhaveanopportunitytogrieve

thisdecisionasoutlinedbelowintheprovisionsoftermination.

e.GuidelinesforProbationandRemediation.Aprobationplanwillbedeveloped

bytheprogramdirector,inconcertwithClinicalCompetencyCommitteeforthe

respectiveprogram.Theprobationplanwillgenerallyhavethefollowing

components:

i.Documentationofdeficiencies.Exceptinextenuatingcircumstances,

probationshouldnotbeevokedforaone-timeevent,includingisolated

performancesonin-serviceexaminations.Apatternofdeficiencyshouldbe

documentedintheresident’sfile.

ii.Formalandexplicitpresentationofthedeficiency.Theresidentwillbe

presentedawrittenaccountofthedeficiency.

iii.Theprobationplanwillhaveadefinedtime-line,nolessthanthree,butnot

morethan12months.

iv.Theprobationplanwillhaveanaprioriend-point(s)thatwilldefinethe

successorfailureoftheremediationeffort.Theprobationplan’send-pointsmust

beachievablewithinthetime-frameoutlinedintheprogram.

v.Thefocusoftheremediationeffortwillmatchthedeficiency.

a.MedicalKnowledge

b.TimeManagement&Organization

c.ClinicalReasoning

d.Communication

e.PatientInteraction

f.Attitude&Motivation

g.Inter-personalandTeamSkills

h.ProceduralSkills

f.Theprogramdirectorwilldesign,inconcertwiththeCCC,theremediation

planandhavetheprobationplanreviewedbytheDIOpriortomeetingwiththe

resident.

g.Theprobationplanwillincludeplannedeffortsbytheprogramdirectororthe

programfacultytohelptheresidentimprove.Whiletheresidentisultimately

accountableforimprovement,theprogramandtheprogramdirectorare

responsibleforhelpingtheresidenttoimprove.

h.Theaccountsoftheprobationplanwillbedocumented,withatleastonemid-

pointevaluationthatwillbecommunicatedtotheresident.

i.Theconsequencesoffailuretosuccessfullycompletetheremediationprogram

willbeclearlyoutlined.

j.Uponsuccessfulcompletionoftheprobationplan,theresidentwillbe

removedfromthisstatus.

Documentationwillremainpartoftheresident’spermanentfile.

k.Uponfailuretosuccessfullycompletetheprobationplan,theresidentwillbe

askedtoeitherrepeattraining,extendtraining,besubjecttonon-renewal,orbe

terminated.Theremediationmaybeextendedforaperiodnottoexceedsix

months,attheprogramdirector’sdiscretion.For55

terminationornon-renewalactions,theresidentwillbeprovidedacopyofthe

grievanceandfairhearingpolicy,andwillsignacknowledgmentofreceiptof

thisdocument.

D.NON-RENEWAL,NON-PROMOTION,DELAYEDGRADUATIONAND

TERMINATION

1.Non-Renewalisadecisiontonotrenewaresident’sparticipationina

residencyprogram.

a.Intheabsenceofextenuatingcircumstances,suchadecisionshouldideallybe

madenolaterthanfourmonthspriortotheinitiationoftheresident’snext

contractstartdate.Terminationandnon-renewalafterthisdateremainsan

option.

b.IfaResident’scontractisnottoberenewed,heorshewillbegivenwritten

notice,andheorshemustbegivenanopportunitytoappealthisdecisiontothe

ClinicalCompetencyCommittee.

Ifuponappeal,theClinicalCompetencyCommitteeupholdsthedecisionto

extendtraining,theresidenthasarighttogrievethisdecisionthroughthe

University’sGrievanceCommittee(SeeXIV.HBelow)

2.Non-Promotionisadecisiontonotpromotetheresidenttohigherlevelsof

trainingbaseduponmerit-basedcompetency.Thedecisiontonotpromotea

residentrestswiththeprogram’sClinicalCompetencyCommittee.

a.Ifthedecisiondoesnotnecessitateextendedtrainingtime,thedecisionisnot

grievable.

b.Ifthedecisionwillrequireextendedtrainingtime,theresidentwillbegiven

writtennotice,andheorshewillbegivenanopportunitytoappealthisdecision

totheClinicalCompetencyCommittee.Ifuponappeal,theClinicalCompetency

Committeeupholdsthedecisiontoextendtraining,theresidenthasarightto

grievethisdecisionthroughtheUniversity’sGrievanceCommittee(SeeXIV.H

Below)

3.DelayedGraduation

a.Iftheresidentisaskedtoextendtotaltrainingtime(i.e.,delaygraduation)for

performancereasons,heorshewillbegivenwrittennotice,andheorshewillbe

givenanopportunitytoappealthisdecisiontotheClinicalCompetency

Committee.Ifuponappeal,theClinicalCompetencyCommitteeupholdsthe

decisiontoextendtraining,theresidenthasarighttogrievethisdecision

throughtheUniversity’sGrievanceCommittee(SeeXIV.HBelow)b.The

decisiontoextendtotaltrainingtimebecauseoftimemissed(i.e.,leaveof

absence)thatexceedsthemaximalamountoftime-missedallowedbythe

respectiveBoardisnotagrievabledecision.

c.Preliminaryinternscannotbemadetoextendtheirpreliminarytrainingtime.

Inadequateperformanceshouldresultinthedecisiontonotgrantcreditforthe

yearoftraining.

4.Terminationisadecisiontoendaresident’scontractwiththeUniversity.

a.Terminationcanariseinthefollowingcircumstances:

i.Thisdecisionisgenerallyreservedfor,butnotlimitedto,academicand/or

professionaldeficitsthat,inthediscretionoftheDIO,aresignificant,repeated,

orirremediable.

ii.Terminationdecisionsmayalsobeevokedforfailuretoparticipatein,or

successfullycomplete,probationagreements.

iii.Failuretomaintaintherequirementsofemployment,asoutlinedinthe

residentcontract.

b.Inallcasesoftermination,theresidentwillbeinformedofthedecisionby

writtennotice.Theresidentwillbeinformedofthegrievancepolicy.Heorshe

willhavefivebusinessdaysafterbeinginformedofthedecisiontofilea

grievancewiththeDIO.

E.SUSPENSION-

1.Suspensionisaformallevelofdisciplineinwhichtheresidentwill

temporarilynolongerengageinhisorhertrainingprogram.Thepurposeof

suspensionistoallowtimetoinvestigatearesidentissueandtofinedetermine

theappropriatepathwaytoresolvethatissue,and/ortoensuretheresident

receivesappropriateassistancetoensurethatheorsheisfitforduty.

a.Suspensiontoenabletimetoinvestigateacomplaintanddeterminethe

appropriateactionwillbesuspensionwithpayandbenefits.

b.Suspensiontoensuretheresidentreceivesappropriateassistancetoensure

thatheorsheisfitforduty(i.e.,thePhysiciansHealthFoundation)willbe

suspensionwithbenefitsbutwithoutpay,unlessdesignatedbytheDIO.

2.SuspensionscanonlybereversedbytheDIOortheDean.

F.SELF-REFERALPATHWAY

1.TheSelf-ReferralPathwayisdesignedtoengageresidentstoseekevaluation

and/ortreatmentofpsychiatricimpairment,drugoralcoholabuse.

2.TheSelf-ReferralPathwayisdescribedinChapterXV:Residents’Assistance

Program.

G.THEADMINISTRATIVE-REFERRALPATHWAY

1.Anyresidentwhoseperformanceisassessedtobeunsatisfactoryby

AdministrativePersonnelmaybereferredtotheDIOforevaluationand

remediationthroughtheAdministrative-ReferralPathway.Oncereferred,a

residentispreliminarilysuspended;payandbenefitswillcontinueduringthe

preliminarysuspension.Thispreliminarysuspensionisnotdisciplinaryin

nature.Rather,itisdesignedtoallowtheDIOsufficienttimetoinvestigatethe

referral.

2.AwrittenrequestmustbemadebytheAdministrativePersonneltotheDIO.

TheDIOmayalsodirectlyinitiatetheAdministrativeReferralprocess.

3.Uponreceivingorinitiatingtherequest,theDIOwillconductaninvestigation

thatmayinclude,butisnotlimitedto,areviewoftheresident’sfile,police

reports,interviewswiththeresidentand/oranymemberofTulaneUniversityor

applicabletraininglocations.

4.Afterreview,theDIOwillrenderoneoffivedecisions:.

a.Theresidentrequiresnocorrectiveaction.Theresidentwillbere-instated.

TheprogramdirectorandtheAdministrativePersonnelwhomadethereferral

willbeinformed.

b.Theresidentrequiresremediationwithoutprobation.Theresidentwillbere-

instated,andtheDIOwillworkwiththerespectiveprogramdirectortodesign

anappropriateremediationstrategy.

TheAdministrativePersonnelwhomadethereferralwillbeinformed.

c.Theresidentrequiresprobation.

i.TheDIOwillliftthesuspensionandcommunicatetotherespectiveprogram

directorthattheresidentshouldbeevaluatedbytherespectiveprogram’s

ClinicalCompetencyCommittee,ifthishasnotalreadybeendone,astowhether

probationisappropriate.

ii.Theprogramdirectorwilltheninstructtheprogram’sClinicalCompetency

Committee(CCC)toreviewtheincitingevent(s)andtheresident’sperformance

evaluationsandtorenderadecisionastowhetherprobationisappropriate.

iii.IftheCCCdeterminesthattheresidentdoesnotrequireprobation,he/she

willbereinstated,attheCCC’sdiscretion,eitherwithnofurtheractionrequired,

oraremediationplanwithoutprobation.

iv.IftheCCCdeterminesthattheresidentrequiresprobation,theprocedure

outlinedinChapterXIV.SectionDwillbefollowed.

d.TheresidentshouldbereferredtoTheResident’sAssistanceProgram(see

ChapterXVI.

Residents’AssistanceProgram).Thisdecisionisgenerallyreservedfor,butnot

limitedto,residentswhoarepsychiatricallyimpaired,orimpairedbecauseof

excessiveuseorabuseofdrugs,includingalcohol.Iftheresidentrefusestobe

evaluatedforfitness-for-duty,heorshewillbeterminatedfromtheUniversity.

He/shewillthenhaveanopportunitytogrievethisdecisionasoutlinedbelowin

theprovisionsoftermination.

i.TheDIOwillsustainthesuspensionandrefertheresidenttotheResidents’

AssistanceDirectorforformalevaluation.

ii.Aftertheresidenthasbeenreferred,AdministrativePersonnelotherthanthe

DIO

shouldhavenocommunicationwiththeResidents’AssistanceDirector,unless

soauthorizedbytheresident.

iii.Uponcompletionoftheevaluation,theResidents’AssistanceDirectorwill

communicatetheresultsoftheevaluationtotheDIO,whowillinturn,notifythe

programdirector.

e.TheresidentshouldbeterminatedfromtheUniversity.SeeXV.D.4

H.GRIEVANCE&FAIRHEARINGCOMMITTEECOMPOSITION

TheGrievance-FairHearingprocedureisusedintheadjudicationofallactions

resultingintermination,ornon-renewal.TheGrievance-FairHearingprocedure

istobefollowedasbelow:1.AresidentmayrequestaGrievance-FairHearing

fortermination,non-renewal,oracontestedCCC

decisiontonotgraduatetheresident.

2.Contestingevaluations,lettersofrecommendation,documentationof

performance,andprobationarenotgroundsforaGrievance-FairHearing.

3.AGrievance-FairHearingmustbefiledinwritingwithinfivebusinessdaysof

thedecisionbeinggrieved,addressedtotheDIOintheOfficeoftheGraduate

MedicalEducation.

4.ThepurposeoftheGrievance-FairHearingistoensurethatthehouseofficer’s

dueprocessrightshavebeenmet.

5.Aresidentmayberemovedfromclinicalresponsibilitypendingthe

Grievance-FairHearing,iftheDIO

determinesthatpatientcaremaybecompromised.

6.Oncetherequesthasbeenreceived,theDIOwillassurethataGrievance-Fair

Hearingisanappropriatemeansforadjudicatingthecomplaint.Iftherequestis

notappropriatedforaGrievance-FairHearing,theresidentwillbenotified.

7.IftheDIOdeemstheGrievance-FairHearingrequestisanappropriatemeans

foradjudicatingthecomplaint,heorshewillconvenetheGrievance-Fair

Hearingboardasoutlinedbelow.Subjecttotheavailabilityofallparties,the

firstmeetingoftheFairHearingBoardwilloccurwithin30daysofthewritten

request.

8.TheFairHearingBoardwillconsistofthefollowingfivevotingmembers,

appointedbytheDIOorhisorherdesigneeincasesofconflictofinterestor

inabilitytoattend.Thechairwillbeanonvotingmember.

a.Three(3)facultymembersfromprogramsnotdirectlyassociatedwiththe

residentwhohasfiledtheGrievance-FairHearing.

b.Two(2)houseofficersfromprogramsnotdirectlyassociatedwiththatofthe

residentwhohasfiledtheGrievance-FairHearing.

I.GRIEVANCEANDFAIRHEARINGPROCEDURE.

Unlessotherwisespecified,thefollowingproceduresaretobeusedinall

Grievance/FairHearingProcedures.Allcapitalizedtermsshallhavethemeaning

assetforthintheTulaneUniversitySchoolofMedicine:GraduateMedical

EducationPoliciesandProcedures.

1.TheChairoftheGrievance/FairHearingBoard,alongwiththecommittee

members,willbeidentifiedatleastthreeweekspriortoformallyconveningthe

FairHearingBoard.Theresidentthenhas4businessdaystoformallysubmitan

objectiontooneorallofthecommitteemember’sparticipation.

a.Inmakinganobjection,theresidentmustestablishreasonableevidencethat

theBoardmember’sparticipationintheGrievance/FairHearingwouldunduly

biastheproceedings.

b.TheChairoftheGrievance/FairHearingBoardwillmakethedecisionasto

theobjection.

2.Atleast5businessdaysbeforethehearingdate,boththeResidentandthe

Institutionshallsubmitwitnesslistsanddocumentstobepresentedatthe

Grievance/FairHearingBoard.TheseitemsshallbedeliveredtotheChairofthe

Grievance/FairHearingBoard.

3.IftheResidentfailstoappear,thehearingswillproceedandthe

Grievance/FairHearingBoardwillrenderadecision.Aresidentwhofailsto

appearafterproperwrittennoticewillbedeemedtohavewaivedhis/herrightto

contesttheInstitution’sdecision.

4.NeithertheResidentnortheInstitutionshallberepresentedbycounselatthe

hearing.TheResidentandtheInstitutionmayhaveanadvisorpresentatthe

Grievance/FairHearingBoard(whichmayincludecounsel)buttheadvisormay

notparticipateintheproceedingsexcepttoadvisetheResidentortheInstitution.

5.Allpersonsshallbeaskedtoaffirmthattheirtestimonyistruthful.Furnishing

falseinformationtotheUniversitymayresultinformalcharges.

6.BoththeResidentandtheInstitutionshallbeofferedtheopportunityto

presenttheirwitnessesandtoquestiontheother’switnesses.

7.ProspectivewitnessesshallbeexcludedfromtheGrievance/FairHearing

duringthetestimonyofotherwitnesses.Allpartiesandwitnessesshallbe

excludedduringdeliberationsoftheGrievance/FairHearingBoardexceptatthat

timeatwhichtheyareprovidingtestimony.

8.TheburdenofproofshallbeontheResident,whomustestablishthatthe

Institution’sdecisionwasinerrorbypreponderanceoftheevidence.Formal

rulesofevidenceshallnotbeapplicable,norshallharmlessortechnical

proceduralerrorsbegroundsforappeal.Allevidencereasonablepeoplewould

acceptinmakingdecisionabouttheirownaffairsisadmissible.Irrelevantor

immaterialevidencewillbeexcluded,asdeterminedbytheChairofthe

Grievance/FairHearingBoard.

9.FinaldecisionoftheGrievance/FairHearingBoardshallbebythemajority

voteofallmembersoftheBoardpresentandvoting.

10.WrittenfindingsandrecommendationsoftheGrievance/FairHearingBoard

willbeforwardedtotheDeanoftheTulaneSchoolofMedicinewithin10

workingdaysoftheGrievance/FairHearingwithacopytotheResidentandthe

Institution.Atthistime,eithertheResidentorDepartmentChairhastherightto

requestameetingwiththeDeantoreviewtheseissues.

11.TheDeanwillrenderhisorherfinaldecisionwithinten(10)workingdays

ofreceiptoftheGrievance/FairHearingwrittenfindingsandrecommendations

orten(10)workingdaysaftermeetingwiththeparties,ifthesemeetingswereso

requested.

12.AllhearingsoftheGrievance/FairHearingBoardwillbetapedforusein

deliberationbytheGrievance/FairHearingBoard,althoughtheGrievance/Fair

HearingBoarddeliberationswillnotbetaped.Anytaperecordingmayonlybe

madebytheChairoftheFairHearingBoardandshallbeprivateandusedfor

Grievance/FairHearingdeliberationsonly.

13.ThefinaldecisionoftheDeanoftheSchoolofMedicineshallbereportedto

theDIO,theGraduateMedicalEducationCommitteeandtheapplicable

programdirector.

J.REPORTINGSUSPENSIONS,TERMINATIONS,NON-RENEWALS,

SURRENDERS,RESIGNATIONS

OFRESIDENTS.

1.PursuanttotheLouisianaStateBoardofMedicalExaminersrule(LAC

46XLV.422),allsuspension,non-renewal,surrender,resignationorwithdrawal

ofaresident’sparticipationintrainingforanyreasonotherthanimpairmentby

drugsoralcoholmustbereportedtotheLouisianaStateBoardofMedical

Examinerswithinthirtydaysofthefinaldecision.

2.Reportingtotheboardofimpairmentbydrugsoralcoholisaddressedviathe

PhysiciansHealthFoundation.ResidentparticipationthePhysiciansHealth

FoundationisoutlinedinChapterXV:Residents’AssistanceProgram.

3.ReportingtotheboardistheresponsibilityoftheDIO.Allprogramdirectors

areresponsibleforreportinganyoftheactionsnotedabovetotheDIO,whowill

thenreporttheactiontotheLSBME.

4.ReportingtotheLSBMEwillonlyoccurafterthegrievanceprocedure,where

applicable,iscomplete.

ApprovedbytheGMEC;May26th,2015.

XVI.RESIDENTS'ASSISTANCEPROGRAM:

A.ResidentWellnessPositionStatement

B.ResidentWellnessInitiatives

Theprogramandtheinstitutionhaveinstitutedseveralinitiativestoaugmentwel

nessandreducetheriskofburnout.Theinstitutionhasputforthmoresupport

fortheTulaneResidentandFelowCongress(theTRFCiscomprisedofpeer-

electedresidentsfromalprograms).TheTRFChasinturnexecutedamore

robustcalendarofsocialevents,eachofwhicharedesignedtoenhancepeerand

socialsupportnetworks,andencourageresidentstointeractinandoutofwork

withresidentsfromotherprogramsaswelasadditionalhospitalstaff.The

institutionhasraisedresidentsalariestobeabovetheAAMCSouthernmean,

andexpandedhealthcareandotherbenefits(particularlyenhancingaffordable

healthcareforresidentswithspousesanddependents).TheUniversityisnow

self-insuredforresidenthealthcare,andaspartofthatinitiative,theUniversity

paysforageneralinternistandnursepractionertobeavailableonsite,Monday

toFridayforaresident-onlydropinclinic.

Whileresidentscanstilchoosetheirownprovider,thedrop-inserviceisfreefor

theresidents,andprovidesimmediateaccesswithoutusingdaysofftotakecare

ofsmalermedicalissues.Asinthepast,theUniversitycontinuestopayfora

psychiatristtoprovidethesametypeofservicetotheresidents(nocosttothe

resident,andnoassociatedpaperwork).Thisservicealsoincludescouples

counseling.Thematernityleavepolicyhasbeenreplacedwitha“parentalleave”

policytobemoreinclusiveofsame-sexcouples,andinclusiveofadopted

children.Thenewpolicyprovidesformorepaidtimeoff,anditismoreflexible

(alowingresidentstotakeleaveanywhereintheninemonthsfolowingthe

birth/adoptionofthechild,therebyalowingtwomarriedresidentstostagger

theirtimeoffforoptimalchildcare).Theprogramispilotinganinitiative

focusingonassessing(andsubsequently,adjusting)workintensityindependent

ofcensus(medicalintensity,socialintensity).Further,theprogramhasinstituted

systematic/curricularinitiativestoimproveresilience.Finaly,theprogramand

institutionareinitiatingfacultydevelopmentsessionstoempowerfacultywith

mentorshiptechniquestoaugmentresilienceandmanageworkintensity.

IndividualfirmmembersnowmeetwiththeirAssociateProgramDirectorand

ChiefResidentfourtimesayear.

TheInternalMedicinePracticeClinicisofferingaprimarycareclinicfor

AGCMEresidentsandfelowsandspousescoveredundertheSchoolof

Medicinehealthplanfortheiracuteandprimarycareneeds.

Convenient,same-dayappointmentsin-betweenroundsorona

lunchbreak.

C.ImpairedPhysiciansAssistance

1.ItisthepolicyofTulaneUniversitySchoolofMedicinetoensurethatthe

highestqualityphysiciansarepracticingmedicineinthehospitalsandclinic.

TheResidents'AssistanceProgramisintendedtoprovideresidentswithaccess

toconfidentialcounselingandbehavioralhealthservices,and/orforthe

identificationandtreatmentofresidentphysicianswithpsychiatricorsubstance

abuseimpairment.

2.Definition.Animpairedresidentphysicianmeansaphysicianinvolvedin

trainingorresearch,licensedtopracticemedicineintheStateofLouisianawho

isunabletopracticemedicinewithreasonableskillandsafetytopatients

becauseofamentaldisorder,physicalillness,and/orexcessiveuseorabuseof

drugs,includingalcohol.

3.Self-Referral.Tulaneencouragesresidentswhofeelthattheymayhavea

psychiatricorsubstanceabuseproblemtoseekconfidentialassistancewiththe

Residents’AssistanceProgram.Aresidentwhofeelsthatheorshemayhavea

problem,maycontacttheResidents’AssistanceProgramDirector,Dr.

AndrewMoroson,bycalling(504-322-3837)oremailhimat

dr.morson@ibhnola.com.

a.Uponself-referral,TheResidents’AssistanceDirectorwillevaluatethe

residentandmakeoneofthefollowingrecommendations.

i.Theresidentneedsnofurthertherapyorevaluation.

ii.TheresidentremainsinatherapeuticrelationshipwiththeResidents’

AssistanceProgramDirectororoneofhisorherstaff.

iii.Theresidentisreferredtoanotherphysicianortherapist.

iv.TheresidentisreferredtothePhysicians’HealthFoundationforfurther

evaluationandtreatment.

b.TulaneUniversityiscommittedtofosteringanenvironmentinwhichresidents

feelsafeinidentifyingandcorrectingconditionsthatmayimpairtheirpersonal

andprofessionalperformance,withoutfearofreprisalorimplicationstotheir

career.ResidentswhoselfreferarenotreportedtoAdministrativePersonnel

unless:

i.Theresidentposesimminentthreattoselforothers.

ii.TheresidentisdeterminedbytheResidencyAssistanceDirectortonotbefit

forduty,andissubsequentlyreferredtothePhysicians’HealthFoundationfor

furtherevaluationandtreatmentforfitnessforduty.

iii.Shouldthisoccur,theDIOwillbenotified,andtheresidentwillceasetobe

intheSelf-ReferralPathway.Theresidentwillbetransferredtothe

AdministrativePathwayforremediation,asoutlinedinTheAdministrative

ReferralPathway(SeeChapterXV.PolicyonRemediation,Suspension,

TerminationandGrievance).

a.Insuchacase,theDIOwillbeinformedofthereferral,butwillnotbe

informedofthedetailsoftheresident’scare,unlesssoauthorizedbythe

resident.

b.ItwillbetheresponsibilityoftheResidents’AssistanceProgramDirectorto

informtheDIOwhenandiftheresidentisdeemedfittoreturntoduty,andany

requirementsofthisre-entry(i.e.,monitoring,etc.).

c.TulaneadministrativepersonnelotherthantheDIOshouldhaveno

communicationwiththeResidents’AssistanceDirector,northePhysicians

HealthFoundation,unlesssoauthorizedbytheresident.

4.AdministrativeReferral.Wheneverthereisareasonablebeliefthataresident

physicianispracticingwhileunderimpairment,theDIOshouldbenotified

immediately.

a.Uponsuchnotification,theDIOwillconductapreliminaryinvestigationand

ifhe/shefindsareasonablebeliefthatsuchimpairmentexists,he/shewillreport

suchinformationtothedirectoroftheResidents’AssistanceProgram.

b.Theresidentwillbetemporarilysuspended,withpayandbenefits,from

his/hertrainingprogramuntilevaluationofthecaseiscomplete.

c.Aftertheresidenthasbeenreferred,eitherself,oradministratively,

AdministrativePersonnelotherthantheDIOshouldhavenocommunication

withtheResidents’AssistanceDirector,unlesssoauthorizedbytheresident.All

communicationsregardingresidentswhohavebeenreferredtotheResidents’

AssistanceProgramDirectorshouldbedirectedtoDIO.

d.Aphysiciansuspendedduetopsychological,chemicaland/oralcohol

impairmentwillberequiredtosuccessfullycompletearehabilitationprogram

approvedbythePhysicians’HealthFoundation.

e.Uponcompletionofarehabilitationprogram,theresidentmayberequiredby

theDIO,thetreatingphysicianorThePhysicians’HealthFoundationtoenteran

aftercareprogram.AftercaretreatmentprogramswillbeapprovedbytheDIO,

thetreatingphysicianandthePhysicians’

HealthFoundation.Iftheresidentphysicianisinaftercarewhenreestablishment

oftrainingand61

credentialsisgranted,theprogramdirectorisrequiredtomaketimeavailablein

theresidentphysician’sscheduletoallowtotalparticipationintheaftercare

program.TheDIOwilldocumentcomplianceintherehabilitationprogramwith

thetreatingphysicianoftheimpairedresidentphysicianwhiletheresident

physicianisinarehabilitationprogram.

f.Iftheresidentphysicianfailstocomplywiththerehabilitationprogramorthe

aftercareprogram,he/sheisautomaticallyterminatedfromresidencytraining

andanoticetothateffectwillbeplacedinhis/herfileandtheappropriatestate

andnationalbodieswillbenotified.Thisdecisionforterminationisnot

grievable.

g.If,aftersuccessfulcompletionoftheaftercareprogram,theresident

subsequentlyredevelopsapsychiatric,chemicaloralcoholimpairment,

terminationfromresidencywillberecommendedunlessthereareextenuating

circumstances.ThefinaldecisionshallrestwiththeDIO.

h.ThePhysicians’HealthFoundationofthestatetowhichtheresidentis

movingwillbenotifiedbytheDIOifaresidentphysicianisinvolvedin

inpatientoraftercaretreatmentatthetimetheresidentiscompletingresidency

training.

ApprovedbytheGMEC;November11th,2015

XVII.POLICYONSUBSTANCEABUSE

A.Theabuseofalcoholandotherdrugscanseriouslydamagephysicaland

mentalhealth,andmayjeopardizesafetyandthesafetyofothers.Wheneveruse

orabuseofanymoodalteringorothercontrolledsubstance(suchasalcoholor

otherdrugs)interfereswithasafeworkplace,appropriateactionwillbetaken.

B.AccordingtotheprovisionsoftheDrug-FreeWorkplaceActof1988,andthe

Drug-FreeSchoolsandCommunitiesActamendmentsof1989,theunlawful

manufacture,distribution,sale,possessionoruseofcontrolledsubstancesinthe

workplaceisprohibited.Residentsmaynotreporttoworkundertheinfluenceof

alcoholorotherdrugs.Residentswhoviolatethispolicywillbesanctionedin

accordancewithTulanepolicyandfederalandstatelaw.

D.Residentsconvictedofillegaldrugactivityintheworkplacemustnotify

Tulanewithinfive(5)businessdaysofconviction.Failuretodosomaybe

groundsforimmediatetermination.

E.Residentsareencouragedtotakeadvantageofthediagnosis,counselingand

treatmentservicesthatareavailablethroughtheOfficeofGraduateMedical

Education’sResidents’AssistanceProgram.(SeeChapterXVI.

Residents’AssistanceProgram).

ApprovedbytheGMEC;September28th,2011

XVIII.POLICYONARREST

A.TheTulaneUniversityHealthSciencesCenterPoliceDepartmentwillmake

reasonableeffortstohelpinarrangingforreleaseofthatindividualbutthere

maybeoccasionsforreasonsbeyondthecontrolofTulaneUniversityHealth

SciencesCenterPoliceDepartmentthateffortstosecurethereleasecannotbe

arranged.

B.Normallythereleasewillbeaccomplishedbycontactingpersonswhohave

parolepowersdesignatedbystatelaw.Therearetimeswhentheseriousnessof

thecrimemaybesuchwhenthiscannotbeaccomplished.Theplanisas

follows:

1.ThepersonarrestedoranacquaintancemustnotifytheTulaneUniversity

HealthSciencesCenterPoliceDepartmentat988-5531.Theinformationneeded

willbethenameoftheindividualarrested,theprogramhe/sheisinsuchas

surgery,ormedicine,alsoalistingofthechargesandthejailorparishprisonat

whichtheindividualisbeingdetained.

2.TheCrimePreventionCoordinatororhis/herdesigneeshalleitherbecalledor

pagedbytheTulaneUniversityHealthSciencesCenterPoliceDepartment.The

CrimePreventionCoordinatorwillhavealistingofpersonswithparolepowers.

AcallwillbeplacedbytheCrimePreventionCoordinatortothatindividual,and

thatpersonwillbeprovidedwiththenecessaryinformationtohelpinobtaining

therelease.

3.Intheeventthattheseriousnessofthecrimeisbeyondthescopeofparole

powers,acallwillbeplacetotheUniversity’sAttorney-at-Law,oradesignee.

Thisofficewillthenprovidelegalcounseltothatpersonastohis/herrightsorto

anappropriatebailagencyunlessthatindividualchoosestoobtainothercounsel

whichishis/heroption.

4.TheCrimePreventionCoordinatorwillthennotifytherespectivesection

head,suchastheAssociateDeanforGraduateMedicalEducation,thechairof

thedepartment,ortheprogramdirector.Areportofwhathasoccurredwillbe

providedwithasmuchinformationaspossible.

5.Shouldtheindividualarrestedbeinneedoftransportationfromthejailor

parishprison,theCrimePreventionCoordinatorwillarrangefortransportation

toeitherthehealthsciencescenterorhis/herresidence.

6.Oncetheindividualisreturnedtohis/herresidence,aconfidentialreportwill

becompiledandforwardedtotheappropriatesectionhead.

7.Thearrestedindividualwillalsobeprovidedwiththeofficenumberofa

Universityattorney,shouldthatindividualwishtofindoutanswerstoanylegal

questions.Thearrestedindividualisnotobligatedtoaccepttheassistanceofthe

TulaneUniversityHealthSciencesCenterPoliceDepartment,TulaneUniversity

SchoolofMedicineoranyrepresentativesoftheUniversity.Theindividualis

alsofreetocontactanylawyerofhis/herchoiceormakeotherarrangementsfor

release.

8.Intheeventthatasignaturebondisimposed(asignaturebondguaranteesthe

appearanceoftheindividual),itwillnotbetheresponsibilityoftheTulane

UniversityHealthSciencesCenterPoliceoritsrepresentativetosignthebond.

Afriend,facultymember,programcoordinatororotherresponsiblepersoncan

signthebondwhichwillsecurethereleaseoftheindividual.Thepersonsigning

thebondpersonallyguaranteesthatthearrestedpersonwillmakeallcourt

appearances.

ApprovedbytheGMEC;September28th,2011

XIX.POLICYONSEXUALHARASSMENT

A.HARASSMENTPOLICY

StatementofPhilosophy

TulaneUniversityiscommittedtocreatingandmaintainingacampus

environmentwhereallindividualsaretreatedwithrespectanddignityandwhere

allarefreetoparticipateinalivelyexchangeofideas.Eachstudenthastheright

tolearnandeachemployeehastherighttoworkinanenvironmentfreefromall

formsofunlawfulharassmentordiscrimination,includingsexualharassment

andsexualmisconduct.AtTulaneUniversity,harassmentordiscrimination,

whetherverbal,physical,written,orvisual,isunacceptableandwillnotbe

tolerated.Discriminationisunlawfulandhurtsallmembersoftheeducational

communityandcontributestoanegativeatmospherewherevictimsandothers

mayfeeltheirsafetyandequalityarecompromised.Discriminationhasno

legitimateeducationalpurpose.Anyonewhoengagesinconductprohibitedby

thispolicyshallbedisciplinedasprovidedbylaw,universitypolicies,and

applicableemploymentagreements.

Tulanewillnottolerateunlawfuldiscriminationorharassmentbyanyone

affiliatedwithTulane(includingnon-employees,suchasvendorsand

independentconsultants),andwillnottolerateadverseacademicoremployment

actions,includingbutnotlimitedto,terminationofanyonereporting

discriminationorprovidinginformationrelatedtosuchacomplaint.

Principles

TulaneUniversityrecognizesthetensionbetweenprotectingallmembersofthe

Universitycommunityfromharassmentandprotectingacademicfreedomand

freedomofexpression.Itisthepolicyoftheinstitutionthatnomemberofthe

communitymayharassanother.Conductthatreasonablyservesalegitimate

educationalpurpose,includingpedagogicaltechniques,doesnotconstitute

harassment.IntheeducationalsettingwithintheUniversity,widelatitudefor

professionaljudgmentindeterminingtheappropriatecontentandpresentationof

academicmaterialisrequired.Thoseparticipatingintheeducationalsettingbear

aresponsibilitytobalancetheirrightoffreeexpressionwithaconsiderationof

thereasonablesensitivitiesofotherparticipants.Therefore,thispolicyagainst

harassmentshallbeappliedinamannerthatprotectsacademicfreedomand

freedomofexpressionincludingbutarenotlimitedtotheexpressionofideas,

howevercontroversial,intheclassroomsetting,academicenvironment,

university-recognizedactivities,oronthecampus.

Nothingcontainedinthispolicyshallbeconstruedtolimitthelegitimate

exerciseoffreespeech,includingbutnotlimitedtowritten,graphic,orverbal

expressionthatcanreasonablybedemonstratedtoservelegitimateeducational

orartisticpurposesnorshallthispolicybeconstruedtoinfringeuponthe

academicorartisticfreedomofanymemberoftheUniversity.Artistic

expressionintheclassroom,studio,galleryandtheatermeritsthesame

protectionofacademicfreedomthatisaccordedtootherscholarlyandteaching

activities.

PolicyCoverage

Allfaculty,administrators,staff,students,andindividualsaffiliatedwithTulane

Universitybycontract(includingnon-employees,suchasvendorsand

independentcontractors)areboundbythispolicy.Thispolicyprotectsall

individualsequallyfromharassment,includingsame-sexharassment,and

protectsstudentsfromharassmentbyotherstudents.

SexualHarassment

DefinitionofSexualHarassment-Sexualharassmentisunwelcomebehaviorof

asexualnaturebyfaculty,administrators,staff,students,andindividuals

affiliatedwithTulaneUniversitybycontract(includingnon-employees,suchas

vendorsandindependentcontractors)orbyanyonewithwhomoneinteractsin

ordertopursueeducationaloremploymentactivitiesattheUniversity.Forthe

purposesofthispolicy,sexualharassmentisdefinedasunwelcomeadvances,

requestsforspecialfavors,andanyotherverbal,written,physicalorother

conductofasexualnaturewhen:

(i)

Submissiontosuchconductisimplicitlyorexplicitlymadeaconditionofan

individual'sparticipationinUniversityprograms,activities,employment,or

educationalstatus;65

(ii)

Submissiontoorrejectionofsuchconductisusedasafactorinemploymentor

academicdecisions;or(iii)

Suchconductwouldbeobjectivelyregardedbyareasonablepersonashaving

thepurposeoreffectofinterferingwithanindividual'sabilitytolearnorworkor

participateinUniversityprogramsoractivitiesbycreatinganintimidating,

hostile,oroffensiveenvironmentevenifthepersonengagingintheconduct

doesnotintendtointerfere,intimidate,orbehostileoroffensive.

ExamplesofSexualHarassment-Sexualharassmentmayinclude,butisnot

limitedto,thefollowing:(i)

Physicalassaultsofasexualnature,suchasrape,sexualbattery,molestation,or

attemptstocommittheseassaults;andintentionalphysicalconductthatissexual

innaturesuchastouching,pinching,patting,grabbing,poking,orbrushing

againstanotherindividual’sbody.

(ii)

Anynonconsensualsexualbehavior;lackofconsentmayresultfrom,among

otherthings,useofforce,threats,orintimidationoradvantagegainedbyuseof

thevictim’smentalorphysicalincapacity,impairment,orhelplessnessofwhich

theaccusedwasawareor

shouldhavebeenaware.Offeringorimplyinganemployment-relatedreward

(suchasapromotion,raise,ordifferentworkassignment)oraneducation-

relatedreward(suchasabettergrade,aletterofrecommendation,favorable

treatmentintheclassroom,assistanceinobtainingemployment,grantsor

fellowships,oradmissiontoanyeducationalprogramoractivity)inexchange

forsexualfavorsorsubmissiontosexualconduct.

(iii)

Threateningortakinganegativeemploymentaction(suchastermination,

demotion,denialofanemployeebenefitorprivilege,orchangeinworking

conditions)ornegativeeducationalaction(suchasgivinganunfairgrade,

withholdingaletterofrecommendation,orwithholdingassistancewithany

educationalactivity)orintentionallymakingtheindividual'sjoboracademic

workmoredifficultbecausesexualadvanceswererejected.

(iv)

Unwelcomesexualadvances,requestsforaromanticorsexualrelationshiptoan

individualwhoindicatesorhasindicatedinanywaythatsuchconductis

unwelcome,propositionsorothersexualcomments,suchassexually-oriented

gestures,noises,remarks,jokes,questions,orcommentsaboutaperson's

sexualityorsexualexperience.

OtherFormsofHarassmentorProhibitedDiscrimination

Prohibiteddiscriminationorharassment,otherthansexualharassment,isverbal,

physical,written,orotherconductthatdenigratesorshowshostilityoraversion

toanindividualonthebasisofrace,color,sex,religion,nationalorigin,age,

disability,geneticinformation,sexualorientation,genderidentity,gender

expression,pregnancy,maritalstatus,militarystatus,veteranstatus,oranyother

statusorclassificationprotectedbyfederal,stateorlocallaw.Discriminationor

harassmentbasedonanyoftheabovecategoriesisstrictlyprohibitedbythis

policy.Discriminationincludesfailingtoprovidereasonableaccommodations,

consistentwithstateandfederallaw,toaqualifiedpersonwithadisability.

Complaintsofharassmentwillbeinvestigatedandresolvedinaccordancewith

applicablelegalguidelinesandthetermsofthispolicy.

Retaliation

NomemberoftheUniversitycommunitywillbedisciplinedorotherwise

retaliatedagainstforrefusingsexualadvances,objectingtosexual,racial,or

otherformsofdiscrimination,harassment,orretaliationormakingagoodfaith

reportofdiscrimination,harassment,orretaliation,orformakingrequestsfor

accommodationsonthebasisofreligionordisability.

Retaliatoryorintimidatingconductagainstanyindividualwhohasmadeagood

faithdiscrimination,harassment,orretaliationcomplaintorwhohastestifiedor

assistedinanymannerinaninvestigationisspecificallyprohibitedandshall

providegroundsforaseparatecomplaint.Examplesofsuchretaliatoryor

intimidatingconductincludedisciplining,changingworkingoreducational

conditions,providinginaccurateinformationtoorabout,orrefusingtocooperate

ordiscusswork-orschool-relatedmatterswithanyindividualwithouta

legitimatebusinessreasonbecausethatindividualcomplainedaboutorresisted

harassment.Theinitiationofagoodfaithcomplaintofdiscrimination,

harassment,orretaliationbyastudentwillnotreflectnegativelyonthatstudent

norwillitaffectthestudent’sacademicstanding,rights,orprivileges.Likewise,

theinitiationofagood66

faithcomplaintbyanemployeewillnotreflectnegativelyonthatemployeenor

willitaffecttheemployee'sworkingconditions,rights,orprivileges.

Confidentiality

Confidentialitywillbemaintainedthroughouttheentireinvestigatoryprocessto

theextentpracticableandappropriateunderthecircumstancestoprotectthe

privacyofpersonsinvolved.Thepersonschargedwithinvestigatingthe

complaintwilldiscussthecomplaintortheunderlyingbehavioronlywith

personsinvolvedinthecasewhohaveaneedtoknowtheinformation,which

mustincludethecomplainantandtheaccusedharasser.

Studentswhoneedtoseekresourcesinaconfidentialsettingwithouttriggeringa

reportforinvestigationshouldgotoCounselingandPsychologicalServicesor

theStudentHealthCenter.ConcernsreportedtoCounselingandPsychological

ServicesortheStudentHealthCenterarenotsharedwiththeOfficeof

InstitutionalEquityforinvestigation.

TheUniversityisrequiredbylawtoinvestigatecomplaintsofdiscrimination,

harassment,orretaliationandwillstrivetoprotect,tothegreatestextent

possible,theconfidentialityofpersonsreportingoraccusedofdiscrimination,

harassment,orretaliation.However,theUniversitycannotguaranteecomplete

confidentialitywhereitwouldconflictwiththeUniversity'sobligationto

investigateorwhereconfidentialityconcernsareoutweighedbytheUniversity’s

interestinprotectingthesafetyorrightsofothers.Individualswhodesireto

discusspossibleclaimsofdiscrimination,harassment,orretaliationinamore

confidentialsettingmaywanttoconsultwithacounselor,therapist,ormember

oftheclergy,whoispermittedbylawtoassuregreaterconfidentiality.

WhileTulaneiscommittedtorespectingtheconfidentialityandprivacyofall

partiesinvolvedintheinvestigationprocess,Tulanecannotguaranteecomplete

confidentiality.Examplesofsituationswhenconfidentialitycannotbe

maintainedinclude:

•

IfTulaneisrequiredbylawtodiscloseinformation(suchasinresponsetolegal

actions),

•

IfdisclosureofinformationisdeterminedbytheOfficeofInstitutionalEquity,

itsdesignee,and/orTulane’sOfficeofGeneralCounseltobenecessaryfor

conductinganeffectiveinvestigation,or

•

WhenconfidentialityconcernsareoutweighedbyTulane’sinterestinprotecting

thesafetyorrightsofothers.

ComplaintProcedures

Allareencouragedtopromptlyreportdiscrimination,harassment,orretaliation

sothatappropriateactioncanbetaken.Thecomplaintproceduresaredesigned

toensuretherightsofthecomplainantwhileatthesametimeaccordingdue

processtoinvolvedparties.

FormofComplaint-Complaintsofdiscrimination,harassment,orretaliation

willbeacceptedorallyorinwriting.Anonymouscomplaintswillbeaccepted

andinvestigatedtotheextentpossible.Complaintformsareavailableatthe

OfficeofInstitutionalEquityormaybefiledonlineat:

www.Tulane.edu/concerns.

ContentofComplaint-Anyindividualwhobelievesthattheyarebeing

discriminated,harassed,orretaliatedagainstinviolationofthispolicyshould

promptlyfileacomplaintincludingthefollowinginformation,ifknowntothe

complainant:thenameofthecomplainant,abriefdescriptionoftheoffending

behaviorincludingtimes,places,andthenameoforidentifyinginformation

abouttheallegedperpetrator,andthenamesordescriptionsofanywitnessesto

thediscrimination,harassment,orretaliation.

ReportingtheComplaint-Itisnotnecessarytofirstconfronttheharasserprior

toinstitutingacomplaintunderthispolicy.However,itisappropriateto

promptlyreportacomplaintsothatafullandcompleteinvestigationispossible.

Anypersondesignatedtoreceivecomplaintsfromstudents,employees,or

facultymustnotifytheOfficeofInstitutionalEquitywithin24hoursof

receivingacomplaintpursuanttothispolicy.

(i)

ComplaintsbyStudents-Astudentwhobelievesthattheybeendiscriminated,

harassed,orretaliatedagainstinviolationofthispolicymustreportthealleged

behaviortoanyofthefollowingindividuals:

•

OfficeofInstitutionalEquity,862-8083

•

VicePresidentforStudentAffairs,314-2188

•

AssociateDeanforStudentAffairs,TulaneUniversityHealthSciencesCenter,

988-5331

(ii)

ComplaintsbyStaff-Anemployeewhobelievestheyhavebeendiscriminated,

harassed,orretaliatedagainstinviolationofthispolicymustreportthealleged

behaviortoanyofthefollowingindividuals:

•

OfficeofInstitutionalEquity,862-8083

•

Dean(orpersondesignatedbysame)withwhichcomplainingemployeeis

affiliated

•

AssociateVicePresidentforWorkforceManagementOrganization,247-1758

(iii)

ComplaintsbyFaculty-Afacultymemberwhobelievestheyhavebeen

discriminated,harassed,orretaliatedagainstinviolationofthispolicymust

reporttheallegedbehaviortoanyofthefollowingindividuals:

•

OfficeofInstitutionalEquity,862-8083

•

DepartmentChairperson

•

Dean(orpersondesignatedbysame)oftheschoolwithwhichthecomplaining

facultyisaffiliated

•

SeniorVicePresidentforAcademicAffairs,865-5261

FailuretoCooperate-FailuretocooperateinanOIEinvestigationwillbe

consideredabreachofresponsibility.IfaRespondentfailstocooperate,hisor

herDepartmentHead,Supervisor,orDeanwillbenotifiedofsuchnon-

cooperation.ARespondent’ssilenceorlackofcooperationwillnotpreventa

complaintfromgoingforward.Failuretocooperateinaformalreview

proceedingmayresultintheinvestigationproceedingsolelyonthebasisofthe

availableevidence.

Investigation&InformalResolutionofComplaints

InitialInvestigation-Afterreceivingacomplaintofdiscrimination,harassment,

orretaliationtheOfficeofInstitutionalEquityshallpromptlyconductaninitial

investigation.

InformalProcess-TheUniversityhasaninformalprocesstoprovidethosewho

believetheyaresubjecttodiscrimination,harassment,orretaliationwitharange

ofoptionsdesignedtobringaboutaresolutionoftheirconcerns.

Dependinguponthenatureandseverityofthecomplaintandthewishesofthe

person(s)claimingdiscrimination,harassment,orretaliation,informalresolution

mayinvolveoneormoreofthefollowingorotherappropriateactions:

(i)

Advisingtheperson(s)abouthowtocommunicatetheunwelcomenatureofthe

behaviortotheallegedharasser;

(ii)

Distributingacopyofthispolicyasaremindertothedepartmentorareawith

whichtheallegedharasserisaffiliated;

(iii)

Ifbothpartiesagree,arrangingandfacilitatingameetingbetweentheperson(s)

claimingdiscrimination,harassment,orretaliationandthoseaccusedtoworkout

amutualresolution.

StudentsarealsoencouragedtoseekadviceorcounselingfromStudent

ResourcesandSupportServices,314-2160,whetherornottheydecidetopursue

aformalcomplaint.Informalresolutionmaynotbeappropriateincertain

circumstances.Forinstance,informalresolutionwouldneverbeappropriatein

casesinvolvingallegationsofsexualassault.Whiledealinginformallywitha

problemofdiscrimination,harassment,orretaliationmaybepreferabletothe

complainant,aformalgrievanceproceduremustbefollowedinorderforthe

Universitytoimposeanykindofdisciplineontheoffender.TheUniversitywill

proceedwiththeinvestigationandformalresolutionprocesswhendeemed

appropriatebytheOfficeofInstitutionalEquity.

10)

Investigation&FormalResolutionofComplaints

FormalInvestigation-Ifthecomplaintcannotbeinformallyresolvedafterthe

initialinvestigation,theOfficeofInstitutionalEquityshallcontinuethe

investigationordesignatesomeonetopromptlyconductfurtherinvestigationof

thecomplaint,whichmayinsomecircumstancesbeaneutralthirdparty.The

personschargedwithinvestigatingthecomplaintmustdiscussthecomplaintor

theunderlyingbehavioronlywithpersonsinvolvedinthecase

whohaveaneedtoknowtheinformation,includingthecomplainantandthe

accusedharasser.

Inthecaseofacomplaintagainstafacultymember,theOfficeofInstitutional

Equitywillworkwiththegrievancecommitteeofhisorherschoolwithinthe

Universitytoinvestigatediscrimination,harassment,or68

retaliationcomplaints.ThecommitteechairshallnotifytheOfficeof

InstitutionalEquityinwritingofthefindingsaswellasanyactiontakenor

recommendationsmadebythecommitteebasedonthosefindings.

Inthecaseofacomplaintagainstastudent,theOfficeofInstitutionalEquity

willinvestigate,orwilldesignatetheOfficeofStudentConducttoinvestigate,

andshallnotifytheOfficeofStudentAffairsinwritingofthefindingsofthe

investigation.TheOfficeofStudentAffairswill,inturn,determinewhetherto

processthematterthroughtheTulaneCodeofStudentConduct.

Inthecaseofacomplaintagainstastaffmemberornon-employeeindividual

affiliatedwithTulane(includingvendorsandindependentcontractors),the

OfficeofInstitutionalEquityshallinvestigateandmakerecommendationstothe

appropriatesupervisorastoanyactiontobetaken.

Resolution-Resolutionwillbeconcludedaspromptlyaspossibleandinmost

caseswithin60daysunlessextenuatingcircumstancesarise.Within60daysof

receivingthecomplaint,theOfficeofInstitutionalEquityoritsdesignee,

includingtheappropriateschoolgrievancecommittee,shallmakeafindingof

whetheritwasdeterminedthatdiscrimination,harassment,orretaliation

occurred.Iftheinvestigationcannotbeconcludedwithinthattime,theOfficeof

InstitutionalEquityshallnotifythecomplainant,andtheUniversity’sGeneral

Counsel,whoshalldesignatetheappropriatepersonorfacultycommitteeto

concludetheinvestigationaspromptlyasreasonablypossible.

Objectivity-Thecomplainantandtheaccusedareentitledtoaninvestigation

conductedbyanimpartialinvestigator.Thus,iftheperson(s)chargedwith

overseeingorinvestigatingcomplaintsisimplicatedinthecomplaint,orhasany

personalissuethatwouldcauseaconflictofinterest,theperson(s)withthe

conflictshallrecusethemselvesfromtheproceeding.Alternatively,the

InstitutionalEquityOfficershallconducttheinvestigationandmakefindingsor

shalldesignatesomeoneimpartialtodoso,whichmayinsomecircumstancesbe

anoutsideneutralthird-party.

StandardofReview-Claimsofviolationsofthispolicywillbereviewedbased

uponthepreponderanceofevidencewhethermorelikelythannotapolicy

violationoccurred.

NoticeofOutcome-

(i)

ComplaintsagainstFaculty,StaffandNon-EmployeeIndividualsAffiliatedwith

theUniversity.Nomorethanten(10)workingdaysoraspromptlyaspossible

afteradecisionhasbeenreached,theInstitutionalEquityOfficershallnotifythe

partiestotheproceedinginwritingofthefindingsandtheoutcomeofthe

investigation.

(ii)

ComplaintsagainstStudents.TheOfficeofStudentAffairsshallnotifythe

partiestotheproceedinginwritingofthefindingsandtheoutcomeofthe

investigationinamannerconsistentwiththeCodeofStudentConduct.

Sanctions-Individualsfoundtohaveviolatedthispolicyshallbedisciplined

appropriately.Appropriatesanctions,rangingfromawarningtodismissal,will

bedeterminedbasedontheseverityoftheconductandinaccordancewiththe

provisionsofapplicablestatutes,employmentcontracts,Universitypolicies,

disciplinaryproceduresforfacultyasdescribedintheFacultyHandbook,

disciplinaryproceduresforstaffasdescribedintheStaffHandbook,and

disciplinaryproceduresforstudentsasdescribedintheCodeofStudentConduct

andotherstudentdisciplinecodes.

11)

Appeals

Anappealbyeitherthecomplainantortheaccusedmustbefiledinwritingwith

theOfficeofInstitutionalEquitywithinten(10)workingdaysofreceiving

writtennoticeoftheoutcomeoftheinvestigation.Responsibilityforreviewing

appealswillturnontheidentityoftheaccused.Wheretheaccusedisastudent,

theappealshallbereviewedinaccordancewithappealsproceduresdescribedin

theCodeofStudentConduct.Wheretheaccusedisastaffmember,theChiefof

StaffandVicePresidentwillreviewappeals.Wheretheaccusedisafaculty

member,theFacultyTenureFreedomandResponsibilityCommitteeofthe

UniversitySenatewillreviewappealsinaccordancewiththegrievance

proceduresdescribedintheUniversitySenateConstitution,By-LawIII:

StandingCommittees,Section1:CommitteeFunctions,CommitteeonFaculty

Tenure,FreedomandResponsibility:Functions.

Inexceptionalcircumstances,exceptincasesinvolvingfaculty,anappealmay

bereviewedbyanoutsideneutralthirdparty.

12)

OtherLegalResources

Theproceduresaboveapplytointernalcomplaintsofdiscrimination,

harassment,orretaliation.Inadditiontothisinternalcomplaintprocedure,

victimsofdiscrimination,harassment,orretaliationmayfileacomplaintwithan

appropriategovernmentagencyor,whereallowed,fileacivillawsuit.Federal

andstatelawscontainstatutesoflimitationbarringclaimsfiledoutsideofthe

applicablelimitationsperiod.

OfficeforCivilRights-TheOfficeforCivilRights(OCR)ischargedwith

investigatingcomplaintsofharassmentunderTitleIX,afederallawthatgoverns

harassmentofstudentsbyteachersorotherstudents.Priortofilingalawsuit,a

chargeshouldbefiledwiththeOCRwithinthetimeperioddesignatedbylaw.A

studentwishingtofileanadministrativecomplaintshouldcontact:

U.S.DepartmentofEducationU.S.DepartmentofJustice

OfficeforCivilRightsDallasOffice

CivilRightsDivision1999BryanStreet,Suite2600

-or-

P.O.Box66560

Dallas,TX75201

Washington,D.C.20035

(214)880-2459(202)307-2222

EqualEmploymentOpportunityCommission-TheEqualEmployment

OpportunityCommission(EEOC)ischargedwithinvestigatingcomplaintsof

harassmentunderTitleVII,afederallawthatgovernsharassmentoffaculty

membersandstaff.Priortofilingalawsuit,TitleVIIrequiresthatachargebe

filedwiththeEEOCwithinthetimeperioddesignatedbylaw.Anemployee

wishingtofileanadministrativecomplaintshouldcontact:

EqualEmploymentOpportunityCommission

RegionalOffice

1555Poydras,Suite1900NewOrleans,LA70112(504)589-2826

13)

DisseminationofPolicy

Thispolicywillbeavailabletofaculty,staff,students,administrators,andwill

beavailabletothird-partiesconnectedwiththeUniversity.AllUniversity

employeesandstudentswhosubsequentlybecomepartoftheeducational

communityshallbeinformedofthispolicyduringtheirorientation.Thispolicy

mayberevisedfromtimetotimeandsuchrevisionswillbepostedonthe

University'swebsitelocatedatwww.tulane.edu.Anyincidentreportedunder

thispolicywillbegovernedbythepolicypostedontheUniversity'swebsiteat

thetimetheincidentisreported.

14)

RevisionstoPolicy

ProposedrevisionstothispolicywillbepresentedtotheUniversitySenatefor

approvalordisapproval.

15)

FalseAccusations

Whileweencouragealltoreportgoodfaithclaimsofdiscrimination,

harassment,orretaliation,falseaccusationscanhaveaseriouseffectoninnocent

people.Ifaninvestigationresultsinafindingthatanaccusationof

discrimination,harassment,orretaliationwasmaliciouslyorrecklesslymade,

theaccusermaybedisciplinedappropriately.

Appropriatesanctions,rangingfromawarningtodismissal,willbedetermined

basedontheseverityoftheconductandinaccordancewiththeprovisionsof

applicablestatutes,employmentcontracts,Universitypolicies,disciplinary

proceduresforfacultyasdescribedintheFacultyHandbook,disciplinary

proceduresforstaffasdescribedintheStaffHandbook,anddisciplinary

proceduresforstudentsasdescribedintheCodeofStudentConductandother

applicablestudentdisciplinecodes.

TITLEIX

ItisthepolicyofTulaneUniversitytocomplywithTitleIXoftheEducation

Amendmentsof1972,whichprohibitsdiscrimination(includingsexual

harassmentandsexualmisconduct)basedonsexintheUniversity'seducational

programsandactivities.TitleIXalsoprohibitsretaliationforassertingclaimsor

sexdiscrimination.

TulanehasadesignatedTitleIXCoordinator.TheTitleIXCoordinatoroversees

theUniversity’scentralizedreview,investigation,andresolutionofreportsof

sexdiscrimination,includingsexualharassmentandviolence.

MeredithM.Smith,TitleIXCoordinator

TulaneUniversityTitleIXOffice

Lavin-BernickCenter,SuiteG03NewOrleans,LA70118

msmith76@tulane.edu(504)865-5615

Faculty,StafforStudentsmaycontactthefollowingforinformation:Deborah

Love,DeputyTitleIXCoordinatorTulaneUniversity

OfficeofInstitutionalEquity200Broadway,Suite105ANewOrleans,LA

70118dlove1@tulane.edu(504)862-8083

WendyStark,DeputyTitleIXCoordinatorTulaneUniversity

OfficeofInstitutionalEquity200Broadway,Suite105ANewOrleans,LA

70118wstark@tulane.edu(504)862-8083

EricaWoodley,DeputyTitleIXCoordinatorforStudentAffairsTulane

UniversityDivisionofStudentAffairs6823St.CharlesAvenue

Lavin-BernickCenterforUniversityLife,RoomG03NewOrleans,LA70118

ewoodley@tulane.edu(504)314-2188

ApprovedbytheGMEC;November29th,2017

XX.POLICYONSOCIALMEDIA&OUT-OF-WORKCONDUCT

A.GeneralPrinciples:

Thispolicyisbaseduponthefollowingfundamentalprinciples;1.Patient

confidentialityisofprimaryimportance,asoutlinedinTheHealthInformation

PortabilityandAccountabilityAct[HIPAA].

2.TulaneUniversity,asaUniversity,valuestheimportanceoffreespeechand

opendiscourse.Assuch,theUniversity,beingrespectfuloffreespeechand

expressionofideas,doesnotprohibitresidentsfromengaginginsocialmedia

and/orvoicingopinionoutsideoftheworkplace.

3.Maintainingrespectforcolleaguesandco-workersisrequisiteforestablishing

aprofessionalenvironmentintheworkplace,therebyensuringoptimalteam-

basedpatientcare.

4.EnrollmentinaTulaneUniversityresidencyorfellowshipprogrambestows

upontheresidentthereputationandprestigeofTulaneUniversity.Inexchange,

itistheresponsibilityofeachresidenttoupholdandprotectthereputationof

TulaneUniversity.

B.PolicyonSocial,ElectronicandPrintMedia:

1.Patients

a.AnyandalldepictionsordescriptionsofpatientsmustcomplywithThe

HealthInformationPortabilityandAccountabilityAct[HIPAA].Personalhealth

informationisdefinedbyHIPAAasanyinformationaboutanindividualinoral

orrecordedform,wheretheinformationidentifiesanindividualorforwhich

thereisareasonablebasistobelieveitcanbeusedtoidentifytheindividual.

b.Atnotimeshallpatientinformationbesharedwithoutthesignedconsentof

thepatient.TheUniversitydoesnotgovernthecontent,formatorprocessfor

obtainingthisconsent;Tulaneresidentsmuststrictlyadheretothepoliciesand

proceduresoftherespectivehospital,clinicorhealthcaresysteminwhichthe

patientreceivedcare.

c.Theseguidelinesapplyeveniftheindividualpatientistheonlypersonwho

maybeabletoidentifyhimorherselfonthebasisoftheposteddescription.

Anonymousdescriptionsmustnotcontaininformationthatwillenableany

person,includingpeoplewhohaveaccesstoothersourcesofinformationabout

apatient,toidentifytheindividualsdescribed.Thisencompassesallemailsand

textmessagessentfrompersonalphones.

d.Atnotimeshallpatients,orpatientstories,bedepictedinadisparaging,

demeaning,orinsultingmanner.Evenifpatientsarenotidentified(byname,

recordnumber,image),orevenifconsenthasbeenobtainedformthepatient,

anydescriptionofpatientcareshouldbeprofessionalandrespectfulofthe

patient.

2.DescriptionofthePatientCare/WorkEnvironment

a.Alldescriptionsoftheworkplaceenvironmentshallrespecttheprivacyrights

ofcolleaguesandco-workers.Individualsshallnotbeidentifiedbyname,orbe

describedinsuchafashionthattheiridentityiseasilyapparent,withoutexplicit

consentofthatindividual.

b.Thetoneandcontentofallconversations,socialmediaandotherwise,shall

remainprofessionalandrespectfulofallhealthcareandUniversitycolleagues.

Postingdemeaningorinsultingcommentsorimagesaboutcolleaguesandco-

workerstothirdpartiesisunprofessionalbehavior,andaviolationoftheTulane

UniversityGMEPolicyonHarassment(ChapterXIX).

c.WhiletheUniversitydoesnotprohibitdescribingdisagreementsonissuesand

withpeopleintheworkplace,residentsarestronglycautionedtonotexpress

thesedisagreementsinsocial,electronicandprintmediaforthefollowing

reasons:

i.Thedescriptionofthedisagreementislikelytobeone-sided,withoutthe

“otherside”havingtheopportunitytopresenttheirsideoftheagreement.

ii.Readershipofthedescribeddisagreementislikelytotakethedescriptionout

ofcontext.

iii.Thedescriptiononsocial,electronicorprintmediaisunlikelytoresultina

meaningfulsolution/resolutionofthedisagreement.

3.DescriptionofSelfand/orSelfOpinions

a.Theresidentretainstherighttoexpresstheirindividualityviapictures,

opinionsandpostsonsocial,electronicandprintmedia.

i.Allpostedopinionsandimages,however,aretobeprofessional;

unprofessionalstatementsevoking,butnotlimitedto,racism,sexism,and

discriminatorystatementswillnotbeallowed,andaregroundsforreviewbythe

program’sclinicalcompetencycommitteewithrespecttotheprofessionalism

corecompetency.

ii.Residentsareadvisedtobecognizantoftheimagebeingportrayed,

particularlywithrespecttopostedimagesandphotographs,andhowthatimage

wouldbeviewedasbeingconsistentwiththeprofessionalphysician.Employers,

patients,andadministratorscansearchandviewallinformationpostedinany

forum.Enactingprivacysettingsdoesnotnecessarilymeanthatinformationwill

notendupinapublicformat.

b.Inengaginginsocial,electronicorprintmediacommunications,residentsare

remindedofthefollowing:

i.Theresidenthasfullresponsibilityforthecontentofindividualonlinepostings

(forexample:blogs,socialnetworkingsitesandotherdigitalmedia).

ii.ThepermanencyofpublishedmaterialontheWeb.Mostelectronicmedia

becomescached.

Thismeansthateveniftheinformationissubsequently“takendown,”itlikely

stillenduresasaccessibletotherestoftheworldontheInternet.

iii.Theimportanceofyourindividualsafetywhenpostingpersonalmaterials,

suchasphone/pagernumbersordailyschedulesonline.

C.AssociationWith,andNamingofTulaneUniversity:

1.Inexpressingopinionsviaexternalcommunications,residentsshouldexercise

cautioninidentifyingthemselvesasTulaneUniversityemployees;comments

madebyanindividualareeasilyascribedtotheopinion/positionofthe

Universityasawhole.IftheresidentdoesdisclosetheirassociationwithTulane

University,thecommunicationshouldexplicitlynotethattheopinion/position

expressedwithinthecommunicationissolelythepositionoftheresident,and

notofTulaneUniversityortherespectivehealthcareinstitution(i.e.,hospital,

clinicorhealthcaresystem)inwhichtheywork.

2.Ifthereisanyquestionastohowanexternalcommunicationwillbereceived,

residentsareencouragedtoconsultwiththeTulaneUniversityand/orrespective

hospital’sOfficeofPublicRelations.TheGraduateMedicalEducationOffice,

andtheresident’sProgramDirectorcanalsoprovideadviceinreferenceto

externalcommunications.

D.OfferingMedicalAdvice:

1.Residentsarenotrestrictedfromvoicingopinionsonmedicaltopicsvia

electronicorprintmedia.

Residentsareadvised,however,toexercisecautioninsuchstatementsandto

utilizethefollowingguidelinesinmakingthesestatements:

a.Residentsshouldnotmisrepresenttheirqualifications.

b.Thediscussionoropinionshouldbeevidenced-basedwherepossible.

c.Thediscussionoropinionshouldbegenerictothetopic,andnotdesignedto

diagnoseortreatanindividualpatientviaelectronicmeans.

d.Adviceshouldnotbeoffered;wherethediscussionoropinioncouldbe

interpretedasofferingadvice,thecommunicationshouldincludeadisclaimer

thatthereadershouldconsultwithaphysicianpriortomakinganydecision.

2.ResidentsareremindedthatthetermsoftheiremploymentwithTulane

Universitylimitstheprovisionofmedicaladvicewithinthecontextofthe

teachingenvironment,whereappropriatesupervisionexists;malpractice

insurancemaynotextendtomedicaladviceoutsideoftheteachingenvironment.

E.Outside-of-WorkConduct:

1.Itisexpectedthatresidentsbehaveprofessionallyinandoutofwork,as

behaviorinbothsettingsexemplifiesthedevelopmentoftheprofessionalism

competency,andreflectsuponTulaneUniversityreputation.

2.TulaneUniversityrespectstheprivacyofallofitsresidents.Tulanedoesnot

prospectivelymonitorresidents’outside-of-workactivities.

3.Allprofessionalshaveacollectiveprofessionaldutytoassureappropriate

behavior,particularlyasitpertainstoprofessionalbehavior

3.Unprofessionalbehavioroutsideofworkmaybeinvestigatedifitisbrought

totheattentionoftheprogramdirectorand/orDIO,andmaybeintegratedinto

theclinicalcompetencycommittee’sassessmentoftheresident’s

professionalismcorecompetency.

F.TheUniversity’sRoleinMonitoringandEnforcement:

1.TulaneUniversitywillnotmonitorresidents’social,electronicorprint

communicationswithoutcausetodoso.TulaneUniversityassumesnoliability

orresponsibilityforresident’ssocial,electronicorprintcommunicationsof

whichitisnotaware.

2.Allprofessionalshaveacollectiveprofessionaldutytoassureappropriate

behavior,particularlyinmattersofprivacyandconfidentiality.Itisthe

responsibilityofeachUniversityemployeetoself-monitorthispolicyandreport

violationstotherespectiveprogramdirectorand/orDIO.

3.TulaneUniversityreservestherighttoinspectaresident’ssocialand/or

electronicmediaforcause,asdefinedbyareportofaviolationofthispolicy.

4.TulaneUniversityreservestherighttomonitoraresident’ssocialand/or

electronicmediaforcause,asdefinedbyapreviousviolationofthispolicy.

5.Penalties

a.Ifasocial,electronic,orprintmediaposts/communicationisdeemedtobe

inappropriatebytheprogramdirectorortheclinicalcompetencycommittee,the

residentwillbeaskedtoredactortakedownthecommunication.Theresident

hasarighttoappealthisdecisiontotheDIO,whoshallhavethefinaldecision

regardingredactingortakingdownthecommunication

b.Theclinicalcompetencycommitteeisentitledtointegrateviolationsofthis

policyintotheirdecisionsregardingprobation,suspension,non-renewaland

termination(ChapterXXX),particularlywithrespecttotheprofessionalismcore

competency.

c.Residentsinviolationofthispolicymayalsobesubjecttodisciplinefromthe

respectivehospital,clinicorhealthcarenetwork.Residentsinviolationofthis

policymayalsobesubjecttoprosecutionoralawsuitfordamagesfora

contraventionofthePHIPA.

G.Electroniccommunicationwithresidents

1.Afferentcommunication:

a.TheGMEOfficerecognizesimportanceofcommunicatingtoresidentsabout

events,opportunitiesandadditionalinformationnecessaryforclinicalcare.

b.However,theGMEOfficealsorecognizesthatexcessiveelectronic

communicationtoresidentscanleadto“alert”fatigue.

c.Further,theGMEOfficealsorecognizesthepotentialforabuseinsending

electroniccommunicationstotheresidentsthatareinappropriate.

2.Efferentcommunication:

a.TheGMEOfficerecognizesthevalueofobtaininginformationfromresidents

viasurveys.

b.However,theGMEOfficealsorecognizesthatexcessivecommunication

leadsto“surveyfatigue.”Insuchascenario(i.e.,excessivesurveys),thereisa

riskthatresidents’compliancewithessentialsurveys(suchastheACGME

annualsurvey)willdiminish.

c.Further,theGMEOfficealsorecognizesthattheresidents’opinionsarethe

intellectualpropertyoftheresidents,andresidentsshouldnotbecompelledto

expressthoseopinionsunlesstheyareessentialtotheviabilityofthetraining

programsandtheclinicaloperationsinwhichourresidentsparticipate.

3.TheGMEOfficewilloperatearesident,programdirectorandprogram

coordinatorlist-serve.Allthreelist-serveswillbecentrallymonitoredinthe

GMEOffice.

a.Thelist-serveaddresswillonlybereleasedtotherespectiverecipients,and

entitiesorindividualsapprovedbytheGMEOffice.

b.Onlyafferentcommunicationsthatarewithintheaboveguidelineswillbe

allowedtobedistributedtotheresidents.

c.Communicationsregardingindustryorpharmaceuticalswillnotbeauthorized,

aspertheguidelinesintheVendorPolicy.

d.Entitiesorindividualswhorepeatedlyviolatetheaboveguidelinesregarding

appropriatemessagingwillbeexcludedfromfurtheruseofthelist-serve.

4.AllsurveysdistributedtotheresidentsmustfirstbeapprovedbytheGME

Office.Residentswillbeinstructedtodisregardanysurveythathasnotbeen

previouslyapprovedbytheGMEOffice.

5.Residents’emailaddresseswillnotbesharedwithanyindividualoutsideof

theUniversityunlessthereis,inthejudgmentoftheDIO,directreason,

consistentwiththetrainingandclinicalcareenvironment,todoso.

ApprovedbytheGMEC;November29th,2017

SECTION4:

INSTITUTIONALPOLICIES&

ORGANIZATIONSASITRELATESTO

GME

XXI.TheOfficeofGME&theGMEC:Composition,Mission,and

ResponsibilitiesA.CompositionoftheOfficeofGraduateMedicalEducation

OfficeTheGMEOfficeislocatedonthe15thfloorattheMurphyBuilding,

empoweredwithabudgetthatisderiveddirectlyfromtheDeanoftheSchoolof

Medicine.ThefundingoftheGMEOfficeoccursonanannualbasis,witha

budgetingprocessthatallowsforperiodicneedsassessmentthroughouttheyear

andallowancesasneededforbothsalaryandgeneraloperatingsupplyincreases.

TheGraduateMedicalEducationOfficeiscomposedof:1.TheAssociateDean

ofGraduateMedicalEducation(DesignatedInstitutionalOfficial,DIO).

a.TheDIO’sprimaryresponsibilityistoassureasafe,effectiveandeducational

workenvironmentforTulaneresidentsatallparticipatingsites.

b.TheDIOisalsoresponsibleforensuringinstitutionalcompliancewithall

ACGMEregulations,aswellasassuringthateachresidencyprogramisin

compliancewiththeCommonRequirementsandtheirrespectivespecialtyand

subspecialtyrequirements.

c.AllcorrespondencefromtheprogramdirectorstotheACGME,andall

communicationtotheUniversity’sgovernancebody,mustbeapprovedbythe

DIO.

d.Allfinancialmatters,complianceissues,andmajoreducationaldecisions,

includingsitesfortraining,thataffectresidentsandfellowsmustbeapprovedby

theDIO.

e.Allremediation,probation,suspensionandterminationissues(SeeChapter

XIV)mustbeapprovedbytheDIO.

f.TheDIOisresponsibleforchairingtheGraduateMedicalEducation

CommitteeaswellastheTulaneEducationalComplianceCommittee,which

overseesallaspectsofeducationasitrelatestocompliancewiththeirrespective

accreditingbodies(LCME,GME,CME).

g.TheDIOisamemberoftheExecutiveMedicalFacultyandreportsdirectlyto

theDeanoftheSchoolofMedicine.

h.TheDIOisresponsibleforpreparinganannualreportontheStateofGMEat

TulaneUniversity,tobedeliveredtotheGMEC,theExecutiveFaculty(the

OrganizedMedicalStaff),andtheAdministrativeBoardofTulane.Awritten

copyofthereportistobedeliveredtoeachoftheliaisonsattheaffiliated

traininglocations.ThereportistoincludeupdatesonthecurrentGMEtraining

environmentasoutlinedinXX.E

j.TheDIOisresponsibleforensuringeachprogramcompletestheirannualself-

study(ChapterXXII.PolicyonProgramEvaluation,ImprovementandAnnual

ProgramReports)j.TheDIOisresponsibleforconductingInternalReviewsof

programsasiswarranted.(ChapterXXII.PolicyonProgramEvaluation,

ImprovementandAnnualProgramReports)k.Atleast50%oftheDIO’s

professionaleffortsmustbedevotedtotheroleofbeingtheDIO;compensation

andsufficientprotectedtimetoeffectivelycarryouthisorhereducational,

administrative,andleadershipresponsibilitiesistobecommensuratewiththis

effort.

l.TheDIOisresponsibleforengaginginprofessionaldevelopmentapplicableto

hisorherresponsibilitiesasaneducationalleader.

2.TheAssistantDeanofGraduateMedicalEducation.

a.TheAssistantDeanisresponsibleforassistingtheDIOinalloftheabove

responsibilities.

b.IntheeventoftheDIO’sabsence,theAssistantDeanofGMEwillfulfillall

dutiesastheyrelatetotheDIO’sposition,includingsupervisionofthetraining

programs,reviewingandco-signingprograminformationformsand

correspondencewiththeACGMEandaffiliatedtrainingsites.

c.Intheeventthatamatterofbusinessinvolvestheresidencyprogramoforigin

fromtheDIO,orthereisotherwiseaperceivedconflictofinterestintheDIO

chairingtheGMEConamatter,theAssistantDeanshallserveastheChairof

theGMECinoverseeingdeliberationsofthatmatterofbusiness.

3.SeniorDepartmentAdministrator.TheSeniorDepartmentAdministratoris

responsibleforthebusinessandgeneraloperationsoftheGMEOffice,including

assistingtheDIO,AssistantDean,andthefinancialmanagertoensureoptimal

operationoftheGMEoffice.

4.GMEProjectManager.TheProgramManagerisresponsibleforensuring

accuratepayrollforeachresidentatTulane,aswellasbenefits.

5.CredentialManager.TheCredentialManagerisresponsibleforensuring

accurateattestationofcredentialsforinquiriesregardingpastgraduatesofthe

TulaneMedicalSchoolandtheTulaneGME

programs.

6.ExecutiveSecretary.TheExecutiveSecretarysupportstheadministrative

functionsoftheoffice.

7.TheOfficeoftheUniversity’sLegalCounselworksdirectlywiththeGME

Office,providingguidanceforallissuethatmayinvolvelegalconsiderations.

8.TheGMEOfficealsoworkscloselywiththeUniversity-supportedResidents’

AssistanceProgram(SeeChapterXVI.Residents’AssistanceProgram).

B.CompositionoftheGraduateMedicalEducationCommittee

1.Mission:TheGraduateMedicalEducationCommittee(GMEC)governsall

activitiesrelatedtothecomplianceandstrategicmissionofallresidency

programsattheTulaneUniversitySchoolofMedicine.

TheTulaneGMEC,workinginconjunctionwiththeDIO,isresponsibleforthe

oversightofallTulaneresident/fellowassignments,andofthequalityofthe

learningandworkingenvironmentatallparticipatingsites.

2.Composition:TheGMECiscomposedof:

a.TheAssociateDeanofGraduateMedicalEducationwhoshallserveasthe

chair.

b.TheAssistantDeanofGraduateMedicalEducationwhoshallserveasthe

vice-chair.

c.ArepresentativefromthefollowingcomponentsofTulane’sGMEProgramsi.

TheInternalMedicineProgramDirector,whoshallalsorepresentthepreventive

medicineprogram.

ii.TheSurgeryProgramDirector,whoshallalsorepresenttheplasticsurgery

program.

iii.TheOb/GYNProgramDirector

iv.ThePediatricsProgramDirector,whoshallrepresentthepediatric

subspecialtiesandthemed-pedsprogram.

v.ThePsychiatryProgramDirector,whoshallrepresenttheneurologyresidency

program,thechildpsychiatryprogram,theforensicpsychiatryprogram,andthe

combinedpsychiatryprograms(tripleboardandmedpsych).

vi.OnerepresentativefromtheInternalMedicineSubspecialtyFellowships,

whoshallrepresentthedermatologyresidencyandtheallergy-immunology,

cardiology,endocrinology,gastroenterology,heme/onc,infectiousdisease,

nephrology,andpulmonary/criticalcarefellowships.

vii.OnerepresentativefromtheSurgicalSubspecialtyResidencies,whoshall

representneurosurgery,orthopedics,otolaryngology,ophthalmology,plastic

surgery,andurology.

vii.Onerepresentativefromthehospital-basedservicesprograms(radiology,

anesthesia,pathology,pathologysub-specialties),whoshallrepresentthese

respectiveprograms.

d.TworesidentrepresentativesaselectedfromtheirpeersthroughtheTulane

ResidencyandFellowshipCongress.

e.TwoprogramadministratorsaselectedfromtheirpeersthroughtheProgram

AdministratorsCouncil.

f.Aqualityimprovement/safetyofficerorhisorherdesigneefromeitherTulane

Hospital,theVAHospital,ortheUniversityMedicalCenter

3.Quorum:Quorumisdefinedbygreaterthan50%ofthevotingmembers,with

aminimumofonerepresentativefromtheTulaneResidentandFellow

Congress.

4.Institutionalhierarchy:ThedecisionsoftheGMECarereportedthroughthe

DIOtotheExecutiveMedicalFaculty,ofwhichtheDeanofMedicineisthe

Chair.TheExecutiveFacultyservesastheprimarygoverningbodyofthe

MedicalSchoolinallmattersacademicandadministrative.Inturn,their

decisionsarereportedthroughtheDeantotheProvostoftheUniversity.The

ProvostanswersdirectlytothePresidentoftheUniversity.ThePresident

answerstotheAdministratorsoftheTulaneEducationalFundthathasfull

governingauthorityoftheUniversity(i.e,the“GoverningBody”).An

organizationalchartisdisplayedinAppendixD.

C.ResponsibilitiesoftheGMEC.TheGMECconveneseveryothermonth,and

hasthefollowingresponsibilities:1.Oversightofinstitutionalaccreditation,

includingreviewtheACGMEinstitutionalletterofnotificationfromtheIRC

andmonitoringofactionplansforcorrectionofcitationsandareasof

noncompliance2.Oversightoftheindividualprograms’ACGMEaccreditation,

includingthequalityoftheGME

learningandworkingenvironmentwithintheSponsoringInstitution,its

ACGME-accreditedprograms,anditsparticipatingsites;

3.ApplicationsforACGMEaccreditationofnewprograms,voluntary

withdrawalofACGMEprogramaccreditation;andoversightofallprocesses

relatedtoreductionsandclosuresofindividualprograms,participatingsitesand

theSponsoringInstitution,asoutlinedinChapterIII:III.PolicyonProgram

Closure,Reduction,orExpansionandChapterIV:IV.Policyon

Disaster/InterruptionofResidentTraining

4.ReviewandapprovalofallinstitutionalGMEpoliciesandprocedures5.

Stipendsandpositionallocation.Thecommitteewillreviewandprovide

recommendationstotheSponsoringInstitution’sleadershipregardingresident

stipends,benefits,andfundingforresidentpositions,asoutlinedinChapterIII:

PolicyonResidencyProgramClosure,Reduction,orExpansion,andChapterV:

PolicyonFinancial&ResourceSupportofResidents

6.ResponsestoClinicalLearningEnvironmentReview(CLER)reports7.

OversightofthefunctionandeffectivenessoftheTulaneResidencyand

FellowshipCongress,asoutlinedinAppendixA.TheResidencyCongress,and

residentrepresentationonHospitalandUniversitycommittees,asoutlinedin

ChapterIX.Residents’ParticipationonInstitutionalCommittees.

8.Vendorinteractionsbetweenvendorrepresentatives/corporationsand

residents/GMEprogramsasoutlinedinChapterVII.PolicyonInteractingwith

Vendors.

9.ApprovaloftheDIO’sAnnualReporttotheOrganizedMedicalStaffas

outlinedinChapterXXII.

PolicyonProgramEvaluation,ImprovementandAnnualProgramReports.

10.OversightofallGMECsub-committees.

a.Thecompositionofad-hocorstandingsubcommittees,unlessotherwise

explicitlyspecified,isatthediscretionoftheGMEC.

b.AnysubcommitteethataddressrequiredGMECresponsibilitiesmustinclude

atleastonepeer-selectedresident/fellow,asassignedbytheTulaneResidents

andFellowsCongress.

c.AllsubcommitteeactionsthataddressrequiredGMECresponsibilitiesmust

bereviewedandapprovedbytheGMEC.

11.ProgramSupervision.TheGMECisresponsibleforensuringthateach

TulaneprogramisincompliancewithallACGMECommonandProgram-

Specificrequirements,andTulaneUniversityrulesandregulations.TheGMEC,

throughreviewofAnnualReports,Programs’Self-Study/AnnualReportsand

ACGMEsitevisitreports,willensurethateachprogrammaintains:a.Oversight

oftheACGMEaccreditationstatusofallTulaneACGME-accreditedprograms,

includingareviewofallACGMEprogramaccreditationlettersofnotification,

monitoringofactionplansforcorrectionofcitationsandareasof

noncompliance,andprogressreportsrequestedbyaReviewCommittee

b.Requestsforalltemporaryorpermanentchangesinresidentcomplementc.

OversightofthequalityofeducationalexperiencesineachACGME-accredited

programthatleadtomeasurableachievementofeducationaloutcomesas

identifiedintheACGMECommonandspecialty/subspecialty-specificProgram

Requirements

i.EffectivecommunicationandappropriateoversightbetweenTulaneprogram

directorsandthesitedirectorsateachparticipatingsitefortheirrespective

programsii.Compliancewithresidentdutyhoursforeachresidencyprogramas

outlinedinChapterVIII.PolicyonResidents’DutyHours.

iii.Residentsupervision,includingsupervisionthatenablesandensuressafeand

effectivepatientcare,educationalneedsofresidents,andprogressive

responsibilityappropriatetoresidents’levelofeducation,competence,and

experience,asoutlinedinChapterXIII.PolicyonSupervisionofResidents

iv.Curriculumandevaluationthatenablesresidentstodemonstrateachievement

ofthe79

ACGMEgeneralcompetenciesasdefinedinChapterX.PolicyonCore

CurriculumandtheCoreCompetenciesandasnotedintheACGMECommon

andSpecialty-specificProgramRequirements.

d.Oversightoftheprograms’annualevaluationandimprovementactivities,e.

OversightofmajorchangesinACGME-accreditedprograms’structureor

durationofeducation

f.OversightofadditionsanddeletionsofACGME-accreditedprograms’

participatingsites;g.Oversightofappointmentofnewprogramdirectors

h.Oversightofallrequestsforexceptionstodutyhourrequirements,and

oversightofallphasesofeducationalexperimentsandinnovationsthatmay

deviatefromInstitutional,Common,andspecialty/subspecialty-specificProgram

Requirements

i.OversightofrequestsforappealofanadverseactionbyaReviewCommittee

andappealpresentationstoanACGMEAppealsPanel.

j.OversightofselectionofresidentsincompliancewithChapterI:Policyon

ResidentEligibilityandSelection,andChapter:II.PolicyonEqual-

Opportunity,AffirmativeAction,&Disabilities,k.Oversightofevaluation,

promotion,andtransferorresidentsincompliancewithChapterI.

PolicyonResidentEligibilityandSelection

l.Oversightofdiscipline,and/ordismissalofresidentsincompliancewith

ChapterXV.PolicyonRemediation,Suspension,TerminationandGrievance

12.DeliberationsandactionsoftheGMECwillbedocumentedinminutesfrom

eachmeeting,whichwillbereviewedandapprovedatthesubsequentGMEC

meeting.

D.OversightofallACGMEcommunications

A.TheOfficeofGraduateMedicalEducationencouragesprogramdirectorsto

interactwiththeirrespectivespecialty-specificRRCformattersofguidanceand

adviceasitpertainstotheircompliancewiththeCommonandProgram-specific

ACGMEregulations.

B.TheDIOandtheGMEC,mustprovideapprovalofallcommunicationswith

theACGMEthatinvolvethefollowing:

1.AllapplicationsforACGMEaccreditationofnewprograms

2.Changesinresidentcomplement

3.Majorchangesinprogramstructureorlengthoftraining

4.Additionsanddeletionsofparticipatingsites

5.Appointmentsofnewprogramdirectors

6.ProgressreportsrequestedbyanyReviewCommittee

7.Responsestoallproposedadverseactions

8.Requestsforexceptionsofresidentdutyhours

9.Voluntarywithdrawalofprogram

accreditation

10.Requestsforanappealofanadverseaction

11.AppealpresentationstoaBoardofAppealortheACGME.

12.Allrequestsforexperimentation/innovationasitregardsexceptionstothe

ACGMECommonandSpecialty-specificrequirements.

E.ConflictsofInterest.

1.TheAssociateDeanofGMEworksdirectlywiththeAssistantDeanofGME

inoversightofalltrainingprograms.TheAssistantDeanofGMEwillassume

oversightofallmatterspertainingtotheprogram(s)oforiginfortheAssociate

DeanofGME,andviceversa.

2.ProgramDirectorswhositontheGMECareallowedandencouragedto

participateandvoteinmattersrelatedtotheirrespectiveprograms.Program

Directorsshouldrecusethemselvesfromadiscussioninwhichtheyhavea

personalinterest.

F.AnnualInstitutionalReport

1.TheGMECwilldemonstrateeffectiveoversightoftheSponsoring

Institution’saccreditationthroughanAnnualInstitutionalReview(AIR),and

willsubmitawrittenannualexecutivesummaryoftheAIRto80

theGoverningBody.

2.Theannualreportwillcontainthefollowinginstitutionalperformance

indicators:a.Resultsofthemostrecentinstitutionalself-studyvisit

b.ResultsofACGMEsurveysofresidentsandcorefaculty

c.NotificationofACGME-accreditedprograms’accreditationstatusesandself-

studyvisits.

d.Monitoringproceduresforactionplansresultingfromthereview.

i.Residentsupervision

ii.Residentresponsibilities

iii.Residentevaluations

iv.Compliancewithduty-hourstandards

v.Residentparticipationinpatientsafetyandqualityofcareeducation.

ApprovedbytheGMEC;January31st,2018

XXII.POLICYONPROGRAMEVALUATION,IMPROVEMENT&

ANNUAL

PROGRAMREPORTINGREQUIREMENTS

A.EachresidencyprogramisrequiredtohaveaResidencyEducation

Committee(REC).

1.TheRECshouldbecomposedoftheprogramdirector(whoshallserveas

chair),theassociateprogramdirectors(whereapplicable),atleasttwofaculty,

andatleastoneresidentfromeachleveloftraining,aselectedbytheirpeers.

2.TheRECshouldmeetatleastquarterlytoreviewtheresidencyprogram.

3.TheresponsibilitiesoftheRECinclude:

a.Areviewofatleastonecomponent(rotation)oftheresidencyprogramateach

meeting.Asummaryreportofresidents’monthlyevaluationsoftherotation

shouldbepresentedandaddressedduringtheevaluationoftherotation.The

rotationevaluationshouldincludeanassessmentofitsfidelitytoprogramand

institutionalpoliciesincludingthefollowing:i.Residenteducationalresources(

ChapterV.PolicyonFinancial&ResourceSupportofResidents)

ii.Residentdutyhoursandworkenvironment(ChapterVIII.Policyon

Residents’DutyHours)

iii.ResidentSupervision(ChapterXIII.PolicyonSupervisionofResidents)iv.

ResidentEvaluation(ChapterXIV.PolicyonEvaluationofResidents)b.

Addressingresidentorfacultyconcernsregardingtheprogramasawhole,as

theymightarise.

c.Onceperyear,theRECshouldconductanannualreviewoftheresidency

program.Thereviewshouldincorporatetheresidents’evaluationoftheprogram

andthefaculty’sevaluationsoftheprograminconstructingthisreview.This

shouldbeusedtosystematicallyevaluatetheprogram,includingthecurriculum,

andtoconstructanannualreportasdetailedbelow.Ifdeficienciesarefound,the

programshouldprepareawrittenplanofactiontodocumentinitiativesto

improveperformanceintheareas.Theactionplanshouldbereviewedand

approvedbytheRECanddocumentedviameetingminutes.

B.EachresidencyprogramisrequiredtohaveaClinicalCompetency

Committee(CCC).

1.TheCCCshouldbecomprisedoffacultyinstrumentaltotheoperationofthe

trainingprogram.

2.TheprogramdirectorcanbeamemberoftheCCC,butshouldnotchairthe

CCC.

3.ResidentsfromtheprogramshouldnotbemembersoftheCCC;chief

residentswhohavefinishedtheirtrainingandareoperatinginafacultyrolemay

participateintheCCC.

4.TheCCCshouldmeetatleastquarterlytoreviewtheperformanceofeach

residentinthetrainingprogramwithrespecttoprogressineachentrustable

professionalactivity(EPA).

a.TheCCCshouldintegratefaculty-of-resident,nurse-of-resident,patient-of-

resident,resident-of-selfevaluationsinassessingatwhichmilestoneeach

residentisoneachEPA.

b.TheCCCmustmakeanassessmentforeachresidentoneachEPAatleast

twiceperyear.

Decisionsforpromotion,retentionandterminationshouldbemadebythis

committeec.TheCCCmustcommunicatetheirassessmentofeachresidentto

theprogramdirector,whowillberesponsibleforuploadingindividualresident’s

milestoneprogresstotheACGME

WebAds.

d.TheCCC,inconcertwiththeprogramdirector,mustensurethateachresident

isinformedofhisorherprogressoneachEPAatleasttwiceperyear.The

programdirectororhis/herdesigneemustmeetinpersonwitheachresident

twiceayeartodiscusstheirsummativeperformanceineachentrustableactivity,

theirperformanceineachofthesixcorecompetencies,andwhereapplicable,

theirperformanceonrequiredprocedures/cases.

5.TheCCCisresponsibleforidentifyinganyresidentwhoseperformance

warrantsremediation,probation,non-renewalortermination.

C.Eachprogramisrequiredtoprovideanannualreportattheendofeach

academicyear.ThereportisduebyJune30thofeachacademicyear,andshould

bepostedtotheprogram’swikipage.

Thegoaloftheannualreportistoidentifyareasofimprovementinthetraining

program.TheGMEOfficerecognizesthatprogramdirectorsandcoordinators

arebusy,andadditionalbureaucraticworkdetractsfromtimethatcouldbe

devotedtotheresidentsandtheresidencyprogram.Assuch,theAnnualReport

isdividedintothreesections:Section1is(therebyrelievingprogramdirectors

fromrepetitivework);Section2isdatathattheProgramDirector/Coordinatoris

responsibleforprovidingonanannualbasis.

Section3isendurablematerialsthatshouldbeonfilewiththeGMEOffice,and

updatedasneeded1.Section1:DatatheGMEOfficewillpulldirectlyfrom

WebAdsa.Theprogram’sresidentroster,includingstart/enddates,demographic

data,andscholarlyactivity

b.Theprogram’sfacultyroster,includingscholarlyactivity.

c.Alistingofprogramcitations,ifany,andprogramresponses.

d.TheACGMEresidentandfacultysurveyreports

e.Financialresidentallocationsbytrainingsite.

f.NotificationofeachofitsACGME-accreditedprograms’accreditationstatuses

andself-studyvisits.

2.Section2:Datatobeprovidedbytheprogramonanannualbasis(See

AppendixF)a.Boardpassratebyresident

b.In-servicescoresbyresident

c.USMLEscoresbyresident

d.Thecompositionoftheprogramevaluationcommitteeandtheprocessusedto

conducttheannualreview.

e.Thesourcedatausedtoinformandmeasuretheannualreviewf.Anarrative

accountofthepreviousyear’sgoalsforimprovement,withsubsequentresults.

g.Thethreepriorityareasforimprovementforthecomingacademicyearh.A

narrativeresponsetoallACGMEfallouts(compliance<80%)ontheresident

andfacultysurveys.

i.Anarrativedescriptionoftheprogram’squalityimprovementproject(s)anda

listingofresidentsandfacultywhoparticipatedintheproject.

3.Section3:EndurableMaterialstobeon-fileintheGMEOffice,withupdates

occurringonaprorenadabasis.

a.TheProgram’sresidentmanual.

b.Acopyoftheresident-of-faculty,resident-of-rotation,resident-of-resident,

patient/nurse-of-residentandfaculty-of-residentevaluations

c.Adescriptionofhowtheprogramaddressesthefollowingcurricular

components:a.Sleepdeprivationandfatiguemitigation

b.Trainingresidentsonhowtoteach

c.Patientsafety/QualityImprovement

d.Residentwellness,sustainabilityandburnoutmitigation

d.Asamplecopyofthemid-year.end-of-yearpromotionandend-of-training

letterstosenttoresidents,documentingtheresident’sintervalprogresswiththe

corecompetencies.

e.UpdatedCopiesofProgramLettersofAffiliation(PLA)foreachParticipating

TrainingSite.

ThePLAshouldinclude(SeealsoChapterXIII)

i.Thefacultyresponsiblefortheeducationalandsupervisoryresponsibilitiesfor

residents;

ii.Theresponsibilitiesoffacultyforteaching,supervision,andformalevaluation

ofresidents.

iii.Thedurationandcontentoftheeducationalexperience

iv.Thepoliciesandproceduresthatwillgovernresidenteducationduringthe

assignment.

v.Thenameofthesitedirectorservingastheliaisonbetweentheprogram

directorandtheclinicalsite.

vi.Thenumberofresidentsassignedtothissiteeachyear,thenatureofthe

rotation(in-housecall,nocall,homecall)andthenumberofmonthsresidents

rotatestothisfacility.

D.TheResidencyManual:Thisshouldbeorganizedasfollows,andpostedto

theprogram’swikiwebpage:1.SectionI:TheAcademicYearCalendar

a.TheResidencyEducationCommittee(REC)Compositionandmeeting

schedulec.TheClinicalCompetencyCommittee(CCC)Compositionand

meetingschedulee.TheCurriculumCalendarandMatrix(bycorecompetency)

2.SectionII:ProgramExpectations

a.OverviewoftheTrainingProgram

b.OverallGoalsandObjectives:CoreCompetenciesandLearningGoalsc.

OverallGoalsandObjectivesbyyearoftraining(ProgressiveLinesof

Responsibility)d.BlockDiagramofaSampleClinicalCurriculum(Rotations)

e.ScholarlyActivityOpportunities

f.ADescriptionofConferencesandEducationalResources

g.ADescriptionofParticipatingInstitutions(includingrationaleforwhythese

siteshavebeenchosentobeapartofthetrainingprogram),andthelocal

directorateachparticipatingsitewhoisaccountableforresidenteducation;

3.SectionIII:DescriptionofClinicalRotationsandElectiveswithGoalsand

Objectives(Organizedbycorecompetencies)

4.SectionIV:Evaluation

5.SectionV:ProgramPolicies.Thesepoliciesshouldbecompatiblewiththe

institutionalpolicies,buttheymustbeuniquetothetrainingprogram(ie.,the

programcannotsimplydefaulttoinstitutionalpolicies).

a.Moonlighting(ChapterVI)

b.Interactingwithvendors(ChapterVII)

c.Dutyhours(VIII)

d.Vacationandleave(ChapterXI)

e.Supervisionandevaluationofresidents(XIII)

ApprovedbytheGMEC;September28th,2011

XXIII.TheSpecialReviewProcess:OversightofUnderperformingProgramsA.

TheSpecialReviewProcessreferstoasystematicreviewofaresidency

program,asconductedundertheleadershipoftheTulaneOfficeofGraduate

MedicalEducation,baseduponcauseasoutlinedbelowB.Criteriafor

identifyingunder-performingresidencyprograms;TheDIOmayselect,withthe

GMEC’sapproval,anyprogramfortheSpecialReviewProcess.Criteriafor

selectioncanincludeanyofthefollowing:

1.AdversereportingontheresidentandfacultyACGMEsurvey

2.Failuretoachieveminimalcompliancewithreportingontheresidentand

facultyACGMEsurvey3.ACGMEcitations

4.Residentorfacultyreportsofadversecompliancewithinstitutionalor

programpolicies,includingbutnotlimitedto,supervisionanddutyhours.

5.FailuretorespondinatimelyfashiontoDIOrequestsforinformation

necessaryinensuringcompliancewithaccreditationandcompliancewith

institutionalorprogrampolicies.

6.Failuretoprovide,inatimelyfashion,orcomplywithfinancialallocationof

residentpositions.

7.Failuretopresentanannualreviewthataddresseseachoftherequired

components.

C.ProtocolfortheSpecialReview

1.TheDIOwillmeetwiththeresidentstoassesscompliancewithinstitutional

and/orprogrampolicies.

TheDIOwillcontinuesuchmeetingsthroughouttheprocess,athisorher

discretion,untiltheconclusionoftheSpecialReviewProcess.

2.TheDIOwillmeetwiththefacultytoassesscompliancewithinstitutional

and/orprogrampolicies.

TheDIOwillcontinuesuchmeetingsthroughouttheprocess,athisorher

discretion,untiltheconclusionoftheSpecialReviewProcess.

3.TheDIOwillmeetwiththeprogramdirectorandchairtoassesscompliance

withinstitutionaland/orprogrampolicies.TheDIOwillcontinuesuchmeetings

throughouttheprocess,athisorherdiscretion,untiltheconclusionofthe

SpecialReviewProcess.

4.TheDIOwillthensharehisorhercollectiveinformationwiththeSpecial

ReviewCommittee,asoutlinedbelow.TheSpecialReviewCommitteewillthen

identifyareasforimmediatecorrectiveaction.

5.TheDIOwillagainmeetwiththeprogramdirectorandchairtosharethe

resultsoftheSpecialReviewCommittee’sdecisions/assessment.

6.TheDIOwillrequestasresponsefromtheprogramdirectorandchairasto

theprogram’sactionplan;thiswillbesharedwiththeSpecialReview

Committee.Theplanshouldincludemeasurableprogressoutcomesaccordingto

atimeline.

D.ParticipantsoftheSpecialReviewProcess

1.TheAssociateDeanofGME(DIO),ortheAssistantDeanofGMEinhisor

herabsence,willchairtheSpecialReviewprocess.

2..AtleastonefacultymemberfromtheGMEC,notfromthedepartmentor

programthatisbeingreviewed.

3..Atleastoneresident/fellowmember,notfromthedepartmentorprogramthat

isbeingreviewed,asappointedbythepresidentoftheTRFC.

4.ProgramParticipants

a.TheProgramDirectorandtheChairoftheprogramthatisbeingreviewed.

b.Arepresentation(atleasttwo)ofthekeyclinicalfacultyoftheprogramthatis

beingreviewed.

c.Arepresentation(atleasttwo)ofpeer-electedresidentsfromtheprogramthat

isbeingreviewed.Atleastonerepresentativefromeachleveloftraininginthe

programmustbepresent.

E.ComponentsoftheSpecialReview.TheDIOandtheSpecialReview

committeewillreviewthefollowing85

componentsasitrelatestotheresidencyprogram’scompliancewiththe

following:1.CompliancewiththeCommon,specialty/subspecialty-specific

Program,andInstitutionalRequirements.

2.Educationalobjectivesandeffectivenessinmeetingthoseobjectives3.

Educationalandfinancialresources

4.Effectivenessinaddressingareasofnon-complianceandconcernsinprevious

ACGMEaccreditationlettersofnotificationandpreviousinternalreviews

5.EffectivenessofeducationaloutcomesintheACGMEgeneralcompetencies

6.Effectivenessinusingevaluationtoolsandoutcomemeasurestoassessa

resident’slevelofcompetenceineachoftheACGMEgeneralcompetencies

7.Annualprogramimprovementeffortsin:

a.Residentperformanceusingaggregatedresidentdata

b.Facultydevelopment

c.Performanceofprogramgraduatesonthecertificationexaminationd.

Programquality

F.TheSpecialReviewReport.

TheSpecialReviewcommitteewillproduceareportthatdescribesthequality

improvementgoals,thecorrectiveactions,andtheprocessforGMEC

monitoringofoutcomes.Thisreportwillbesharedwiththerespectiveprogram

directorandchair,andtheDeanoftheMedicalSchool

ApprovedbytheGMEC;September28th,2011

XXIII.POLICYONACGMECOMMUNICATIONS

A.TheOfficeofGraduateMedicalEducationencouragesprogramdirectorsto

interactwiththeirrespectivespecialty-specificRRCformattersofguidanceand

adviceasitpertainstotheircompliancewiththeCommonandProgram-specific

ACGMEregulations,exceptasnotedinChapterXXII.

B.TheAssociateDeanofGMEandsubsequently,theGMEC,mustapproveall

communicationswiththeACGMEthatinvolvethefollowing,priortotheir

submission.

1.AllapplicationsforACGMEaccreditationofnewprograms

2.Changesinresidentcomplement

3.Majorchangesinprogramstructureorlengthoftraining

4.Additionsanddeletionsofparticipatingsites

5.Appointmentsofnewprogramdirectors

6.ProgressreportsrequestedbyanyReviewCommittee

7.Responsestoallproposedadverseactions

8.Requestsforexceptionsofresidentdutyhours

9.Voluntarywithdrawalofprogram

accreditation

10.Requestsforanappealofanadverseaction

11.AppealpresentationstoaBoardofAppealortheACGME.

12.Allrequestsforexperimentation/innovationasitregardsexceptionstothe

ACGMECommonandSpecialty-specificrequirements.

C.TheAssociateDeanofGMEmustreceiveallprograminformationforms

(PIF’s)onemonthpriortosubmissiontotheACGME.

ApprovedbytheGMEC;September28th,2011

APPENDIXA:THERESIDENTANDFELLOWCONGRESS

A.ARTICLEONE:NAME,PURPOSE,ANDOBJECTIVES

Section1.Name.Thenameofthisorganizationshallbe:TheTulaneResident

andFellowCongressSection2.Purpose.TheResidentandFellowCongressis

theresidents’voicetoensuretheOfficeofGraduateMedicalEducation’s

missionofstrivingforexcellenceineducation.Thisorganizationwillprovidea

mechanismbywhichresidentscanparticipatedirectlyinGMEactivitiesforthe

purposeof:A.OpeningdialogtoidentifyconcernsandfacilitateresolutionB.

Encouragingresidentinputintograduatemedicaleducationgovernanceand

policyC.Fosteringprofessionalism,empathyandpersonalgrowthand

developmentforourphysiciansintraining

D.Improving:

a.Theeducationalexperienceandopportunities

b.Representationoftheinterestofitsmembersindeliberationswithaffiliated

hospitalsonissuesregardingworkingconditionsandbenefits

c.Communicationwithotherhealthcareproviders,programdirectors,the

medicalstaffandadministration

d.Activemembershipandparticipationinconstituentsocietiesoforganized

medicinee.Overallqualityofpatientcare

f.Residentandresident’ssignificantother’swell-beingthroughsocialand

charitableactivities

B.ARTICLETWO:MEMBERSHIP

Section1:Membership

Themembershipshallbecomprisedofallphysiciansholdinganinternship,

residency,orfellowshipappointmentatTulaneUniversitySchoolofMedicine

anditsaffiliatedhospitalsandclinics.

Section2:RightsofMembership

Physicianmembersingoodstandingshallbeentitledtoallprivilegesof

membershipasprovidedintheconstitutionandbylawsoftheassociation,

includingthedutytovoteandtherighttoholdoffice.

Section3:TerminationofMembership

Membershipshallbeterminatedupon:

A.Writtenresignation

B.Death

C.Completionoftrainingprogram

D.Transferordismissalfromtrainingprogram

E.Adeterminationby2/3majorityvoteoftheCongressthatanindividual’s

actionsarecontrarytotheConstitution,Bylaws,orbestinterestofthe

Organization.

C.ARTICLETHREE:MEETINGS

Section1.Meetings

AllregularandannualmeetingsoftheResidentandFellowCongressshallbe

conductedfollowingtheguidelinesofRobert’sRulesofOrder.

Section2.BoardMeeting

Theexecutivecouncilshallmeetatleastsixtimesannually,andothertimesas

deemednecessarybythePresident.

Section3.Quorum

NomeetingoftheCongressshalltakeplacenorshallanybusinessofthe

CongressbeconductedintheabsenceofaquorumasoutlinedintheBylawsto

thisconstitution.

D.ARTICLEFOUR:OFFICERS

Section1.ElectionofOfficers.

A.Nominationsforalltheelectedpositions,exceptPresident-elect,shallbe

madebytheResidentandFellowCongressmembershipnolessthan30days

priortotheAnnualMeeting.

B.NominationsforPresident-ElectshalltakeplacebeforeNovember30.

ElectionbymajorityshalltakeplaceinJanuary.

C.Intheeventthattherearenonominationsforanelectedposition,aspecial

meetingoftheBoardshallbecalledandthepositionfilledviaappointment.

D.Absenteevotingmayoccurduringthe30daysimmediatelypriortothe

election.

E.Electionwillbedeterminedbymajorityofvotesreceived.Run-offelections

willbeheldifnocandidatereceivesamajorityvote.

Section2.Officers

A.GMELiaison:AssistantDeanofGraduateMedicalEducation

1.SupervisealloperationsoftheResident

Congress

2.AvenuefordirectinterfacebetweentheResidentandFellowCongressandthe

DIOandGMEC

3.AssistandadvisethePresidentinOperationsoftheResidentandFellow

Congress4.AttendordesignateattendeeforallAnnualandSpecialCongress

meetingsB.President—DutiesofthePresident:

1.PresideoverallAnnualandSpecialmeetings;underthesupervisionofthe

GMELiaison2.PresideoverallBoardmeetings

3.Shallappointallcommitteechairpersonsandmaintainsummary

documentationofactivecommittee’sandagendaitems.Thiswillbe

communicatedtotheGMELiaisonatleastquarterly

4.Serveasanex-officiomemberofallcommittees

5.Withinsevendaysofanymeetingsubmit,inwritingtotheGMELiaison,all

recommendationsarisingfromtheResidentandFellowCongress

6.MaintainopenlinesofcommunicationwiththeGMELiaisononallissues

whichpertaintoandencompasstheoverallResidentandFellowCongressgoals

andobjectives7.ServeastheResidentandFellowCongressGMEC

representativeandreportfindingstothisorganization

C.Vice-President(President-Elect)—DutiesoftheVice-President:1.Preside

overallmeetingswherethePresidentisnotinattendance2.Willworkdirectly

withthepresidenttohelpsupervisetheoperationsoftheassociation3.Facilitate

communicationbetweencommitteesanddepartments4.Willbearepresentative

tomeetingwiththechiefresidentsofalldepartments.

5.MayserveasChairpersonofanycommittee

6.ServeastheGraduateMedicalEducationCommitteerepresentativeD.

Secretary—DutiesoftheSecretary:

1.MaintainsacurrentrosterofmembershipandBoardmembers

2.Overseesinterdepartmentalcommunications

3.Ensuresthetakingofminutesand

communications

4.ChairofMembershipCommittee.

E.Treasurer—DutiesofTreasurer:

1.ProvidetheAssociationwithaproposedbalancedbudgetfortheyear2.Keep

theAssociationinformedonmonetaryissuesaffectingtheAssociation3.Chair

ofFinanceCommittee

4.Investigatemechanism’sforfunding

Section3.Terms

Officersshallbeelectedorappointedforthetermofoneacademicyearatthe

AnnualMeeting,withtheexceptionofthePresident-Electwhowillbegin

servicewhenelectedandbecomePresidentattheconclusionoftheAnnual

Meeting.

Section4.

Qualifications

Candidatesforelectedorappointedofficesshallbeamemberingoodstanding.

CandidatesfortheofficeofPresident-Electmustbemembersingoodstanding

foratleastoneyearbeforerunningforoffice.

ExceptionsmustbeapprovedbytheBoard.

Section5.

Vacancies

Electedorappointedofficerswillbeconsideredvacantwhenanofficerceasesto

performtheirdutiessecondarytodeath,resignation,removaland/or

disqualification.

Section6.

RemovalofOfficers.

AnofficermayberemovedduringanyAnnualorBoardmeetingbyasimple

majorityvote.

Theofficershallbeaffordeddueprocesspriortoanydismissalproceedings.

Anyofficerwhodisqualifiesfrommembershipimmediatelyceasestobean

officer.

E.ARTICLEFIVE:BOARDOFDIRECTORS

Section1.

BoardMembership.

A.TheExecutiveBoardshallconsistofaminimumofthePresident,Vice-

President,President-Elect,Secretary,TreasurerandsixDirectors;oneshallbe

fromasurgicalresidencyprogram,oneshallbefromanon-surgicalresidency

program,twoshallbeinternsfromanyprogram,oneshallbeafellow,andone

shallbefromanyprogram.

B.AllboardmembertermsexpireattheconclusionoftheAnnualMeeting

followingtheirelection.

Section2.

SelectionofExecutiveBoardMembers

A.TheDirectorsoftheBoardshallbeelectedbymajorityvoteattheAnnual

MeetingaccordingtoArticleFour,Section1oftheConstitution.

B.Qualifications,vacanciesandremovalofmembersfromtheExecutiveBoard

willfollowthesameguidelinesasotherofficers.

Section3.

MeetingsoftheBoard

A.AllmeetingsoftheResidentandFellowCongressExecutiveBoardshallbe

conductedundertheRobert’sRulesofOrder.

B.SpecialmeetingsoftheExecutiveBoardmaybecalledbyeitherthePresident

orbythemajorityofBoardmembers.TheGMELiaisonwillbenotifiedof

Boardmeetingsandattendsuponformalinvitation.

TheGMELiaisonwillattendallAnnualandRegularResidentandFellow

Congressmeetings.

Section4.

DutiesoftheBoardofDirectors

ThedutiesoftheExecutiveBoardmembersshallbe:

A.Advisetheofficersonmattersbroughttotheassociation’sattention

B.ToaidindevelopingpolicythatshallguidetheaffairsoftheResidentand

FellowCongress

C.Toassistinthedisseminationofinformationtothemembersandserveasa

voicefromtheirrepresenteddepartments

D.ToassistinthedisseminationofinformationfromtheExecutiveBoardback

totheirrespectivedepartments.

F.ARTICLESIX:COMMITTEES

ThecommitteesoftheAssociationshallbecomposedofmembersofthe

Congress.

Committeeswillbedesignatedeachyearaccordingtotheconcernsandgoalsof

theCongress.

G.ARTICLESEVEN:DUES,FUNDINGANDASSESSMENT

Fundsmaybesetbyannualduesorassessmentofthemembersoron

recommendationoftheBoardasprovidedbythebylaws.

H.ARTICLEEIGHT:AMMENDMENTOFTHECONSTITUTION

1.TheResidentandFellowCongressConstitutionmaybeamendedatany

annualmeeting.

2.Proposedamendmentstotheconstitutionshallbepresentedinwritingtothe

TulaneDeanofGraduateMedicalEducationandpublicizedtothemembership

atleastsixmonthspriortotheproposedamendmentshallbeconsidered

3.Membersingoodstandingmayvoteinabsenteewithasignedlettertobe

openedonlyatthetimeofcountingvotes.

4.AnamendmenttotheConstitutionmustbeapprovedbya¾majorityvoting

membershipinordertopass.

Bylaws

TulaneUniversitySchoolofMedicine:

ResidentandFellowCongress

ArticleI.Membership

Section1.Goodstanding

Amembershallbeconsideredtobeingoodstandingwhocurrentlyisaresident

orafellowwithTulaneUniversityandisnotonprobationorservingany

disciplinarysanctions.

Section2.Privileges

Amemberingoodstandingshallhavethe:

Righttovote

Righttoholdoffice

Righttoserveonthecommittees

Righttoparticipateandattendallmeetings

Section3.GMELiaison

TheGMELiaisonshallbetheAssistantDeanofGMEandheshallserveasthe

interfacebetweentheResidentCongressandtheDIOandGMEC.TheGME

Liaisonwillprovidedirectsupervisionandfunctioninanadvisoryrole.The

GMELiaisonwillattendallRegular,SpecialandAnnualResidentCongress

Meetings.

ArticleII.Meetings

Section1.Boardmeetings

A.Anymemberoftheresidentcongressmayattendanygeneralmeeting.Any

personotherthanresidentcongressmembers,whowishtoparticipatein

discussionsofanagendaitempertinenttotheirresponsibility,mustbeinvitedby

eitheramemberoftheBoardoroneoftheofficers.

B.TheTRFCreservestherighttomeetwithouttheDIO,facultymembers,or

otheradministratorspresent.

C.BoardmeetingmaybecalledintoexecutivesessionrestrictedtoOfficersand

Directorsupon2/3majorityvoteoftheBoardmemberspresentataBoard

meeting.

Section2.Specialmeetings

SpecialorexecutiveboardmeetingmaybecalledatanytimebythePresidentor

uponwrittenrequestofamajorityoftheBoard.

Section3.AnnualMeetings

AnnualMeetingsshallbeheldeachMayaccordingtotheConstitution.The

GME

LiaisonwillattendbothAnnualandRegularCongressMeetings.

Section4.RegularMeetings

RegularMeetingsshallbeheldquarterly.

Section5.Quorum

Anassemblyof1/3ofthemembershipshallconstituteaquorumforthe

conductionofbusinessofallAnnualandSpecialmeetingoftheCongress.

Anassemblyof50%oftheBoardofDirectorsshallconstituteaquorumforthe

conductionofbusinessatallBoardmeetings.Boardmembersonscheduled

vacation,leaveofabsenceorrotationsmorethan30milesfromTulane’s

downtownmedicalcampusareexcusedfromBoardmeetingsandshallnotcount

fororagainstaquorum.

ArticleIII.Officers

Section1.Voting

Absenteevotingmayoccurduringsevendaysimmediatelypriortotheelection

bysubmittingballotstotheResidentCongressSecretaryordesignee.

Eachmembervotingabsenteeshallinitialtherostersignifyingthatthemember

hasvoted.

TherosterandballotsshallbesubmittedtotheAssistantDeanofGME’soffice

thedaypriortotheelection.

TheGMELiaisonshallbeanon-votingmember.

Section2.Dueprocess

Anofficerorexecutiveboardmembermayberemovedfromofficeatany

Annual,Special,orBoardmeetingoftheCongress.

TheofficerorBoardmembershallbegivennoticeoftheintenttoremoveone

weekpriortothemeeting.Theofficershallhavetherighttospeakonhis/her

behalftothegeneralassemblypriortoanyremovalvote.

ArticleIV.Vacancies

Avacancyofanyelectedofficeshallbefilledbyamembernominatedbythe

PresidentandconfirmedbysimplemajorityvoteoftheBoardatanyBoard

meeting.AvacancyintheofficeofPresidentshallbefilledbytheVice-

President.

ArticleV.Board

Theboardshallbecomprisedofintern,residentandfellowmembers.

ArticleVI.Committees

CommitteeChairpersonsshallbeappointedbythePresident.Allcommittee

membersshallbeselectedatthediscretionoftheChairperson.

Anypersonotherthancommitteemembersthatshouldattendacommittee

meetingmustbeinvitedbyoneofthecommitteemembers.

Anypersondeniedparticipationonanycommitteeshallhavetherighttopetition

theCongressforreview.TheBoardshallhavethepowerbymajorityvoteto

assignadditionalcommitteemembers.

ArticleVIII.Amendments

TheResidentCongressBylawsmaybeamendedatanyAnnual,Special,or

Boardmeeting.

Proposedamendmentstothebylawsshallbepresentedinwritingatleastone

meetingbeforetheproposedamendmentshallbeconsidered.Thetwomeetings

mustbeatleastfourteendaysapart.

Membersingoodstandingmayvoteinabsenteewithasignedlettertobe

openedonlyatthetimeofcountingthevotes.

AnamendmenttotheBylawsmustbeapprovedbya2/3majorityofthevoting

membershipinordertopass.

BylawschangesshallbeforwardedtotheTulaneDeanofGraduateMedical

Educationupontheirpassage.

ArticleVIII.Reporting

ThePresidentoftheResidentCongressshallreport,totheGMELiaison,within

sevendaysandinwriting,theminutesandrecommendationsfromallmeetings.

ThePresidentinconsultationwiththeGMELiaisonshallregularlyreporttothe

GMEC.TheGMELiaisonisresponsibletodirectlyoverseeoperationsofthe

ResidentCongress.

AppendixB:WrittenStatementofInstitutionalCommitment

AppendixC:SampleContract.

TULANEUNIVERSITYSCHOOLOFMEDICINERESIDENT

AGREEMENT

1430TulaneAvenue,NewOrleans,Louisiana70112

THISAGREEMENTbetweenTheAdministratorsoftheTulaneEducational

Fund,onbehalfoftheTulaneUniversitySchoolofMedicine(hereinafter

“MedicalCenter”)and___nnnnnn_______

(hereinafter“Resident”)isenteredintofortheperiodfrom_dd/mm/yyythrough

dd/mm/yyy.UnderthesponsorshipoftheMedicalCenterandsupervisionby

facultymembersoftheMedicalCenter,Residentwillserveasa#(PGY)year

residentinthe_pppppppp____Residency/FellowshipProgram.

PoliciesandProceduresResidentHandbook.TheResidentandStaffGraduate

MedicalEducationPoliciesandProcedures2017-2018(hereinafter“the

Manual”)containstheinstitutionalguidelines,policiesandprocedures

governingtheselection,appointment,evaluation,andretentionofresidentsat

theMedicalCenter.TheResidentwillreceiveacopyoftheManualduring

orientationanditispostedontheGMEwebsitehttp://tulane.edu/som/gme/;

however,theManualissubjecttorevision.TheprovisionsoftheManual

referredtointhisAgreement,intheirmostrecentversion,arehereby

incorporatedintothisdocumentbyreference.Itistheresponsibilityofthe

Residenttofamiliarizehim/herselfwiththeinformationcontainedinthe

Manual,includinganyrevisions,andtoassurethathe/sheisincompliancewith

allpoliciesandprocedurescontainedthereinatalltimesduringthetermofthis

agreement.

Stipend.Commencing_dd/mm/yyythroughdd/mm/yyy,theResidentwill

receiveanannualizedstipendof$__________.Thisamountwillbesubjectto

theappropriatefederalandstateincometax,socialsecuritytax,andanyother

applicabledeductions.

Leaves.TheMedicalCenterprovidesforvacation/sickleave,parentalleave,

personalleave,leaveofabsence,andprofessionalleaveassetforthinSections

V.andXIoftheManual.Theuseofleaveexceedingthelimitsestablishedbythe

MedicalCenterorProgrammayrequireextensionoftheresident’strainingas

describedinSectionXIoftheManual.

AdditionalBenefits.

a.SupportServices.Itisunderstoodthatcounseling,medicalandpsychological

supportiveserviceswillbemadeavailableonanasneededbasis.

b.Insurance.Health,lifeanddisabilityinsurancewillbeprovidedandare

effectiveonthefirstdayofResidencyprogramunlessspecificallyrefused.

Dental,aswellasfamilymedicalinsurancecoveragemaybepurchasedfor

eligibledependentsthroughpayrolldeductionasdescribedinSectionVofthe

Manual.

c.ProfessionalInsurance.Liabilityinsurancewillbeprovidedthroughthe

TulaneSelf-InsuranceTrustProgram:$1,000,000;andtheLouisianaPatient

CompensationFund–Act817

Qualification,orbytheStateorFederalplanswhenrotatingthroughtheir

supportedfacilities.

Theseareoccurrence-basedcoveragesprovidingthatanyclaimoractionarising

outofaneventthatoccurredwhilethepersonwasaresidentactingonbehalfof

MedicalCenter,regardlessofwhentheactionisfiled,iscoveredunderthe

respectiveinsuranceprogramsorplans.

d.EducationalResources.Residentshallhaveaccesstoinformationrelatedto

eligibilityforspecialty-basedexaminationsasdescribedinSectionVofthe

Manual.

e.OtherBenefits.FreeparkingwillbeavailablewhileonrotationintheTulane

UniversityMedicalCenterarea(TMC,VA,MCLNO).Sleepingquartersand

mealswillbeprovidedwhileon-call.Labcoatsandbeeperswillbeavailableat

nocharge.

DurationofAppointment/Termination.

a.One-YearTerm.Thetermofthisagreementisforoneyearonly(asstatedin

theopeningparagraphofthisagreement),andnoguaranteeofasubsequent

contract(s)isexpressedorimpliedeventhoughtheResidentmaybe

participatinginamulti-yearresidencyprogram.

b.ConditionforReappointment.Conditionsfortheofferofanysubsequent

trainingagreementfollowinganinitialappointmentandforpromotionwithinthe

programaredescribedinSectionXIVoftheManual.

c.TerminationwithCause.Duringthetermofthisagreement,theMedical

Centermayterminatethisagreementwithcauseaccordingtotheconditions

describedinSectionXIVoftheManual.

6.GrievancesandFairHearing.Thepoliciesrelatingtoresidentgrievancesand

theappealandfairhearingprocessarepresentedinSectionXIVoftheManual.

ResidentResponsibilities.Residentphysiciansareexpectedto:a.Meetthe

qualificationsforresidenteligibilityoutlinedinSectionIoftheManual.

b.ComplywithTulane’sverificationprocedures,whichincludes:i)

Documentationofidentityandrighttowork.

ii)

Proofofcompliancewithimmunizationpolicy.

iii)AccuratecompletionoftheTulaneapplicationforappointmenttothe

housestaff,listingallinformationrequestedandreturningthedocumentina

timelymannerpriortothehiringdatesoallinformationcanbeverified

includingmedicalschoolandpreviousresidencytrainingpriortobeginning

patientresponsibilities.

c.Obtainavalid,unrestrictedLouisianaStateMedicallicenseoratraining

permitfromtheLouisianaStateBoardofMedicalExaminers.

d.Developapersonalprogramofself-studyandprofessionalgrowthunderthe

generalsupervisionofappropriatelycredentialedattendingteachingstaff.

e.Participateinsafe,effectiveandcompassionatepatientcareundersupervision,

commensuratewithlevelofadvancementandresponsibility.

f.Participatefullyintheeducationalactivitiesofyourprogramand,asrequired,

assumeresponsibilityforteachingandsupervisingmedicalstudents,andother

residentsandparticipatefullyininstitutionalorientationandatleast50%in

educationprogramsandotheractivitiesinvolvingtheclinicalstaff.

g.Participateininstitutionalprogramsandactivitiesinvolvingthemedicalstaff

andadheretoestablishedpractices,procedures,andpoliciesoftheInstitution.

h.Developanunderstandingofethical,socioeconomicandmedical/legalissues

thataffectgraduatemedicaleducationandparticipateininstitutionalcommittees

andcouncils,especiallythosethatrelatetopatientcarereviewactivities,quality

assurance,andapplycostcontainmentmeasuresintheprovisionofpatientcare.

i.Charts,records,and/orreportswillbykeptuptodateandsignedatalltimes.

Failuretocompleteoutstandingpaperworkwillresultindiscipline,including,

butnotlimitedto,suspensionwithoutpay.

j.Followtherules,regulations,policiesandproceduresofTulaneUniversity

SchoolofMedicine,TulaneUniversityanditsaffiliatedinstitutionsthatrelateto

graduatemedicaleducation.

k.Actinaprofessionalandethicalmanner.

FailuretomeetanyoftheresponsibilitieslistedinSection7mayresultin

discipline,uptoandincludingtermination.

ResidentReview.Itisunderstoodthatasthepositionofhousestaffphysician

involvesacombinationofsupervised,progressivelymorecomplexand

independentpatientevaluationandmanagementfunctionsandformal

educationalactivities,thecompetenceofthehousestaffphysicianisevaluatedon

aregularbasis.Theprogrammaintainsaconfidentialrecordoftheevaluations.

ClosuresorReductioninFunding.Shouldanyaffiliatedhospitalcloseorreduce

theirfundingofresidencyslotsduringaresidencytrainingprogram,every

attemptwillbemadetoreplacethosetrainingslotsatanotheraffiliated

institutionandtolocatefundsforcompletionoftheacademicyearassetforthin

SectionIIIoftheManual.Shouldthatnotbeavailableanditisnecessaryto

reducethenumberofresidencypositionsinagivendepartment,theaffected

houseofficerswillbeinformedasearlyaspossible.Assistancewillbeprovided

infindingatrainingpositionatanotherhospital,asoutlinedinSectionIIIofthe

Manual.Additionally,ifaresidency-trainingprogramisclosedorreducedin

size,theaffectedhouseofficerswillbenotifiedassoonaspossibleand

assistancewillbeprovidedtolocateanothertrainingprogramforthem.

10.CounselingServices,Disability,andImpairment.TheMedicalCenter

providesaccessand/orreferraltomedical,psychologicaland/orfinancial

counseling,andsupportservicesasdescribedinSectionsV,XIVandXVofthe

Manual.SectionIIoftheManualdescribesthepoliciespertainingtoresidents

withdisabilities.SectionXVoftheManualincludespoliciesrelatingto

physicianimpairmentandsubstanceabuse.

11.

DutyHours.Itisunderstoodthattraining,research,teachingandclinical

assignmentswillbeapprovedbytheChairmanoftheDepartmentof

______________.Dutyhourswillbeconsistentwithinstitutionalandprogram

requirementsbasedoneducationalrationaleandpatientneed,including

continuityofcarewithsupervisionavailableatalltimesandarediscussedin

SectionVIIIoftheManual.

12.

Moonlighting.TheMedicalCenterhasincorporatedpoliciescovering

professionalactivitiesoutsideoftheresidencyprogram(moonlighting)in

SectionVIoftheManualandResidentagreestoabidebysuchpolicy.

13.Harassment/Discrimination.Concernsrelatedtoharassment,discrimination,

orunwelcomeconductofasexualnaturewillbehandledasdescribedinTulane

University’sEO/Anti-DiscriminationPolicy.AcopyofTulane’sEO/Anti-

DiscriminationPolicycanbefoundat:http://tulane.edu/equity/reporting-

policies.cfm.

All

concerns

harassment,

discrimination,orunwelcomeconductofasexualnaturemustbedirectedtothe

OfficeofInstitutionalEquity(504-862-8083).

14.Severability.Ifanyprovisionofthisagreementisheldinvalid,such

invalidityshallnotaffectanyotherprovisionofthisagreementnotheldso

invalid,andeachsuchotherprovisionshall,tothefullextentconsistentwith

law,continueinfullforceandeffect.

15.

ModificationandWaiver.Thisagreementmaynotbemodifiedoramended

exceptbyaninstrumentinwritingsignedbythepartieshereto.Notermor

conditionofthisagreementshallbedeemedtohavebeenwaived,norshallthere

beanyestoppelagainsttheenforcementofanyprovisionofthisagreement,

exceptbywritteninstrumentofthepartychargedwithsuchwaiverorestoppel.

Nosuchwrittenwaivershallbedeemedacontinuingwaiverunlessspecifically

statedtherein,andeachsuchwaivershalloperateonlyastothespecifictermor

conditionwaivedandshallnotconstituteawaiverofsuchtermorconditionfor

thefutureorastoanyactotherthanthatspecificallywaived.

16.

GoverningLaw.ThisagreementismadeinthestateofLouisianaandshallbe

controlledbythelawsofthestateofLouisianainallmattersorinterpretationsof

thisagreement.

Iaccepttheappointmentoutlinedaboveandagreetoallrulesandregulationsof

TulaneUniversityandaffiliatedinstitutionstowhichIamassigned.Iagreeto

dischargeallthedutiesofaresidentasdeterminedjointlybytheaffiliated

institutionsandtherespectivedirectorsoftrainingprogramsatTulane

UniversitySchoolofMedicine,andIacknowledgethatIhavereadand

understandtheInstitutionalPoliciesreferredtoinParagraph1.

ACCEPTED:

_______________

____________________________________,M.D.

Date

Resident/FellowSignature

____________________________________,M.D.

Resident/FellowPrintedName

_______________

_____________________________________

Date

Residency/FellowshipProgramDirectorSignature

_____________________________________

Residency/FellowshipProgramDirectorPrintedName

_______________

_____________________________________

Date

ProgramDepartmentChairSignature

______________________________________

ProgramDepartmentChairPrintedName

_______________

______________________________________

Date

JefferyG.Wiese,M.D.

AssociateDeanforGraduateMedicalEducation

AppendixD:OrganizationalChart.

100

AppendixE:CodeCloudandCodeGreyArmyCoverageAssignments

101

102

AppendixF:ListofAffiliatedSites

103

APPENDIXG:ANNUALEVALUATIONANDSELF-STUDYTEMPLATE

AnnualProgramEvaluationTemplate

AcademicYear(AY)________

Usethistemplateforaggregatinginformationfromasingleyear’sAnnual

ProgramEvaluation.Thetemplateissuggested,andyoumayadaptitinanyway

youfindusefultofacilitateprogramimprovement.Youmayalsouse

attachmentsorappendicesifadditionaldetailisrelevanttotrackingagiven

issue.

Program:_______________________________________Date:

_______________

A.Membership:ProgramEvaluationCommittee(IncludePGYlevelforpeer-

electedresidentsparticipating)andanarrativeaccountoftheprocessusedto

conducttheannualreview

10.

B.MandatorySourceDatatobeusedintheannualreview,andtobeprovided

directlytotheGMEOffice.

a.BoardPassRatebyresident

b.In-Servicescoresbyresident

c.USMLEscoresbyresident

C.AdditionalSourceDatausedinthereviewofthetrainingprogramResident

ofRotationEvaluations

ResidentofProgramEvaluations

ResidentofFacultyEvaluations

ResidentofInstitutionEvaluations

FacultyofProgramEvaluations

DutyHourReports

104

Evaluationcompliance

ACGMEsurveydata

Internalsurveydata

Summaryresultsofresidentfocusgroups/retreats

In-serviceScores

BoardPassRate/Scores

Procedure/CaseLogReports

Scholarlyactivity

Felowship/CareerPlacementresults

Recruitment/Matchresults/scores

Other_______________________

D.ProgramGoalsforImprovementfromthePreviousYearandInterval

ProgressReports1.Goal

Result

2.Goal

Result

3.Goal

Result

105

E.TheThreeAreasofGreatestImprovementfortheComingYear.Goalsshould

beoperationalizedasSMARTGoals(Specific,Measurable,Aggressivebut

Realistic,Time-Limited)

1.Goal

Narrativedescriptionoftheactionplan

2.Goal

Narrativedescriptionoftheactionplan

3.Goal

Narrativedescriptionoftheactionplan

F.NarrativeresponsetoalFacultyandResidentACGMEsurveyresponsesthat

werebelow80%compliance(identifythesource/causeofthefalout,and

plannedcorrectiveaction).

G.Adescriptiveaccountofthequalityimprovementproject(s)conductedbythe

residentsoverthepreviousyear.Includeresidentandfacultyparticipants,the

topic,sourcedatausedtoinformtheproject,andprojectresults.

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