Edward Via College of Osteopathic Medicine
Resident Manual
Document Owner(s)
Project/Organization Role
John Kauffman, DO
Signature
Director of Medical Education
Resident Manual Version Control
Version
Date
Author
Change Description
1
08/24/07
Dawn Stull
New/Revised
Note
The content of a manual does not constitute nor should it be construed as a promise of
employment or as a contract between Edward Via Virginia College of Osteopathic
Medicine and any of its employees.
Edward Via Virginia College of Osteopathic Medicine at its option, may change, delete,
suspend, or discontinue parts or the policy in its entirety, at any time without prior notice.
AOPTIC is a proud sponsor of the Edward
Effective 07/01/07
Resident Manual
Last printed 7/11/2016 7:21:00 PM
Via Virginia College of Osteopathic Medicine
Resident Manual
TABLE OF CONTENTS
1
2
3
INTRODUCTION ...................................................................................................................... 8
1.1
Welcome ..................................................................................................................... 8
1.2
Changes in Policy ....................................................................................................... 8
APPOINTMENT ....................................................................................................................... 9
2.1
Eligibility and Selection ............................................................................................... 9
2.2
Resident Contract ....................................................................................................... 9
2.3
Re-Appointment ........................................................................................................ 10
2.4
Non-Renewal of Contract/Appointment .................................................................... 11
2.5
Completion of Training .............................................................................................. 11
2.6
Program Closure or Reduction ................................................................................. 11
2.7
Restrictive Covenants ............................................................................................... 12
2.8
Visa Policies & Procedures for Foreign/US Medical School Graduates ................... 12
EMPLOYMENT POLICIES .................................................................................................... 13
3.1
Equal Employment Opportunity/Diversity ................................................................. 13
3.2
Americans with Disabilities Act ................................................................................. 13
3.3
Employee Background Check................................................................................... 13
3.4
Drug Screening ......................................................................................................... 13
3.5
Criminal Records....................................................................................................... 13
3.6
Controlled Substance (DEA) ..................................................................................... 14
3.7
Physician Impairment & Substance Abuse ............................................................... 14
3.8
Licensure ................................................................................................................... 15
3.9
Certificates ................................................................................................................ 15
3.10
Change of Personal Data .......................................................................................... 15
3.11
Chain of Communication ........................................................................................... 16
3.12
Safety ........................................................................................................................ 16
3.13
Personal Property ..................................................................................................... 16
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 2
Resident Manual
4
5
3.14
Professional Activities outside the Program ............................................................. 16
3.15
Visitors in the Workplace .......................................................................................... 16
3.16
Weather-related and Emergency-related Closings ................................................... 17
DISCIPLINARY PROCESS ................................................................................................... 18
4.1
Performance.............................................................................................................. 18
4.2
Summary Suspension ............................................................................................... 19
4.3
Automatic Suspension .............................................................................................. 19
4.4
Resident Appeals Process ........................................................................................ 20
4.5
Grievance and Due Process Procedure ................................................................... 21
4.6
Maintaining Discipline among Patients, Nurses and Employees .............................. 24
STANDARDS OF CONDUCT ................................................................................................ 25
5.1
General Guidelines ................................................................................................... 25
5.2
Duty Hours ................................................................................................................ 25
5.3
On-Call Activities ....................................................................................................... 26
5.4
Unscheduled Absence .............................................................................................. 26
5.5
Harassment Policy .................................................................................................... 27
5.6
Sexual Harassment Policy ........................................................................................ 27
5.7
Violence in the Workplace ........................................................................................ 27
5.8
Confidential Information and Nondisclosure ............................................................. 27
5.9
Ethical Standards ...................................................................................................... 28
5.10
Dress Code ............................................................................................................... 28
5.11
Use of Equipment...................................................................................................... 28
5.12
Use of Computer, Phone, and Mail ........................................................................... 28
5.13
Use of Internet........................................................................................................... 29
5.14
Use of Computer Software ........................................................................................ 29
5.15
Smoking Policy.......................................................................................................... 29
5.16
Alcohol and Substance Abuse .................................................................................. 30
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 3
Resident Manual
6
7
8
5.17
Subpoenas, Claims, & Other Requests .................................................................... 30
5.18
Disputes between Residents & Medical Supervisors ............................................... 30
5.19
Corporate Communications ...................................................................................... 30
5.20
Corporate Compliance .............................................................................................. 31
5.21
Obligation to Treat .................................................................................................... 31
5.22
Moonlighting .............................................................................................................. 31
5.23
Departing Residents ................................................................................................. 32
5.24
Hospital Property....................................................................................................... 32
RESPONSIBILITIES .............................................................................................................. 33
6.1
Trainers ..................................................................................................................... 33
6.2
Department ............................................................................................................... 33
6.3
Medical Education Committee .................................................................................. 33
6.4
Administrative............................................................................................................ 34
6.5
Director of Medical Education ................................................................................... 34
COMPENSATION/INSURANCE POLICIES .......................................................................... 36
7.1
Payroll/Stipend .......................................................................................................... 36
7.2
Auxiliary Benefits....................................................................................................... 36
7.3
Insurance .................................................................................................................. 37
7.4
Relocation ................................................................................................................. 38
7.5
Housing ..................................................................................................................... 38
7.6
Malpractice Insurance ............................................................................................... 38
7.7
Timekeeping Procedures .......................................................................................... 38
TIME-OFF BENEFITS ............................................................................................................ 39
8.1
Vacation Time ........................................................................................................... 39
8.2
Family Medical Leave ............................................................................................... 39
8.3
Maternity/Paternity Leave ......................................................................................... 39
8.4
Extended Leave of Absence ..................................................................................... 40
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 4
Resident Manual
9
8.5
Bereavement Leave .................................................................................................. 40
8.6
Sick Leave................................................................................................................. 41
8.7
Military Reserves or National Guard Leaves of Absence ......................................... 41
8.8
Jury Duty ................................................................................................................... 41
8.9
Professional Leave of Absence ................................................................................ 41
8.10
Additional Benefit & Leave Considerations ............................................................... 42
INSTITUTIONAL POLICIES .................................................................................................. 43
9.1
Policy & Procedure Manuals ..................................................................................... 43
9.2
Communicable Diseases .......................................................................................... 43
9.3
Reporting Requirements for Communicable Diseases ............................................. 43
9.4
Advocacy Efforts ....................................................................................................... 44
10 EVALUATIONS ...................................................................................................................... 45
10.1
Evaluation of Faculty ................................................................................................. 45
10.2
Evaluation of Resident’s Performance ...................................................................... 45
10.3
Evaluation of Training Programs............................................................................... 46
11 MEDICAL RECORDS ............................................................................................................ 47
11.1
Guidelines for Use of Medical Records .................................................................... 47
11.2
Guidelines for Documentation in the Medical Record............................................... 47
11.3
Medical Record Completion Guidelines .................................................................... 48
11.4
Protected Health Information .................................................................................... 48
11.5
Medical Staff Rules & Regulations............................................................................ 49
11.6
Physician’s Orders .................................................................................................... 49
11.7
Service to In-patients ................................................................................................ 49
12 INSTITUTIONAL RESOURCES ............................................................................................ 50
12.1
Blood Bank ................................................................................................................ 50
12.2
Child Protection Program .......................................................................................... 50
12.3
Employee Health Service .......................................................................................... 51
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 5
Resident Manual
12.4
Employee Assistance ................................................................................................ 51
12.5
Nursing Department .................................................................................................. 51
12.6
Nutrition Services ...................................................................................................... 52
12.7
Pharmacy .................................................................................................................. 52
12.8
Security ..................................................................................................................... 53
12.9
Rehabilitation Services ............................................................................................. 53
12.10
Social Work ............................................................................................................... 53
12.11
Communications/Information Services ..................................................................... 54
12.12
Transport of Patients ................................................................................................. 54
12.13
Paging System .......................................................................................................... 54
13 RESIDENT RESOURCES ..................................................................................................... 56
13.1
Conferences, Rounds, Lectures ............................................................................... 56
13.2
Resident Participation on Hospital Committees ........................................................ 56
13.3
Computer Use and Support ...................................................................................... 56
13.4
Food Services ........................................................................................................... 57
13.5
Interpreter Services ................................................................................................... 58
13.6
Library Facilities ........................................................................................................ 58
13.7
Meals ......................................................................................................................... 58
13.8
On-Call Rooms.......................................................................................................... 58
13.9
Uniforms & Laundry .................................................................................................. 58
14 UNIVERSAL PRECAUTIONS ............................................................................................... 59
14.1
Basic Elements of BSI .............................................................................................. 59
14.2
Nurses & Other Direct Care Providers Role in BSI System ..................................... 60
14.3
Precautions for Patients with Airborne Diseases ...................................................... 60
14.4
Supplies Needed for BSI ........................................................................................... 61
14.5
Other BSI Procedures ............................................................................................... 62
15 EMPLOYEE COMMUNICATIONS ........................................................................................ 63
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 6
Resident Manual
15.1
Open Communication ............................................................................................... 63
15.2
House Staff Meetings ................................................................................................ 63
15.3
Bulletin Boards .......................................................................................................... 63
15.4
Suggestions .............................................................................................................. 63
15.5
Closing Statement ..................................................................................................... 63
16 ACKNOWLEDGMENT ........................................................................................................... 64
17 APPENDICES ........................................................................................................................ 65
17.1
Approved Abbreviations ....................................................................................... 65
17.2
Non-Approved Abbreviations .............................................................................. 65
17.3
Communicable Diseases ...................................................................................... 65
17.4
Directory .................................................................................................................. 65
17.5
Resident Contract .................................................................................................. 65
17.6
Clearance Sheet ..................................................................................................... 65
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 7
Resident Manual
1
INTRODUCTION
This document has been developed by the Department of Medical Education in order to familiarize
house staff with Edward Via Virginia College of Osteopathic Medicine and provide information
about working conditions, key policies, procedures, and benefits affecting employment at Edward
Via Virginia College of Osteopathic Medicine.
Throughout this Resident Manual (the “Manual”), the terms “Resident,” “House Officer” and
“House Staff” refer to Residents. Residents have an obligation to the patient care program of the
institution and to the effectiveness of the educational program to which they have been
appointed. The most important criterion of the service of the Resident is the performance of their
professional duties. Professionalism includes honesty, integrity, respect, and compassion, which
includes introducing yourself to patients, explaining your role, and treating patients as if they
were members of your family.
The proper discharge of the responsibilities of the Resident requires their full time effort while on
duty. All Residents shall remain within the Hospital as required by their patient care
responsibilities and shall be immediately available if on call.
The Program Directors have the responsibility and authority at all times to assure the Residents’
effectiveness in the programs.
As part of the Edward Via Virginia College of Osteopathic Medicine is a long established
community hospital with a mission to furnish an integrated program to provide the highest
quality medical care for the sick and injured, to advance knowledge regarding the cause,
prevention and treatment of disease and disability, and to educate men and women in the
healing profession.
1.1
Welcome
Welcome to Edward Via Virginia College of Osteopathic Medicine! We are happy to have you as a
new member of our family!
1.2
Changes in Policy
This manual supersedes all previous residency manuals and memos.
While every effort is made to keep the contents of this document current, Edward Via Virginia
College of Osteopathic Medicine at its option, may modify, delete, suspend or discontinue
portions of this manual at any time without prior notice. It is the Resident’s responsibility to
obtain the most current version of this manual. A current copy of this manual is available in the
VCOM Medical Education Department. Any changes in this manual shall apply to existing as well
as to future Residents.
Edward Via Virginia College of Osteopathic Medicine reserves the right to modify, suspend, or
terminate any of the policies, procedures, and/or benefits described in the manual with or without
prior notice to employees.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 8
Resident Manual
2
APPOINTMENT
Purpose of this manual: The information contained in this Manual is presented for the benefit of
the Residents of Edward Via Virginia College of Osteopathic Medicine. The intent of this Manual is
to provide and direct the Resident to necessary information concerning the policies, procedures
and practices of VCOM. Edward Via Virginia College of Osteopathic Medicine reserves the right to
revise, withdraw, suspend or discontinue its policies, procedures and practices at any time.
Except as may be set forth in the sections below, referred to as Grievance Procedures, Corrective
Action/Appeal Process, Summary Suspension, Automatic Suspension and Resident Appeals
Process and the contract of employment between VCOM and the Resident, this Manual is not
intended to and does not enlarge or create any additional rights of employment. It does,
however, set forth and direct the Resident to many matters that the Resident is obligated to obey
or observe.
In no way should this Manual be considered as the only, or final, source of information on the
policies, procedures and practices of VCOM. Residents are to refer to the specific VCOM hardcopy
Policies and Procedures Manual for issues concerning employment or patient care, and are
encouraged to ask the DME/ADME for additional information or clarification on any such matters.
2.1
Eligibility and Selection
The following is the policy of VCOM regarding the recruitment, eligibility and selection of
Residents. Each applicant must file an application through the training program’s respective
match process, provide three reference letters, a Dean's letter, board scores, medical school
transcripts, medical school diploma; and, finally, appear for a series of interviews.
A.
B.
Eligibility. Applicants must meet the following qualifications to be eligible for
appointment to an AOA residency program:
1.
Graduate of an AOA accredited College of Osteopathic Medicine.
2.
Have successfully passed all examinations as deemed required by each training
program.
3.
Have a full and unrestricted license (training certificate) to practice medicine in
a U.S. licensing jurisdiction.
Selection.
1.
Programs at VCOM select from among eligible applicants on the basis of their
preparedness, ability, aptitude, academic credentials, communication skills, and
personal qualities such as motivation and integrity and other relevant qualities
pertaining to OGME.
2.
Programs shall not discriminate with regard to gender, race, age, religion,
color, national origin, disability, sexual orientation or veteran status.
In selecting from qualified applicants, programs participate in an organized matching program,
where available, such as the Resident and Resident Matching Program (NRMP).
Eligibility and Selection
2.2
Top of the Document
Resident Contract
Upon completion of the “match”, VCOM’s Department of Medical Education will send to the
matched Residents, the institutional Resident contract. The Resident must return this contract
within 30-days of issuance for the contract to become valid.
A Resident who breaches the Resident contract may not serve an AOA-approved residency,
residency or fellowship program for a period of twelve (12) months following the date of the
breach.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 9
Resident Manual
Contract requirements must be met in full. Resident’s failing to pass Complex Part II prior to the
start of residency will result in a breach of the contract and immediate termination of the
Resident. Violation of the contract by a Resident may result in the loss of credit for time served in
the program.
All appointments are for one year or less, and may be renewed at the discretion of the institution,
upon continued evidence of satisfactory performance.
The Resident contact shall reference: (these items shall be outlined in detail in the Resident
Manual)
1.
Resident responsibilities
2.
Duration of appointment
3.
Financial support
4.
Conditions under which living quarters, meals, laundry are provided
5.
Conditions for reappointment and promotion
6.
Grievance and due process procedures
7.
Professional liability insurance
8.
Liability coverage for claims filed after program completion
9.
Health and disability insurance
10.
Leave of absence policy
11.
Sick leave policy
12.
Policy on effects of leaves on satisfying criteria for program completion
13.
Duty hours policies and procedures
14.
Policy on moonlighting
15.
Policy on other professional activities outside the Program Director Counseling,
medical, psychological support services
16.
Policy on physician impairment and substance abuse
17.
Policy on sexual harassment
18.
Policy closure of hospital/training programs or reduction in approved Resident
positions
The contract will be maintained in the individual trainee’s personnel file.
All institutional human resource policies may be applicable to Residents at the discretion of the
training program.
Resident Contract
2.3
Top of the Document
Re-Appointment
All Residency reappointment contracts carry the condition that Residents must complete their
present year of training in a satisfactory manner for the reappointment to be valid at the
beginning of the new academic year beginning July 1. Advancement to the next PGY level is
based upon the recommendation of the Program Director/Director of each training program.
The following are perquisites for promotion of the Resident to the following year of training:
1.
Complete all rotations with a passing grade as per rotation schedule.
2.
Copies of ALL activity (didactic) summaries, case logs, monthly and concurrent
summaries, evaluations, time logs are completed and turned in to the
appropriate Director(s) of the AOA.
3.
Evaluations demonstrate an acceptable performance for Residents at his/her
academic level for advancement.
4.
Successful completion of the Comlex Step III exam prior to the start of the PGY
II.
5.
Evaluations demonstrate no disciplinary or professional behavioral problems.
6.
Complies with didactic program per program requirements.
Re-Appointment
Effective 07/01/07
Version 1
Top of the Document
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 10
Resident Manual
2.4
Non-Renewal of Contract/Appointment
If at any time a Program Director determines that a Resident is not meeting the standards of the
program, he/she may recommend non-renewal of the Resident’s appointment, or contract.
Circumstances which might result in non-renewal of appointment are outlined in the Corrective
Action section of this Manual.
The Program Director must submit the recommendation for non-renewal in writing to the Director
of Medical Education, and will include the basis on which the action is being taken. If the Director
of Medical Education determines that there is sufficient reason not to renew the contract, he/she
will notify the Program Director, who will so inform the Resident in writing no later than four
months prior to the end of the Resident's current contract.
A Resident receiving notice of non-renewal of contract/appointment may implement his/her right
to due process through the Appeals Process, as presented in this Manual.
2.5
Completion of Training
Before departing VCOM at the conclusion of your residency training, you must complete
obligations to your Program Director and also to the institution. An official clearance sheet must
be completed and turned into the Department of Medical Education Director along with your ID
badge. This form can be obtained from the Medical Education office. It will show evidence of your
completed medical records, and that you have returned all hospital property such as keys,
equipment, parking pass, radiation dosimeter, keys, scrubs, etc. The form also requests a
forwarding address, and reminds you of your right to continuing health insurance coverage
through COBRA.
VCOM’s official certificates of completion are presented to departing residents by the Director of
Medical Education.
VCOM is justified in withholding such certificate if the Resident fails to complete the residency
program or if the Resident’s performance has been such as to indicate that the Resident is not
yet prepared for the practice of medicine. In the event of illness necessitating the Resident’s
withdrawal from training, the Hospital may properly issue a certificate to include the period of
training completed or arrange for additional training at a later date to complete the training.
A checklist of graduation requirements must be completed prior to issuing a final paycheck and
graduation certificate. This will be sent to the Resident during the last six-weeks of training.
2.6
Program Closure or Reduction
If VCOM intends to reduce the size of, or close a residency program, the institution will inform the
Residents as soon as possible. In the event of such a reduction or closure, the institution will
make every effort to allow Residents already in the program to complete their education. If any
Residents are displaced by the closure of a program or a reduction in the number of Residents,
the institution will make every effort to assist the Residents in identifying a program in which
they can continue their education.
1.
2.
3.
Effective 07/01/07
Version 1
The training institution will immediately notify the AOA, its OPTI and its trainees
of a program closure or reduction in positions, which would impact trainees
prior to program completion.
If VCOM reduces in size or closes a program, every attempt will be made to
permit the current Residents enrolled in the program to complete their training
prior to such an action.
In the event of the hospital or program closure or reduction in positions which,
would impact trainees prior to program completion. VCOM will immediately
notify the OPTI to aid in placement of the enrolled Residents in other AOA
approved programs within that OPTI structure.
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 11
Resident Manual
Severance pay shall be provided for two months when institutional program closure or reduction
decisions prevent the Residents from program completion in that or another geographically
proximate program arranged by the institution and/or the OPTI.
Top of the Document
2.7
Restrictive Covenants
VCOM strictly prohibits the request for any Resident to sign non-competition guarantees.
2.8
Visa Policies & Procedures for Foreign/US Medical School Graduates
It is policy of VCOM to comply with the immigration laws of the United States, and all Residents
must obtain and maintain an immigration status that permits employment by the Hospital in a
clinical capacity if applicable.
All offers of employment are contingent on verification of the candidate’s right to work in the
United States. On the first day of work, every new employee will be asked to provide original
documents verifying his or her right to work and, as required by federal law, to sign Federal Form
I-9, Employment Eligibility Verification Form.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 12
Resident Manual
3
EMPLOYMENT POLICIES
3.1
Equal Employment Opportunity/Diversity
VCOM is committed to diversity that will build on the strengths of our current workforce and
continually enhance the diversity of our organization. Members from the Medical Education
Committee will attend a number of hospital days throughout the year. All Resident candidates are
encouraged to apply for the residency program through the National Resident Matching Program.
Edward Via Virginia College of Osteopathic Medicine is an equal opportunity employer and does
not discriminate on race, color, citizenship status, national origin, ancestry, gender, sexual
orientation, age, weight, religion, creed, physical or mental disability, marital status, veteran
status, political affiliation, or any other factor protected by law.
3.2
Americans with Disabilities Act
It is the policy of VCOM to comply with all the relevant and applicable provisions of the Americans
with Disabilities Act (ADA). VCOM will not discriminate against any qualified employee or job
applicant with respect to any terms, privileges, or conditions of employment because of a
person’s physical or mental disability.
3.3
Employee Background Check
Prior to making an offer of employment, VCOM may conduct a job-related background check. A
comprehensive background check may consist of prior employment verification, professional
reference checks, education confirmation, and criminal check.
Refer to VCOM Human Resource Policy & Procedure Manual.
3.4
Drug Screening
VCOM has a strong commitment to the health and safety of its employees, as well as its patients.
This commitment includes the assurance of a drug and alcohol-free work environment. The
Hospital has, therefore, implemented a substance abuse policy that applies to all VCOM
employees, making mandatory drug screening a regular part of the pre-employment physical.
Any refusal of a Resident to complete, or failure to satisfactorily pass this screening will be turned
over to the Committee of Impaired Physicians for review.
Refer to VCOM Human Resource Policy & Procedure Manual.
3.5
Criminal Records
When appropriate, a criminal record check is performed to protect VCOM’s interest and that of its
employees and clients.

All VCOM entities conduct criminal background checks on all final candidates for
employment. The results of criminal background checks may take several weeks to be
processed. Residents are permitted to begin work before the results are received. In the
event that a disqualifying conviction is returned on a Resident, he/she will be subject to
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 13
Resident Manual
separation from the Hospital and terminated from the Residency Program. This
separation will occur even if the Resident has successfully completed some period of the
residency program before the results are received. The Resident’s contract will then
become Null and Void.
Criminal Records
3.6
Top of the Document
Controlled Substance (DEA)
Controlled Substance Licensure:
Each Resident must have a Drug Enforcement Administration (DEA) Controlled Substance
Registration Number. A temporary DEA number, which is issued to each Resident by the Hospital
and terminates at the conclusion of the Resident’s training, is a combination of the Hospital DEA
and the Resident's unique alphanumeric suffix. Federal law mandates that use of this temporary
DEA is strictly limited to the care of patients served by Residents as part of their training
program.
During orientation, each Resident will sign two (2) Prescription Signature Verification cards before
the temporary DEA number can be used. The numbers will be kept on file in the Department of
Pharmacy Services.
To obtain a permanent DEA number, contact the Drug Enforcement Administration in Washington
D.C., at (202) 633-1000.
Prescribing Controlled Substances over the Telephone:
Under no circumstances should Residents prescribe controlled substances over the telephone for
any patient, unless the Resident personally knows the patient as a result of providing medical
treatment to him/her as part of the Resident's training program. In addition, prior to prescribing
any controlled substance over the telephone, the Resident should first review the patient's
medical record to verify any pharmacies, patients, or other individual's request for the
prescription. The appropriate response to a telephone request for controlled substances from
anyone claiming to be the patient of a VCOM attending physician is as follows:
1.
2.
Take the patient’s name and phone number, and the name of the patient’s
attending physician;
Call the attending physician with the information; and
Let the attending physician instruct you on how to respond to the request.
Controlled Substance (DEA)
3.7
Top of the Document
Physician Impairment & Substance Abuse
To provide a safe environment, VCOM Resident’s have a responsibility to report to work in a fit
condition. In keeping with federal drug-free regulations, VCOM is committed to a drug and
alcohol free work environment. As a health care provider, we are aware of our responsibility to
our patients, visitors, employees, and medical staff to ensure that our facilities are drug and
alcohol free. Therefore, the use, sale, purchases, negotiation of sale, manufacture, distribution,
dispensation or possession of illegal drugs or the abuse of legal drugs and alcohol is prohibited.
This policy is designed to ensure a drug and alcohol free work environment while protecting the
privacy of employees and applicants with respect to personal health information. Residents are
required to meet the medical school’s requirements as defined in Human Resources Policy and
Procedure.
1)
Fitness for Duty – A confidential and mandatory referral process, which evaluates an
employee’s ability to perform his/her job functions when pronounced changes, which
negatively impact his/her work performance, are demonstrated. Fit employees are those
physically and mentally able to perform the standards required of his/her position.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 14
Resident Manual
Types of impairment covered by Fitness for Duty include:
(a) Psychological Impairment. Significant changes in behaviors and/or psychological
state. This may include but not be limited to: threats of harm against self or others,
destruction of property or threats of destruction, dramatic mood swings, explosive
anger or acting-out behaviors, extreme disclosure of personal information, and
disorganized thoughts.
1. Physical Impairment. Significant changes in physical ability to perform job duties
and meet the physical standards that impact current job responsibilities. They may
include, but are not limited to, diminished ability to walk, lift, climb, operate
equipment, see, hear, or any physical deterioration that compromises and
Resident’s ability to perform his/her job.
3.8
Licensure
An individual pursuing a residency in the State of Virginia must be licensed by the State of
Virginia Medical Board. The individual may either hold a Certificate (permanent license) to
practice medicine and surgery in Virginia, or apply to the Board for a Training Certificate
(temporary license). The Medical Education office will provide the necessary application forms for
the Training Certificate, but responsibility for timely completion and fee payment lies with the
applicant. A Training Certificate is valid only for a period of one year, but may be renewed
annually for a maximum of five years.
The Training Certificate allows Residents to follow the schedule of prescribed services, rotations,
and clinical activities that have been issued by their Program Directors. Please be advised of the
following limitations regarding temporary licensure:
A Resident without a permanent license cannot “moonlight.”
Permanent licensure can be initiated by contacting the Medicine Board of Virginia Board of Medicine (804) 3674600. The Office of Medical Education must be kept informed of any change in licensure status.
Licensure
3.9
Top of the Document
Certificates
Each Resident, at the completion of service, will receive a certificate certifying that the Resident
has performed all the requirements set forth by the American Osteopathic Association, the
attending staff, and administration of VCOM.
The Hospital is justified in holding such a certificate back only if the Resident fails to complete the
residency, residency or fellowship program including all required paperwork or if the Resident’s
performance has been such as to indicate that the Resident is not yet adequately prepared for
the practice of osteopathic medicine. Under no circumstances will the hospital arbitrarily refuse to
issue such a certificate for relatively minor reasons. In the event of illness necessitating the
Resident’s withdrawal from training, the hospital may properly issue a certificate to include the
period of training completed or arrange for additional training at a later date to complete the
training.
Top of the Document
3.10
Change of Personal Data
It is the responsibility of each Resident to report any changes in name, address or phone number
to the Department of Medical Education, their respective residency training program. Efficient
distribution of W-2 forms, benefits information, and other important hospital mailings is
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 15
Resident Manual
dependent upon the data an employee has provided and timely submission of reimbursement
items as well as end-of-year tax information.
3.11
Chain of Communication
Residents shall follow the “Chain of Communication” policy of Edward Via Virginia College of
Osteopathic Medicine (Hospital’s Policy and Procedure Manual).
When necessary the CEO presides over all areas and is the final step in the chain of command.
When issues/problems occur, the Residents should contact/speak with:
1.
2.
3.
4.
5.
3.12
Attending Physician
Department Chair
Director of Medical Education
Vice President of appropriate area
CEO
Safety
VCOM strives to provide its employees, patients, and visitors with a safe and healthy
environment. Should conditions or hazards be identified that pose an immediate threat to life,
health or safety, the situation must be immediately and appropriately addressed and report to
the Safety Officer at extension 1567.
3.13
Personal Property
VCOM assumes no risk for any loss or damage to personal property and recommends that all
employees have personal insurance policies covering the loss of personal property left in the
Department of Medical Education.
3.14
Professional Activities outside the Program
Residents may be required to attend educational programs based on the Residency Program’s
requirements. Refer to Residency Training Program Manual for details.
Top of the Document
3.15
Visitors in the Workplace
For safety, insurance, and other business considerations, only authorized visitors are allowed in
the workplace. When making arrangements for visitors, employees should request that visitors
enter through the main reception area and sign in.
The hours and regulations for visiting are published and given to all patients. Recommendations
for individual exceptions to the regulations should be made to the Nursing Supervisor.
Residents have the obligation to discuss and answer questions about a patient’s condition with
those who have a legal right to know. Information concerning a patient is privileged and
confidential and should not be divulged to anyone except individuals specifically designated by
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 16
Resident Manual
the patient. Non-designated friends, relatives and visitors are not entitled to such information,
but their inquiries must be handled in a friendly and tactful manner .
Top of the Document
3.16
Weather-related and Emergency-related Closings
At times, emergencies such as severe weather, fires, or power failures can disrupt company
operations. In such instances, Executive Staff will decide on the closure and Human Resources
will provide the official notification to the employees.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 17
Resident Manual
4
DISCIPLINARY PROCESS
4.1
Performance
At any time during the Residency Training Program, the Residency Program Director, or Director
of Medical Education may determine that the Resident is not meeting the standards of the
program or the profession, for reasons that may include, but are not limited to:
1.
2.
3.
4.
Lack of professional competence, insufficient medical knowledge, or technical skills
needed to carry out their duties and responsibilities;
Any conduct that is detrimental or potentially detrimental to VCOM patients or
employees;
Demonstrated inability to work with others or behavior that is reasonably likely to be
disruptive to Hospital operations;
Activities or professional conduct that are reasonably likely to be in violation of the
Medical Staff Bylaws, Medical Staff Rules and Regulations, or any other Hospital policies
and procedures; and,
If the Residency Program Director or Director of Medical Education believes that corrective action
is warranted, he/she may do one or more of the following:
1.
A written reprimand will either be given to or mailed to the Resident, and a copy will be
placed in the Resident's file.
2.
If a remedial program is required, the Resident shall be so informed in a meeting with
the Residency Program Director. At that meeting, the Resident's deficiencies will be
identified, a remedial program will be established, and a time frame for completion of
the remedial program will be discussed and documented.
A copy of this document will be given to the Resident, and a copy will be placed in the
Resident's file. The remedial plan may include limitations or restrictions on the amount
and level of the Resident's patient care activities. Such action may necessitate extension
of the Resident's educational program. At the end of the remedial period, the Resident
will receive an evaluation. At that time, the Residency Program Director or Director of
Medical Education may or may not take further corrective action.
3.
Recommend Leave of Absence, Suspension or Dismissal of the Resident. The Residency
Program Director or Director of Medical Education/ may recommend a Leave of Absence,
Suspension, or Dismissal of the Resident. The Leave of Absence or Suspension may be
with or without pay. Suspension shall be without pay. Such recommendation will be
made in writing, accompanied by any written documents necessary to support the
recommendation, and will be filed with the Director of Medical Education. The
recommendation will include a time frame for a Leave of Absence or Suspension. The
Director of Medical Education, or his designee, will convene an Initial Review Panel
within 10 calendar days of the recommended action, which will include the Director of
Medical Education (who will chair the Panel), the Residency Program Director (or
representative), and representatives of the Law Department and Human Resources.
Prior to the meeting, the Panel Chair will review the submitted documents, and
determine a list of individuals who the Panel may wish to interview. These individuals
will be notified to be available in the event the Panel wants to interview them. The Panel
will present its findings to the Director of Medical Education, who will promptly issue a
decision on the recommendation for Leave of Absence, Suspension or Dismissal of the
Resident.
In the event the Director of Medical Education upholds such recommendation, the action
shall become effective immediately. During the period of Suspension without pay, or
Leave of Absence without pay, the Resident will not receive any cash, or other
compensation. Health-related benefits will continue if the Resident elects to pay for them
directly. In all cases of Suspension or Leave of Absence, the Resident will not be
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 18
Resident Manual
permitted any Hospital privileges, nor be permitted to attend Conferences or Rounds.
The period of Leave of Absence or Suspension will result in an extension of the
Resident’s educational program. In the event the Director of Medical Education rejects
the recommendation, and the Director of Medical Education imposes no other sanction or
action, the record of the event will be expunged from the Resident’s file.
4.
Recommend non-renewal of the Resident’s contract. If a Residency Program Director
determines that a Resident is not meeting the standards of the program, he/she may
make a recommendation for non-renewal of the Resident’s contract. The
recommendation must be submitted in writing to the Director of Medical Education, and
will include the basis on which the action is being taken, along with any written
documents necessary to support the recommendation. All written information regarding
the recommendation will become part of the Resident’s file. If the Director of Medical
Education/ determines that there is sufficient reason not to renew the contract, he/she
will notify the Program Director, who will so inform the Resident in writing.
Recommendations for non-renewal should be made no later than four months prior to
the end of the Resident’s current contract. If the primary reason(s) for non-renewal
occur(s) within the four months prior to the end of the current contract, every effort will
be made to ensure that the program provides its Resident as much written notice of the
intent not to renew as circumstances will reasonably allow. A Resident receiving notice
of non-renewal of contract may implement his/her right to due process through the
Appeals Process, as presented in this Manual. In the event the Director of Medical
Education rejects a recommendation for non-renewal of contract, the Resident’s contract
will be renewed for the following year.
5.
No appeal is available when the action is to reprimand or institute a remedial program
for the Resident. A decision to impose a leave of absence, suspend, dismiss, or fail to
renew the Resident’s contract shall entitle the affected Resident to the Appeals Process
contained in this Manual.
Where a Resident receives notice of a corrective action under the terms in this Resident
Manual, inclusive of any amendments to this Manual that are in effect on the date of receipt
of the notice, this Manual shall govern, irrespective of any later amendments or revisions to
the Manual.
Performance
Top of the Document
4.2
Summary Suspension
The Residency Program Director, Medical Education Committee or Director of Medical Education
shall have the authority, whenever action must be taken immediately in the best interest of
patient care or the Hospital, to summarily suspend all or any portion of the privileges of a
Resident, and such summary suspension shall become effective immediately upon imposition.
At the discretion of the Director of Medical Education, such suspensions may be with or without
pay depending on the allegations and the facts and status of any applicable investigation.
The Director of Medical Education will convene an Initial Review Panel within 10 calendar days of
the suspension. The Panel will include the Director of Medical Education (who will Chair the
Panel); the Director of Human Resources, the Residency Program Director (or representative);
the Clinical Department Chairman (or representative); and a representative of Human Resources.
The Panel may request an interview with the suspended Resident. Whoever summarily suspended
the Resident will provide written documents necessary to support the recommendation. The panel
will decide whether to reverse, modify, or sustain the Summary Suspension.
A Resident who has been summarily suspended shall be entitled to all of the rights provided in
the Appeals Process contained in this Manual.
4.3
Automatic Suspension
A suspension of a Resident shall be imposed automatically if action by the Virginia Medical Board
results in revocation or suspension of the Resident’s license or temporary certificate. Such
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 19
Resident Manual
automatic suspension shall become effective immediately upon action by the Virginia Medical
Board. During the suspension, the Resident will be on “unpaid leave status” and, in order to
continue health benefits, will need to pay the premium directly since, in the absence of a
paycheck, deduction of that premium is not possible. If the license or temporary certificate is
reinstated, the Resident may apply for readmission into the program. If readmission into the
program is denied, the Resident is entitled to all the rights provided in the Appeals Process
contained in this Manual.
Top of the Document
4.4
Resident Appeals Process
A.
Whenever a Corrective Action that can be appealed (Leave of Absence, Suspension,
Summary Suspension, Dismissal, Failure to Renew Contract, Failure to be Re-accepted
into Program after Termination of Automatic Suspension) is imposed on a Resident, the
Residency Training Director or Director of Medical Education shall provide written
notification to the Resident, either in person or by certified mail, return receipt
requested, of the Corrective Action. Such notice shall contain a specific statement of the
grounds for such Corrective Action and shall refer to the Resident’s right of appeal as set
forth below.
B.
To appeal a Corrective Action, the Resident must submit, within ten (10) calendar days
after receiving such notice, a written request either in person or by certified mail, return
receipt requested to the Director of Medical Education/ for a hearing before an Appeals
Committee. No electronic requests will be accepted.
C.
Upon receipt of a written request for a hearing, the Director of Medical Education shall
appoint an Appeals Committee consisting of seven individuals, five of whom will have a
vote. The Director of Medical Education will Chair the committee. If the Resident
requesting the Appeal Hearing is from the same Department as the Director of Medical
Education, the Vice President of Medical Affairs or his/her designee will function as the
Chair. The voting members will include:
a.
b.
c.
d.
An Resident who is a member of the Medical Education Committee or a Chief
Resident from a Clinical Department different from that of the Resident
requesting the Appeal Hearing,
Two Residency Program Directors from different Departments than that of the
Resident requesting the Appeal Hearing;
A representative from Human Resources; and
A Medical Staff Member from a different Clinical Department than that of the
Resident requesting the Appeal Hearing and that of the two Program Directors
on the Committee.
The non-voting members will be:
a. The Director of Medical Education; and,
b. A Resident, from a different Department, at a similar level of training as the
Resident who filed the Appeal. The non-voting Resident member may
participate in all aspects of the deliberations prior to the vote.
D.
The Director of Medical Education will appoint the Administrative Director or Coordinator
of the Office of Medical Education to serve as Secretary, who will keep minutes of the
meeting. The Director of Medical Education, or his/her designee, will determine the date,
time, and place of the meeting.
E.
No later than ten (10) business days after receipt of the Resident's request for a
hearing, the Director of Medical Education or his/her designee, shall notify the Resident
by certified mail, return receipt requested, of the date, time, and place of the hearing.
F.
The hearing shall be held no fewer than thirty (30) and no more than forty-five (45)
business days after receipt of the Resident's request for a hearing. A hearing for a
Resident who is under suspension shall be held as soon as the arrangements may
reasonably be made, but not later than thirty (30) calendar days from the date of
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 20
Resident Manual
receipt of the request for a hearing, unless extended by mutual consent.
G.
From the date upon which the Director of Medical Education receives the Resident's
request for a hearing until the date of the hearing, the Residency Program Director or
Director of Medical Education, or his/her designee, shall permit the Resident, upon
his/her request, to examine and duplicate any written materials that relate in any way to
the suspension, termination, or corrective action. No later than ten (10) business days
prior to the scheduled hearing date, the parties shall provide each other with a list of
witnesses that each intends to call at the hearing. A maximum of 3 witnesses each may
be called by the Resident and by the Program Director to appear in person. An unlimited
number of witnesses, however, may submit written testimonials for review by the
Appeals Committee.
H.
At the hearing, the Resident's personal presence is required. The Resident may be aided
or represented by another Resident in the Hospital's graduate Medical Education
program or by a member of the Hospital's Medical Staff. None of the parties to the
appeal shall be aided or represented at this hearing by an attorney.
I.
At the hearing, both the Residency program Director and the Resident may make
opening statements. The Residency Program Director shall then present his/her case
supporting the corrective action. The Resident shall then present his/her case opposing
such suspension, termination, or corrective action. Both the Residency Program Director
or Director of Medical Education and the Residents may make closing arguments.
J.
At the hearing, both the Residency Program Director and the Resident may present
written evidence, examine witnesses, and cross-examine witnesses. The Rules of
Evidence that govern proceedings in a court of law shall not apply.
K.
Within five (5) business days after the hearing, the Committee Chair (i.e., the Director
of Medical Education) shall prepare and send to both the Residency Training Director or
Director of Medical Education and the Resident, by certified mail, return, receipt
requested; a written decision which shall affirm, modify or reverse the Resident's
corrective action. This decision shall be by a majority vote of the Committee's members
and shall be based solely upon the written and oral evidence presented by the Residency
Training Director and the Resident at the hearing. The Director of Medical Education
shall receive a copy of the written decision.
L.
The decision of the Committee shall be final and binding upon both the Residency
Program Director or Director of Medical Education and the Resident.
M.
A Resident who has been suspended or dismissed from the Hospital's Medical Education
Program, and who has instituted an appeal as provided herein, may resume clinical
practice only if recommended in writing by the Appeals Committee.
N.
The Resident's failure to exercise any right provided by the Appeals Process shall
constitute an irrevocable waiver of such right.
Resident Physician Appeals Process
Top of the Document
4.5
Grievance and Due Process Procedure
The following Grievance Procedure is available to all Residents who are members of the Resident
Staff of VCOM. It is not applicable to Residents from other affiliated institutions that are on
rotation at VCOM.
A.
B.
C.
Complaint procedures are established to protect the integrity and the maintenance of
educational standards as they relate to approved OTPIs.
To provide a mechanism for concerned individuals or organizations to bring to the
attention of the accrediting agency information concerning specific actions and programs
that may be in noncompliance with the AOA’s educational standards.
To recognize the responsibility of the AOA to provide responsible complainants the
opportunity to use the AOA as a vehicle to address specific grievances.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 21
Resident Manual
1.
2.
3.
4.
5.
6.
7.
Effective 07/01/07
Version 1
Grievances. If a Resident has reason to believe that established Hospital policies
and procedures including applicable personnel policies (with the exception of any
action, policy, practice or procedure connected with the periodic evaluation of
Resident, corrective action or appeals, as set forth in this Resident Manual) have
been denied him/her or have been erroneously applied to him/her, or if a Resident
has a problem (collectively, hereinafter a “Grievance”) with any employee of the
Hospital, any member of the Hospital’s Medical Staff, or any other individual
affiliated or associated with the Resident’s residency training program, the following
procedure has been established for the discussion and resolution of such a
Grievance.
Meeting with the Administrative Director of Medical Education. Make an
appointment to discuss the Grievance with the Administrative Director of Medical
Education (“ADME”). The ADME will explain the established policies and procedures
to assist the Resident in determining whether a formal Grievance should be filed.
The Resident shall maintain authority over the final decision as to whether a
Grievance exists and/or whether a formal Grievance should be filed.
Filing Grievance Notice. If, after discussing the Grievance with the ADME, the
Resident believes that a Grievance exists, then the Resident must submit a written
notice (the “Grievance Notice”) of the Grievance to the ADME and the Resident’s
respective Program Director. All Grievance Notices must be set forth in reasonable
and sufficient detail an explanation of the Resident’s Grievance. All Grievance
Notices must be properly filed by the respective Resident no later than (30)
calendar days after the Resident discusses the Grievance with the ADME.
Form of Filing and Disclosure of Grievance. A properly filed Grievance Notice is
one that is either: (1) personally delivered by the Resident to each of the
appropriate parties and for which the Resident obtained a time stamped copy
(reflecting the date and time of delivery of the Grievance Notice) from each party to
whom the Resident personally delivered the Grievance Notice; or (2) mailed by
certified mail, return receipt requested to each appropriate party. The ADME may
provide copies of all Grievance Notices to the following individuals: (1) the
Resident’s Program Director; (2) the DME; and (3) the Director of Human
Resources.
Filing Grievance Notice with Alternate Parties and Chiefs of Staff. If due to
the nature of the Grievance, the Resident reasonably believes that it would be
inappropriate to file the Grievance Notice with the Program Director, then the
Resident shall so inform the ADME who shall then instruct the Resident to file the
Grievance Notice to the Director of Medical Education. In lieu of filing the Grievance
Notice with the ADME or Program Director, the Resident may, for good cause, file
the Grievance Notice directly to the Director of Medical Education. “Good cause”
shall be determined by the Director of Medical Education in his/her sole discretion
and he/she reserves the right to redirect the Resident to the file the Grievance with
any other party deemed appropriate by the Director of Medical Education.
Discussion with the Program Director. If the Resident filed the Grievance Notice
with his/her respective Program Director pursuant to Step 3, above, then the
Resident and the Program Director shall meet to discuss the Grievance. Unless the
Resident otherwise agrees, such meeting shall occur no later than five (5) business
days after the Program Director’s receipt of the Grievance Notice. If the Resident
chooses, the ADME may accompany him/her to this meeting to assist in the
discussion of the Grievance. The Program Director shall reply in writing to the
Resident’s Grievance within five (5) business days after their meeting.
Program Director Grievance Review. At any time before, during or after a
Resident meets with his/her respective Program Director, such Program Director
may request the Resident to submit the names of two other Residents from his/her
service whom the Program Director may want to ask about the Grievance or specific
aspects thereof. In addition, the Program Director may ask the Resident’s respective
Chief Resident to answer questions relating to the Grievance and/or to be present at
any meeting pertaining to the Resident’s Grievance. In the event the Grievance
concerns an incident that is not directly related to the Resident’s training program,
the Program Director may request the Resident to submit the names of two Hospital
employees who witnessed the incident. If a person identified as a witness leaves the
employ of the Hospital prior to resolution of the Grievance, that person shall
nevertheless be recognized and accorded an opportunity to be heard during the
Grievance Process set forth herein, provided that such person left the Hospital in
good standing.
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 22
Resident Manual
8.
9.
10.
11.
12.
13.
14.
Effective 07/01/07
Version 1
Follow-Up after Discussion with the Program Director: Filing of Continuation
Notice.
If the Resident is not satisfied with the Program Director’s resolution, and
desires to follow through on the Grievance to the next step, the Resident shall meet
with the ADME. The ADME will help the Resident with a further review of the
Grievance to enable the Resident to make an appropriate decision whether to
pursue his/her Grievance. If the Resident desires to pursue the Grievance, then
he/she shall file a written notice (the “Continuation Notice”) that he or she wishes to
continue to pursue the Grievance. This Continuation Notice may include a
restatement of the Grievance Notice, but it must also further expand or explain the
Resident’s reasons for continuing to pursue the Grievance. This Continuation Notice
must be filed with the ADME within thirty (30) calendar days after the Program
Director issues his/her written resolution.
Discussion with the Director of Medical Education. After a Resident meets with
his/her respective Program Director, if the Resident desires to pursue the
Grievance, then he/she shall meet with the Director of Medical Education. Unless
the Resident otherwise agrees, such meeting shall occur no later than five (5)
business days after the Director of Medical Education’s receipt of the Grievance
Notice. If the Resident chooses, the ADME may accompany him/her to this meeting
to assist in the discussion of the Grievance. The Director of Medical Education shall
reply in writing to the Resident’s Grievance within five (5) business days after their
meeting.
Director of Medical Education Grievance Review. At any time before, during or
after an Resident meets with the Director of Medical Education, the Director of
Medical Education shall follow the same process as in Step 7, above, offering only
the same individuals an opportunity to be heard who were heard at Step 7.
Follow-Up after Discussion with the Director of Medical Education: Filing of
Continuation Notice. If the Resident is not satisfied with the Director of Medical
Education’s resolution, and desires to follow through on the Grievance to the next
step, the Resident shall meet with the ADME. The ADME will help the Resident with
a further review of the Grievance to enable the Resident to make an appropriate
decision whether to pursue his/her Grievance. If the Resident desires to pursue the
Grievance, then he/she shall file a written notice (the “Continuation Notice”) that he
or she wishes to continue to pursue the Grievance. This Continuation Notice may
include a restatement of the Grievance Notice, but it must also further expand or
explain the Resident’s reasons for continuing to pursue the Grievance. This
Continuation Notice must be filed with the ADME within thirty (30) calendar days
after the Director of Medical Education issues his/her written resolution.
Establishment of Grievance Review Committee. The ADME will inform the
Hospital’s Director of Human Resources (or his/her designee) in writing of the
Resident’s desire to proceed on the Grievance and will provide him/her with a copy
of the Continuation Notice. The Director of Human Resources will then: (1) select
three individuals to serve as members of the Grievance Review Committee in
accordance with Step 16, below; and (2) arrange a mutually convenient meeting
time to hold a hearing on the Grievance. Subject to extenuating circumstances, the
hearing shall be held within five (5) business days after the Director of Human
Resource’s receipt of the Continuation Notice.
Composition and Administration of Grievance Committee. The Grievance
Review Committee shall consist of a combination of three persons: the Director of
Medical Education, one who is a General Administrative Officer of the Hospital, and
one who is a Residency Program Director. The Grievance Review Committee will not
include anyone who has been involved in the Grievance. The Director of Human
Resources will be the chairperson of the meeting, and shall conduct the meeting
pursuant to this Grievance Procedure and all applicable policies and procedures of
VCOM to ensure an orderly and fair opportunity for all parties to present their
positions.
Witnesses. The Resident may, at any time prior to one (1) day before the hearing,
submit to the Director of Human Resources the names of two Hospital employees
who have information relating to the Grievance. These employees may be asked to
appear before the Grievance Committee either by the Resident, the Director of
Human Resources or by any member of the Committee. The Director of Medical
Education may also request not more than two people to appear before the
Committee. The Resident’s appearance before the Committee shall be limited to:
(1) making a presentation not to exceed ten (10) minutes (unless a longer period of
time is permitted by unanimous approval of the Committee); and (2) responding to
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 23
Resident Manual
questions posed by the Committee. Unless otherwise permitted by unanimous
approval of the Committee, neither the Resident nor any witness shall be permitted
to sit through, attend or participate in the entire hearing. The Committee shall have
sole discretion to determine which portion(s), if any, of the hearing the Resident
and/or any witnesses shall attend.
15. Additional Information Relating to Grievance. The Committee may, in its sole
discretion, interview additional individuals and/or seek additional information from
other persons, organizations or entities if the Committee believes that such actions
would facilitate resolution of the Grievance.
16. Providing Copies of Grievance. The Director of Human Resources may, in his/her
sole discretion, forward copies of the Grievance Continuation Notice to all persons
(including any witnesses) scheduled to attend all or any portion of the hearing.
17. Final Decision of Committee. The Committee must use its best efforts to give its
decision in writing to the Resident within three (3) business days after the hearing.
The Committee’s decision shall be final, except in the event such decision results in
the full and final termination of the Resident’s participation in his/her residency
training program.
18. Appeals. A Resident may appeal only a final decision hereunder. Any such appeal
may be brought by the Resident only if: (1) the Resident has complied with and
exhausted all remedies pursuant to the Grievance Procedure set forth herein; and
(2) the final decision rendered hereunder expressly imposes a Leave of Absence,
Suspension, or Dismissal of the Resident or Termination of the Resident’s
participation in his/her respective training program at the Hospital. Any appeal
hereunder shall follow and be in accordance with the procedures set forth in the
“Resident Appeal Process” section of the Resident Manual.
19. Waiver of Grievance. The Resident shall waive any and all rights under this
Grievance Procedure in the event such Resident materially fails, without good cause,
to comply with any of the requirements set forth herein, including, without
limitation, missing any: (1) deadline for filing a Grievance Notice or Continuation
Notice; or (2) any meeting or hearing with any party hereunder. “Good cause” shall
be determined by the Director of Medical Education in his sole discretion, acting
reasonably.
20. Confidentiality. All Grievances shall be kept confidential. The Resident, ADME,
Chief Resident, Program Director, Department Chair, Director of Medical Education
and any other Hospital employees, agents or representatives that receive a
Grievance Notice or otherwise receive or initiate information pertaining to a
Grievance shall keep all such information strictly confidential and shall disclose the
same only to those other employees or agents of the Hospital or other third parties
or government agencies having a reasonable need to know the Grievance and
information pertaining thereto.
21. Modification of Time Limits. All Grievance Procedure time limits may be modified
by mutual agreement of the parties based on the absence of one or more of the
parties for good reason, such as scheduled vacation, previously determined work
schedule, illness or similar absence.
Grievance and Due Process Procedure
Top of the Document
4.6
Maintaining Discipline among Patients, Nurses and Employees
Members of the Resident staff may not attempt to discipline a patient, nurse or other employee.
If a patient refuses to observe regulations or obey orders for treatment, the facts must be
reported to the attending physician and the Director of Medical Education. The manner of the
Resident with the patient should be gentle, polite and serious at all times in keeping with the
dignity of the profession. Situations arising with nurses or other hospital employees that would
require disciplinary action should be reported to the Director of Medical Education, or in his
absence, to the Director of Human Resources and CEO. Under no circumstances are Residents to
engage in arguments with the patient and employee.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 24
Resident Manual
5
STANDARDS OF CONDUCT
5.1
General Guidelines
All employees are urged to become familiar with VCOM rules and standards of conduct and are
expected to follow these rules and standards faithfully in doing their own jobs and conducting the
company’s business.
5.2
Duty Hours
VCOM strives to meet institutional and program requirements of the American Osteopathic
Association (AOA) to ensure that the learning objectives of its residency programs are not
compromised by excessive reliance on Residents to fulfill service obligations. Providing Residents
with a sound academic and clinical education must be carefully planned and balanced with
concerns for patient safety and Resident well-being. Didactic and clinical education has priority in
the allotment of Residents’ time and energies. Duty hour assignments recognize that faculty and
Residents collectively have responsibility for the safety and welfare of patients. Hours in excess of
the average 80 hour work week will be adjusted by the Residency Program Director and/or the
Director of Medical Education.
1.
Duty hours are defined as all clinical and academic activities related to the
residency program, i.e., patient care (both inpatient and outpatient), administrative
duties related to patient care, the provision for transfer of patient care, time spent
in-house during call activities, and scheduled academic activities such as
conferences. Duty hours do not include reading and preparation time spent away
from the duty site.
2. Duty hours must be limited to 80 hours per week, averaged over a four-week
period, inclusive of all in-house call activities.
3. The Resident shall not work in excess of 24 consecutive hours inclusive of morning
and noon educational programs. Allowances for inpatient and outpatient continuity,
transfer of care, educational debriefing and formal didactic activities may occur, but
may not exceed 6 hours. Residents may not assume responsibility for a new
patient after working 24 hours.
4. The Resident shall have on alternate weeks, 48-hour periods off, or at least one
24-hour period off each week free from all educational and clinical responsibilities,
averaged over a four-week period, inclusive of call. One day is defined as one
continuous 24-hour period free from all clinical, educational, and administrative
activities.
5. Upon conclusion of a 24-hour duty shift, trainees shall have a minimum of 12 hours
off before being required to be on duty again. Upon completing a lesser hour duty
period, adequate time for rest and personal activity must be provided.
6. A 10-hour time period for rest and personal activities must be provided between all
daily duty periods, and after in-house call.
7. All off-duty time must be totally free from assignment to clinical or educational
activity.
8. Rotations in which the Resident is assigned to Emergency Department duty shall
ensure that the Resident work no longer than 12 hours shifts.
9. The Resident and the hospital must always remember the patient care
responsibility is not precluded by the work hour policy. In cases where a Resident is
engaged in patient responsibility which cannot be interrupted, additional coverage
should be provided as soon as possible to relieve the Resident involved.
10. The Resident may not be assigned to a 24-hour call shift more often than every
third night averaged over any consecutive four-week period.
The Medical Education Committee (MEC) is committed to assuring that Residents are able to
report concerns regarding duty hours without retribution. Residents may report issues by:
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 25
Resident Manual
1.
2.
3.
Scheduling an appointment with the Administrative Director of Medical Education.
Scheduling an appointment with the Director of Medical Education.
Contacting the Resident representative of the Medical Education Committee who will
supply a report to the MEC.
MONITORING OF DUTY HOURS:
The Department of Medical Education requires Residents to report daily activities on a monthly
calendar. The calendar is turned in at the end of each rotation. Hours above 80 are reported to
the Director of Medical Education who will investigate each occurrence.
Duty hours will be discussed at the MEC meeting at least quarterly.
Duty Hours
5.3
Top of the Document
On-Call Activities
The objective of on-call activities is to provide Residents with continuity of patient care
experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond
the normal workday when Residents are required to be immediately available in the assigned
institution.
1.
In-house call must occur no more frequently than every third night, averaged over a
four-week period.
2.
Continuous on-site duty, including in-house call, must not exceed 24 consecutive
hours. Residents may remain on duty for up to 6 additional hours to participate in
didactic activities, maintain continuity of medical and surgical care, transfer care of
patients, or conduct outpatient continuity clinics.
3.
No new patients may be accepted after 24 hours of continuous duty, except in
outpatient continuity clinics. A new patient is defined as any patient for whom the
Resident has not previously provided care.
4.
At-home call (pager call) is defined as call taken from outside the assigned
institution.
a.
The frequency of at-home call is not subject to the every third night
limitation. However, at-home call must not be so frequent as to preclude
rest and reasonable personal time for each Resident. Residents taking athome call must be provided with 1 day in 7 completely free from all
educational and clinical responsibilities, averaged over a 4-week period.
b.
When Residents are called into the hospital from home, the hours
Residents spend in-house are counted toward the 80-hour limit.
c.
The program director and the faculty must monitor the demands of athome call in their programs and make scheduling adjustments as
necessary to mitigate excessive service demands and/or fatigue.
Top of the Document
5.4
Unscheduled Absence
Absence from work for three (3) consecutive days without notifying the Department of Medical
Education or the Human Resources Department will be considered a voluntary resignation.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 26
Resident Manual
5.5
Harassment Policy
VCOM does not tolerate workplace harassment. Workplace harassment can take many forms. It
may be, but is not limited to, words, signs, offensive jokes, cartoons, pictures, posters, e-mail
jokes or statements, pranks, intimidation, physical assaults or contact, or violence.
Refer to Human Resources Policy and Procedure Manual.
Top of the Document
5.6
Sexual Harassment Policy
It is the policy of VCOM to provide an employment environment free of sexual harassment.
Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of
a sexual nature are violations of our policy. If you believe you have been subjected to sexual
harassment, you should report it immediately in writing to your Program Director and the director
of human resources.
All complaints of sexual harassment will be promptly and confidentially investigated. Any
Resident who violates this policy will be subject to corrective action, based on the severity of the
violation, up to and including termination.
Any other form of repeated behavior, which the Resident perceives as harassment, should be
reported to the Director of Medical Education.
Refer to Human Resources Policy and Procedure Manual.
Top of the Document
5.7
Violence in the Workplace
VCOM has adopted a policy prohibiting workplace violence. Consistent with this policy, acts or
threats of physical violence, including intimidation, harassment, and/or coercion, which involve or
affect VCOM or which occur on VCOM or client property, will not be tolerated.
Refer to Human Resources Policy and Procedure Manual.
Top of the Document
5.8
Confidential Information and Nondisclosure
The confidential nature of medical information and the patient's right to privacy are well
established. All hospital personnel are expected to treat patient-related information in a
confidential manner, sharing it only with those who have a need to know, whether in written,
oral, electronic, or any other format. Hospitals and physicians can be held liable for the improper
or unauthorized disclosure of medical information. As such, discussion of patient-related
information should be conducted only in appropriate settings, and especially not in elevators or
other public areas.
At the start of your residency at VCOM, you will be asked to sign a confidentiality & nondisclosure agreement, documenting your acceptance of this policy.
The Health Insurance Portability and Accountability Act (HIPAA), passed by Congress in 1996, will
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 27
Resident Manual
affect the healthcare industry more profoundly than any action by the federal government since
Medicare. While HIPAA will require a redesign of many of the Hospital’s formats for electronic
transmission of billing information, approximately 70% of HIPAA compliance depends upon
changing our business behaviors and procedures regarding privacy and security. As all Hospital
employees will be affected by HIPAA and subject to its penalties for non-compliance, it is
important that everyone keep abreast of new developments and understands the overall impact
and intent of the legislation.
Refer to Human Resources Policy and Procedure Manual.
Top of the Document
5.9
Ethical Standards
VCOM insists on the highest ethical standards in conducting its business. Doing the right thing
and acting with integrity are the two driving forces behind VCOM’s great success story. When
faced with ethical issues, employees are expected to make the right professional decision
consistent with VCOM’s principles and standards. If a Resident cannot determine the correct
decision, the Resident should contact their respective program director and/or the Department of
Medical Education.
5.10
Dress Code
Dress, grooming, and an overall professional appearance are important aspects of patients'
expectations, and project an image of quality healthcare. When scrubs are worn outside of clinical
areas, a white coat or similar cover-up should be worn.
Residents must appear neat and clean at all times. The uniform for floor duty during the day is
long white clinical coats. Coats must be worn at all times. Socks must be worn. Male Residents
are to wear a shirt with a collar and tie under the white clinical coat. Female Residents are
required to wear professional business attire under the white clinical coat.
Surgical scrub suits are not to be worn on the floors during the day by a Resident; however,
scrubs may be worn from 7 p.m. – 7 a.m. on night call. It is permissible to wear surgical scrub
suits on the floor between surgical cases if a long white clinical coat covers them. As soon as
surgery is completed for the day, proper attire must be worn as mentioned above. Haircuts must
be neat and hair growth not overly excessive. Mustaches and well-trimmed beards are permitted.
Fingernails must be clean and trimmed.
Top of the Document
5.11
Use of Equipment
VCOM will provide employees with the equipment needed to do their job. None of this equipment
should be used for personal use, nor removed from the physical confines of VCOM—unless it is
approved for a job that specifically requires use of company equipment outside the physical
facility.
5.12
Use of Computer, Phone, and Mail
VCOM property, including computers, phones, electronic mail, and voice mail, should be used
only for conducting company business. Incidental and occasional personal use of company
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 28
Resident Manual
computers, phones, or electronic mail and voice mail systems is permitted, but information and
messages stored in these systems will be treated no differently from other business-related
information and messages.
Top of the Document
5.13
Use of Internet
Employees are responsible for using the internet in a manner that is ethical and lawful. Use of the
internet must solely be for business purposes and must not interfere with employee productivity.
VCOM encourages employee use of electronic mail, the VCOM Intranet and the internet when it
creates a more efficient work environment. However, it should be clear that:
1.
2.
3.
4.
5.
Sending and receiving E-mail, Intranet or Internet messages regarding personal matters is
not permitted.
Under no circumstances will the E-mail system, the Intranet or the Internet be used as a
forum for inappropriate, offensive or discriminatory comments.
An employee should not consider the contents of his or her E-mail account (VCOM or
residence) private.
The password used to restrict access to employees’ E-mail accounts is a mechanism for
preventing an unauthorized person from gaining access to VCOM’s information rather than
maintaining the privacy of employees’ messages.
The E-mail system, including the contents of messages and accounts, can be monitored to:
a. Evaluate the effectiveness and operation of the E-mail system.
b. Find lost messages.
c. Recover after system failure.
d. Investigate suspected criminal acts or suspected breach of security.
e. Enforce other VCOM policies.
Employees, including Residents, who use email, the Intranet or the Residence improperly, will be
subject to disciplinary action according to policy the Human Resources Policy and Procedure
Manual.
All VCOM employees must sign a form documenting that they understand the conditions under
which an email account may be used and what conduct is permitted.
Top of the Document
5.14
Use of Computer Software
VCOM does not condone the illegal duplication of software. The copyright law is clear. The
copyright holder is given certain exclusive rights, including the right to make and distribute
copies. Title 17 of the U.S. Code states that, “it is illegal to make or distribute copies of
copyrighted material without authorization” (Section 106). The only exception is the user’s right
to make a backup copy for archival purposes (Section 117).
5.15
Smoking Policy
To provide a healthier and safer environment for patients, visitors, staff, and employees, the
hospital prohibits smoking and the use of tobacco products inside the hospital building.
All employees are required to adhere to this policy to ensure that VCOM is a healthier and safer
place in which to work. To protect the health of our patients, medical staff, hospital employees,
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 29
Resident Manual
visitors and volunteers, VCOM has a Zero Tolerance Policy on smoking and the use of tobacco
products within the hospital.
Top of the Document
5.16
Alcohol and Substance Abuse
It is the policy of VCOM that the workplace be free of illicit drugs and alcoholic beverages, and
free of their use. In addition to damage to respiratory and immune systems, malnutrition,
seizures, loss of brain function, liver damage, and kidney damage, the abuse of drugs and alcohol
has been proven to impair the coordination, reaction time, emotional stability, and judgment of
the user. This could have tragic consequences where demanding or stressful work situations call
for quick and sound decisions to be made.
5.17
Subpoenas, Claims, & Other Requests
Residents may periodically receive requests for information regarding a legal claim, or potential
claim, involving a patient and the Hospital. Whenever a Resident receives such a request he/she
should immediately contact the Department of Medical Education who will notify Risk
Management. The Resident is not to provide any written or verbal response to such a request
without authorization. This will ensure compliance with the Hospital's procedures for release of
information only to authorized persons.
Residents may not witness wills or other legal documents for patients. Requests for such
assistance should be referred to the Administration Offices or the Nursing Supervisor in charge .
Top of the Document
5.18
Disputes between Residents & Medical Supervisors
VCOM adheres to the AMA Council of Ethical and Judicial Affairs, Ethical Opinion 9.055, which
states, in part, “Residents should refuse to participate in patient care ordered by their superiors
in cases in which the orders reflect serious errors in clinical or ethical judgment, or physical
impairment, that could result in a threat of imminent harm to the patient or to others.”
In such a circumstance, the Resident may refuse to provide the care ordered by the supervisor,
provided the omission will not threaten the patient’s immediate welfare. Residents should
communicate their concerns, immediately, to the physician issuing the orders, and to the
Program Director, Director of Medicine Education or Department Director. Residents who raise
such a complaint will not be subject to retaliatory or punitive actions, if the complaint was made
in good faith, in the interest of patient care.
The Program Director, Director of Medical Education or the Department Director shall immediately
notify the Chief Medical Officer regarding the Resident’s concerns. The Chief Medical Officer may
take such action as he deems reasonable, in his sole discretion, to investigate and resolve the
situation, subject to the rights and obligations of the parties as set forth in this Manual and the
Policies and Procedures of VCOM.
Top of the Document
5.19
Corporate Communications
Because of your constant relationship with patients and their visitors, your role in establishing a
positive reputation for the Hospital is important.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 30
Resident Manual
Patients are seldom qualified to judge the technical quality of medical care they receive. To
patients, the most important thing is usually the personal concern of each individual they contact
in the Hospital. The patients are extremely conscious of the many little things that add up to
kindness, sympathy and understanding. Edward Via Virginia College of Osteopathic Medicine,
through the compassion and caring of its physicians, nurses, and support staff, has consistently
achieved excellent patient satisfaction ratings.
VCOM’s Communications (Public Relations) Department is responsible for handling inquiries and
requests from newspapers, magazines, and radio and television stations. Refer any such request
to the CEO’s office in Administration. During evening and night shifts, the Nursing Supervisor on
duty may release basic condition reports, as permitted by law, on public record cases .
Top of the Document
5.20
Corporate Compliance
The compliance program at VCOM is a comprehensive strategy to ensure employees and medical
staff complies with applicable rules, regulations, and laws.
5.21
Obligation to Treat
A primary mission of the hospital is to serve and heal all persons who need its help. In addition to
general legal and ethical requirements, hospitals participating in the Medicare program are
required to provide examinations and treatment to individuals with emergency medical
conditions, or women in labor, regardless of their ability to pay. This is the Emergency Medical
Treatment and Active Labor Act (EMTALA). EMTALA was passed as part of the Consolidated
Omnibus Budget Reconciliation Act of 1986, and it is sometimes referred to as “the COBRA law.”
This law requires hospitals with emergency departments to provide a medical screening
examination “within the capabilities of the Emergency Department” to any person requiring one
without regard to the ability to pay. We must determine whether the person has an “emergency
medical condition” or is in “active labor.” If so, the law requires the hospital to either:
1.
2.
Provide treatment “within the capabilities of the staff and facilities of the hospital” as
may be necessary to stabilize the emergency medical condition; or,
Arrange for a transfer of that person as set forth by the law. An emergency patient who
is not stabilized can generally only be transferred if the individual requires the transfer
or if a physician certifies that the medical benefits of transfer outweigh the risk of
affecting the transfer.
Substantial penalties for violation of this law exist for both the Hospital and the physician and the
statute may be enforced by the government or an aggrieved individual.
Top of the Document
5.22
Moonlighting
Residents (PGY 1’s) are not permitted to moonlight. Other residents must obtain approval from
their Program Director and the Director of Medical Education prior to moonlighting. All requests
must be submitted in writing. Understand that engaging in moonlighting activities will require
residents to obtain a state license to practice in the state they reside and obtain their own
malpractice coverage for these activities.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 31
Resident Manual
Moonlighting activities within the same institution where residency training occurs will be
documented on the resident’s duty hour form and will be counted towards the 80 hour work week
rule.
Top of the Document
5.23
Departing Residents
Upon the completion of residency training, the Resident is required to complete the “Clearance
Sheet” to ensure that all items are returned, that required documents are completed and that all
patient record information is fulfilled prior to the Resident’s departure from their training
program. Once all items are completed, the Resident will be issued their training certificate
indicating satisfactory completing the program, if so warranted.
Prior to the Resident’s departure, an “exit interview” will be conducted with the Resident to obtain
information regarding their training experience as well as their thoughts of VCOM. This process
will help to enhance future trainees experience with VCOM.
5.24
Hospital Property
No x-ray films, instruments, drugs, scrub suits or other hospital property shall be taken from the
hospital unless permission has been granted by the Director of Medical Education.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 32
Resident Manual
6
RESPONSIBILITIES
6.1
Trainers





6.2
Department






6.3
Each service has one or more trainers with responsibilities to the department, the
Resident or student and the Medical Education Committee
To meet with residents at the beginning of each rotation to review the rotation
curriculum and it’s goals and objectives
To meet and discuss with the resident midway through the rotation the resident’s
performance: areas of satisfactory performance and suggestions for greater
performance; as well as areas needing improvement
To complete a performance evaluation after completion of the rotation
To assign a reading and study program
To help organize, supervise, and carry out the teaching program for the resident
Responsible for overseeing the work assignment of the resident
Responsible for supervising and participating in the “patient care experience” training of
the resident
Responsible for reviewing the patient’s workup completed and documented on his/her
patients by the resident
Responsible for overseeing the functions of the resident, e.g. on duty promptly,
availability, performance, etc
To oversee the study program of the resident.
Medical Education Committee
The education committee shall consist of the DME, the intern program director, if different than
the DME, all residency directors at the institution, intern and resident representatives, who have
been nominated by their peers. Representatives from major affiliate institutions shall be
members of the education committee and shall be strongly encouraged to attend the education
committee meetings when logistically possible.











The education committee shall meet at least 10 months of the year and minutes of the
committee meetings be maintained.
There shall be verifiable evidence of communication between the education committee
and those representatives of major affiliate institutions where attendance at the monthly
meetings is not feasible.
Report to the Director of Medical Education in writing any inferior function on the part of
the resident, e.g. tardiness, attitude, lack of cooperation, etc. so the Director of Medical
Education can become involved early in the service
To assist the Director of Medical Education and the Program Directors in developing the
service or changes in it to improve the training and service to the patient and the
attending physician
To review compliance of resident duty hours
To participate in the interviewing and selection of residents for each training program
To maintain and improve program quality
To approve affiliations within the scope of AOA policies and procedures
To assist the DME in developing and implementing a high-quality educational program
for interns and residents
To assist in the development of a curriculum and methods to evaluate the educational
experience of the intern and residents during training
To assist in the program, faculty, intern and resident evaluations, as well as program
modification as needed in accordance with evaluation results
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 33
Resident Manual
6.4
Administrative
Program Responsibilities: A Resident assigned to an attending physician will be expected to
participate in the case management of his/her patient, under direct supervision of the trainer.
This will involve rounds with the attending physician on patients in the hospital, as well as
participating in office practice under supervision. The Resident will keep a complete log of
patients seen and procedures performed in this time period.
Resident Responsibilities: The Resident shall obtain and write or dictate the history, perform
and record the results of the physical examinations, and state the diagnosis on all patients
assigned. The non-operative and non-specialized treatment of each patient under his/her care is
the Resident’s responsibility under the supervision of the attending physician.
The Resident shall make rounds with the attending physician and Resident staff daily as well as
other suitable intervals. The Resident shall receive instructions, information, criticisms, advice,
suggestions and assistance from his/her superiors who thus contribute to the Resident’s
education. The Resident will be responsible for the management of the attending physician’s
patients under direct supervision.
The Resident will make daily progress notes on the record describing the patient’s clinical course
and should record all treatment or special diagnostic procedures, or make certain they are
recorded. When a patient is discharged, the Resident shall write a concluding note, which
summarizes the patient’s course in the hospital, describing the patient’s condition on discharge
and the final diagnosis.
Other Responsibilities: The Resident will keep a log of each day’s activities. This must be
available for inspection at the end of each trainer’s time period. It will be submitted to the
Director of Medical Education at the conclusion of the rotation.
6.5
Director of Medical Education
Position Description:
The Director of Medical Education (DME) is responsible for assuring the development of high
quality education programs providing high quality residency training.
The DME is responsible for assuring the development of a high quality curriculum as well as
assuring quality clinical experiences for the residents. Assuring the development of postgraduate programs is a major priority. The DME will also serve as an advisor to students and
residents regarding their career choices. The expectation is that the allocation of time will be
evenly split between administrative and clinical duties.
The Director of Medical Education must be qualified to manage and direct program directors and
residents in a graduate medical education program within the residency training requirements of
the American Osteopathic Association and applicable laws and regulations.
The Director of Medical Education is directly responsible for the overall program administration of all
Residency Programs within the Institution.
Qualifications:
1. Graduate of an AOA-approved college of osteopathic medicine.
2. Successful completion of an AOA-approved internship and residency, or establishment of AOA
certifying board eligibility. (If board certified by the American Board of Medical Specialties [ABMS]
through a recognized AOA pathway.
3. Member in good standing of both the AOA and Association of Osteopathic Directors and Medical
Educators (AODME).
4. Possess a minimum three years practice experience.
5. Possess a minimum three years experience as teaching faculty member in an OGME program or
college of osteopathic medicine (COM).
6. Possesses the leadership skills and personality characteristics to recruit and motivate top caliber
trainees.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 34
Resident Manual
7.
8.
9.
Be an experienced and successful clinician in his or her own right.
Demonstrated success in managing relationships within the AOA.
Be well informed of AOA GME program requirements and have successfully guided training
programs through review and re-certification processes.
10. Ability and desire to continue a part-time clinical practice while serving as DME.
11. Unrestricted, active license to practice medicine in the State of said practice and be in good
standing with the State Medical Board and all applicable professional societies.
Responsibilities:
1. Ensuring a high quality curriculum.
2. Authorized point of contact regarding all official communication from the AOA.
3. Prepare annual medical education report.
4. Develops and monitors house staff training programs. Establishes schedules in conjunction with
Chairpersons of clinical departments, the Medical Education Committee and attending physicians.
5. Identifies core curriculum for house staff through communication with medical school and
consultation with appropriate committee chairperson, program directors, house staff, and attending
staff. In cases where requirements of internship conflict with the desires of the Residency Program
Director, the Director of Medical Education will be responsible for the intern program.
6. Evaluates performance of house staff members, counsels’ house staff concerning performance and
takes appropriate disciplinary action if warranted subject to compliance with medical staff bylaws,
rules and regulations and prior consultation with President and/or his designee(s).
7. Responsible for development of budget for educational programs and for submitting budgets to
President for review and approval. Maintains awareness of outside financial resources for
programs and utilizes them as appropriate. Strives to achieve financial targets associated with
GME reimbursement and expense management.
8. Directs recruitment activities for medical students, interns and residents.
9. Enforces the educational standards of AOA, the various residency boards and the institution
regarding intern and residency training.
10. Prepares annual reports to the AOA on the status of the graduate medical education program and
coordinates surveys required to maintain accreditation of all affiliated graduate and postdoctoral
medical education training programs. Responsible for ensuring that, individuals are adequately
prepared for program inspections and that required accreditations are achieved and maintained.
11. Oversees lecture schedule and attends morning report and noon lecture daily, participating as a
speaker periodically. Maintains attendance records and evaluates quality of presentations, taking
action as appropriate.
12. Determines the schedule of rotations for all interns, within the curriculum requirements outlined by
the AOA. Coordinates with Residency Directors on the schedule of rotations for residents, within
the curriculum requirements outlined by the AOA and specialty boards.
13. Meets with interns and residents on a periodic basis and as required insuring that Program
objectives are met.
14. Responds to communications form the AOA, arranges institutional payment of required fees, and
cooperates in the arrangement of Program inspections.
15. Collaborates with the sponsoring College of Osteopathic Medicine and attend meetings as
scheduled.
Director of Medical Education
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 35
Resident Manual
7
COMPENSATION/INSURANCE POLICIES
7.1
Payroll/Stipend
After registration through the Medical Education office, all Residents are on the VCOM payroll and
commence with being paid an annual stipend. The stipend amount appropriate to a Resident's
contracted Post-Graduate Year (PGY) level will be stated in his/her contract. These established
stipend amounts are reviewed annually and amended from time to time. For information on the
compensation schedule, please consult the Medical Education Office.
Payrolls are prepared bi-monthly. Pays are dispersed through direct deposit on the the 15th and
last date of each month unless these dates fall on a weekend or holiday.
At the time of registration, each Resident must complete a Withholding Allowance Certificate (W4) for the purpose of withholding Federal Income Tax and State of Virginia Withholding
Exemption Certificate for the purpose of withholding State Income Tax. A new W-4 and state tax
form must be filed when there is a change in family status. A Social Security number and/or
immigrant visa number is required. Residents must also complete an I-9 form, and submit
supporting documentation.
DIRECT DEPOSIT:
VCOM strongly encourages direct deposit of payroll, with a bank of your choice. The necessary
enrollment forms can be obtained from Human Resources.
TAX/SOCIAL SECURITY DEDUCTIONS:
VCOM is required by law to withhold federal and state income taxes from your pay. The Hospital
pays its social security tax assessed by the federal government on your wages. You pay a
matching amount through payroll deduction. The amount of your contribution to social security as
well as amounts withheld for federal, state and city income taxes appear on your paycheck stub.
While on rotation at other affiliate hospitals/surgery centers, Residents may be required to use
that facilities parking tag.
Top of the Document
7.2
Auxiliary Benefits
Parking: Parking is available free of charge to all VCOM employees. When you hold a parking
permit, you assume responsibility for observing all parking regulations. All employees will park in
designated employee lots. Failure to do so may result in disciplinary action. The parking permit
must be returned to Medical Education Office in order to cancel your parking assignment. Any
questions concerning parking or appeals of parking violations should be brought to the prompt
attention of the Security Department.
Holidays: Holidays are granted and scheduled at the discretion of the Medical Education
Department. The Hospital recognizes the following holidays: New Year’s Day, Independence Day,
Thanksgiving Day, Memorial Day, Labor Day, and Christmas Day.
I.D. Badges: Photo identification badges are issued to all VCOM Residents by Human
Resources/Security. You are expected to wear your I.D. badge at all times while on duty. The
proper way to wear your badge is above your waist with the photo/name side showing. Contact
Security for replacement I.D. badges. The hours of operation are: 8:00 a.m. to 5:00 p.m.,
Monday through Friday.
Flexible Spending Accounts: Flexible spending accounts are available for pre-tax payment of
employee’s health and dental premiums, and certain un-reimbursed medical and/or dependent
care expenses. Enrollment in the flexible spending benefit must be within the first 30 days of
employment or during the annual election period. You are able to designate the amount of money
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 36
Resident Manual
that you wish to have placed in a flexible spending account. Note: IRS rules require that any
money left in your account at the end of the plan year will be forfeited. Please plan
carefully so that you will be able to use all the funds you set aside.
403B Matched Retirement Savings Plan: All Residents are eligible to contribute to the 403b
Matched Retirement Savings Plan. VCOM will match 15% for up to the first $2000 of employee
contributions. You will be vested to your matching contributions after they are posted to your
account. Refer to the Summary Plan Description for further details.
Top of the Document
7.3
Insurance
VCOM offers Residents a flexible benefits program which offers a wide selection of benefits and
allows you the flexibility to select the benefits that best meet your individual needs. From timeto-time, the specifics of the benefit programs change. For this reason, you should obtain copies
of each Summary Plan Description (SPD) directly from Human Resources.
HEALTH INSURANCE: Residents are eligible to enroll in the Health Insurance Program during the
first 30-days of employment. Residents who enroll in one of the plans pay pre-tax premiums
through payroll deduction. The effective date of the coverage is the first-day of the month, on or
after, the Resident’s hire date.
CONTINUATION OF MEDICAL COVERAGE: COBRA: On termination of your contract with VCOM,
you may arrange for continued coverage under the Consolidated Omnibus Budgeted
Reconciliation Act, which guarantees an employee the right to uninterrupted coverage by his/her
employer’s medical insurance for up to 18 months after termination. Regular coverage ends on
the last day of the month in which you leave the employ of VCOM. If you elect to continue
coverage, you must pay the entire cost. Information on COBRA is available through the VCOM‘s
Human Resources Department.
DENTAL INSURANCE: Dental coverage is available for purchase for you and your family. You are
able to choose from two dental plans, basic and comprehensive. Your semi-monthly contribution
is payroll deducted on a pre-tax basis. Coverage is effective the first day of the month coinciding
with or following your employment date.
PROFESSIONAL LIABILITY INSURANCE: The Hospital furnishes professional liability insurance to
Residents without cost to them. This insurance covers Residents during the time they are within
and acting on behalf of VCOM, following schedules that have been issued by their Program
Directors. Residents are also covered for legal actions relating to their residency training, which
are initiated after they leave the program.
LIFE INSURANCE: The Hospital provides $10,000 of group term life insurance at no charge.
Additional coverage up to three times your annual base salary is available for purchase, as well
as dependent life insurance. You become eligible for coverage the first of the month following
your employment. You can also purchase Voluntary AD&D Insurance.
SHORT-TERM DISABILITY (STD): You are eligible for this benefit on the first of the month
following your employment. Employees have several choices regarding waiting periods for Short
Term Disability, which include a 14 day, 30 day, 60 day, or 90 day waiting period. Premiums are
calculated based on the waiting period and age of the employee. This benefit is purchased with
after-tax dollars.
LONG-TERM DISABILITY (LTD): The first day of the month following your employment you are
eligible to purchase long term disability insurance. Benefits are purchased with after tax benefits.
ADDITIONAL BENEFITS: Residents will receive free meals while on duty at VCOM. Residents will
receive an educational stipend as set forth by the Department of Medical Education. Please
contact the department for the current salary.
Insurance
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 37
Resident Manual
7.4
Relocation
Relocation expenses for Residents entering VCOM’s residency programs are at the expense of the
individual Resident.
7.5
Housing
Housing and all it’s associated fees, utilities, etc. are the responsibility of the Resident.
7.6
Malpractice Insurance
Residents are covered under the VCOM malpractice insurance as it relates to residency training.
Residents participating in activities outside the scope of the Residency Training Program will not
be covered under the Hospitals malpractice coverage.
Activities outside the Residency Training are strictly prohibited unless prior approval is obtained
from the Program Director and the Director of Medical Education. Participation in activities
outside the Residency Training Program without the expressed written consent of the Program
Director and Director of Medical Education are grounds for immediate dismissal.
7.7
Timekeeping Procedures
By law, VCOM is obligated to keep accurate records of the time worked by employees. Each
resident must fill out the appropriate time log for their monthly activities. The time logs must be
completed in accordance with the VCOM time-reporting guidelines.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 38
Resident Manual
8
TIME-OFF BENEFITS
8.1
Vacation Time
Vacations are granted and scheduled at the discretion of the department to which the resident is
assigned. Vacation allowance is 20 days per academic year. A “Time-Away” form needs to be
completed for all time away from the Medical Center.
To Appendices
8.2
Family Medical Leave
In accordance with the “Family and Medical Leave Act,” VCOM’s unpaid leave-of-absence policy
supports up to twelve work weeks of leave during a 12-month period for the following:
•
Pregnancy/birth of a child
•
Placement with an employee of a child for adoption or foster care
•
Caring for a spouse, same-sex domestic partner, child, or parent with a
“serious health condition”
•
Your own “serious health condition”
The 12-month period is measured forward from the date your first FMLA leave begins. To be
eligible for FMLA, you must first have been employed at VCOM for at least twelve months and
have worked 1,250 recorded hours in the 12 months preceding the leave. You must apply for this
leave and it must be approved by Human Resources. The forms are available in the Human
Resources office.
If eligible for FMLA, FMLA must be applied for concurrently with any leave due to maternity or
paternity, short or long-term disability, and leave pursuant to “Extended Leave of Absence” in the
Resident Manual.
Leave under this provision only protects your job, i.e., job security. It does not provide any
income guarantee or entitlement. Time taken off for leave may extend the training period as
necessary to comply with the appropriate accreditation guidelines.
While on FMLA, Residents are entitled to up to twelve weeks of VCOM-subsidized benefits only
(see “Benefits While on Leave”). See Human Resources Policy and Procedure Manual.
Note: Residents are allotted 20-days off per year. Additional training will be required
for time taken beyond this allotment.
8.3
Maternity/Paternity Leave
Time off for Maternity Leave will be subject to the Leave of Absence Policy located in the VCOM
Human Resources Policy and Procedure Manual. It is the Resident's responsibility to notify the
Program Director at least 60 days in advance of anticipated utilization of a maternity/paternity
leave. Time taken off for a maternity/paternity leave may extend the training period, as
necessary, to comply with appropriate accreditation guidelines. The department to which the
Resident is assigned must approve any leave of absence. If eligible for FMLA, FMLA must be
applied for at the same time a maternity/paternity leave is requested.
Note: Residents are allotted 20-days off per year. Additional training will be required
for time taken beyond this allotment.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 39
Resident Manual
8.4
Extended Leave of Absence
Depends on how many months completed:
Residents with extraordinary and long-term personal or family tragedies may be granted
extended leave without pay and without loss of previously accepted residency position or status
for periods of up to one year in the following circumstances:
1.
2.
3.
4.
Terminal illness.
Permanent disability
Complications of pregnancy that threaten maternal or fetal life.
Other “devastating conditions” or personal tragedies from which eventual
recovery and/or return to regular employment may be reasonably expected.
If extended leave is requested, the residency Program Director will provide the Resident written
information regarding its potential impact on:
1.
2.
Requirements for successful program completion.
Requirements for board eligibility.
The Program Director will also provide written information regarding availability of alternative
accommodations, such as reduced hours, night-call accommodations, modified rotation schedules
and part-time scheduling.
Eligibility for extended leave will be determined on a case-by-case basis by the Residency
Program Directors and/or Committee for that department. In case of a dispute, a panel consisting
of three Program Directors and two Chief Residents of other departments shall be convened by
the Director of Medical Education to hear arguments on both sides and make a final
determination.
If extended leave or other accommodations are granted, the Residency Program Director will
prepare written documentation of the circumstances and conditions of these accommodations, as
well as the necessary requirements for the Resident to return to full active status.
Note: Residents are allotted 20-days off per year. Additional training will be required
for time taken beyond this allotment.
8.5
Bereavement Leave
Residents are eligible to receive up to three (3) consecutive scheduled workdays off with pay in
the event of the death of an immediate family member. The three days should be scheduled
between the dates of the death through the day following the funeral. You must immediately
notify your Program Director and the Department of Medical Education of your need for
bereavement/funeral leave.
Paid bereavement leave is provided for immediate family members who are defined as: spouse,
children, stepchildren, parents, stepparents, brothers, stepbrothers, sisters, stepsisters,
grandparents, grandchildren, and parents-in-law.
You may request time off if additional days of bereavement leave are required or to attend the
funeral of other family members or friends.
Additional time off, whether paid or unpaid, must be arranged through your Program Director and
the Director of Medical Education is based on the ability of your department to staff adequately
during your absence. See Bereavement Policy, located in the Human Resources Policy and
Procedure Manual.
Note: Residents are allotted 20-days off per year. Additional training will be required
for time taken beyond this allotment.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 40
Resident Manual
8.6
Sick Leave
Full-time employees who become incapacitated due to illness, injury or other forms of medial
disabilities, may be granted a Medical Leave, not to exceed one (1) year.
After one (1) year of Medical Leave of Absence status access to health and other elected
insurance plans is terminated. The employee is removed from the active payroll, and Human
Resources will notify the employee of his/her post employment rights.
The employee requesting medical leave must submit a certification of health care provider,
identifying the reason for the medical leave, with prognosis and expected return to work date.
This certification must be returned within ten (10) days of VCOM giving notice that certification is
required. Going beyond ten (10) days will cause VCOM to make a decision on the leave status
without the information on the certification or to even deny the leave request. If circumstances
exist where even a diligent, good faith effort on the part of the employee will not produce the
certification in that time frame, then the employee should notify his/her Department Director as
soon as he/she becomes aware of the delay.
VCOM reserves the right to request a second opinion (at no cost to the employee) on any request
for Medical Leave.
Every effort will be made to retain an employee’s original position while on Medical Leave.
However, it may be necessary to fill the position wit a full-time employee before the leave
terminates. In these instances, VCOM will make every attempt to place the employee in a similar
position on the same shift, with the same rate of pay, as before the leave commenced, and in
accordance with any federal or state laws, regulations or statutes that contain return to work
compliance requirements. Refer to Human Resources Policy and Procedures for complete details.
Note: Residents are allotted 20-days off per year. Additional training will be required
for time taken beyond this allotment.
8.7
Military Reserves or National Guard Leaves of Absence
Employees who serve in U.S. military organizations or state militia groups such as the National
Guard may take the necessary time off to fulfill this obligation and will retain all of their legal
rights for continued employment under existing laws.
8.8
Jury Duty
If you receive a notice that you are to report for jury duty, notify your Program Director and the
Department of Medical Education immediately so coverage can be arranged for you. VCOM will
pay you your regular salary for the length of time connected with either the selection process or
jury duty. Upon returning to work, written proof of your jury duty must be submitted to your
Program Director and the Department of Medical Education in order to be reimbursed.
8.9
Professional Leave of Absence
Unpaid professional leave of absence is granted at the discretion of the Program Director of each
residency program. Time taken off for leave may extend the training periods as necessary to
comply with appropriate accreditation guidelines.
Note: Residents are allotted 20-days off per year. Additional training will be required
for time taken beyond this allotment.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 41
Resident Manual
8.10
Additional Benefit & Leave Considerations
Effect of Leave for Satisfying Completion of Program:
Time taken off for any leave may extend the training period, as necessary, to comply with
appropriate accreditation guidelines. Residents should check with their Program Director to make
sure they are not in jeopardy of needing to extend their training and, therefore, changing plans
for a job or fellowship opportunity.
Residents are not automatically guaranteed re-entry into the training program and therefore
should discuss future arrangements with their Program Director prior to commencing a leave of
absence.
An employee remains eligible for health benefits during the time he/she is on unpaid leave.
During the time the employee is not receiving pay, the usual payroll deduction obviously cannot
be made. The employee, therefore, is responsible for direct payment of benefits costs. A check or
the appropriate amount must be received by the benefits office before the 15th of each month to
assure uninterrupted coverage.
An employee requiring further leave after FMLA has expired, or an employee exercising any of
the other forms of unpaid leave, assumes full cost of any insurance coverage.
Any leave of any kind must be coordinated through Human Resources and notification to the
Department of Medical Education is required.
Note: Residents are allotted 20-days off per year. Additional training will be required
for time taken beyond this allotment
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 42
Resident Manual
9
INSTITUTIONAL POLICIES
9.1
Policy & Procedure Manuals
The Human Resources Policy and Procedure Manuals (HP&P), as well as a Management Policy and
Procedure Manual can be found in the Department of Medical Education and the Department of
Human Ressources. These manuals contain Hospital policies concerning standing orders for each
clinical service, medications, laboratory and X-ray routines, isolation, fluid intake, transfusion,
and infusion procedures, permits and legal forms, visiting regulations, and many other Hospital
policies and routines pertinent to your professional activities.
These manuals should be reviewed at the start of your clinical service. Residents are held
responsible for the performance of their duties in conformance with these policies and routines.
Each Residency Program is required to develop and maintain the policy and procedure manual for
their Residency Program. These manuals are to be reviewed with the residents at the start of
their training program.
The program director is required to update these manuals on an annual basis (more often if
required). The Residents are to receive notification of any policy change at the time of change.
Program Directors are to ensure that the Department of Medical Education has a current copy of
each manual and distributes updates of policies and procedures as they occur.
Each Resident will sign an “Acknowledgement of Receipt” attesting that they have received and
reviewed their residency program manual. This acknowledgement will be maintained in each
Resident’s personnel file located in the Department of Medical Education.
Residents are required to remain current on all policies and procedures as they occur for the
hospital and their residency program.
9.2
Communicable Diseases
A record shall be maintained of all infections, and or communicable disease acquired within this
facility. All diseases that are required to be reported shall be reported to appropriate health
department officials through the Infection Control Practitioner via order entry, who will complete
the appropriate interviews and paperwork.
9.3
Reporting Requirements for Communicable Diseases
Who shall report?
Reports of modifiable diseases required by law and those listed as Class A and Class B shall be
reported to the board of health by the infection control department. A person in charge of a
hospital, dispensary, clinic, or other institution providing care or treatment, having knowledge of
such case, shall report it unless he/she has evidence that it has been reported by a physician.
When no physician is in attendance, it shall be the duty of any individual having knowledge of a
person suffering from a disease presumably communicable or suspected of being communicable
to report forthwith to the board of health all the facts relating to the case, together with the
name and address of the person who is ill.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 43
Resident Manual
9.4
Advocacy Efforts
The Ethics Committee of VCOM assists in resolving ethical problems in patient care through its
interdisciplinary Ethics consultation Service (ECS), a subcommittee of the Hospital Ethics
Committee (HEC). The ECS is available to all hospital care professionals, patients, patient’s
families, and other patient representative/surrogate.
Although primary responsibility for identifying and resolving problems in the clinical setting rests
with health care professionals in concert with patients or their representative/surrogate, hospital
staff is encouraged to seek timely involvement of the ECS in ethically troublesome situations.
The hospital assures that persons requesting ethics consultation may do so without intimidation
or fear of reprisal.
The recommendation of the ECS is advisory only. The process of ethics consultation is intended
to supplement and support – not supplant – existing institutional mechanisms for making
decisions and resolving conflicts in clinical practice.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 44
Resident Manual
10
EVALUATIONS
All components of a Resident’s program must be evaluated and meet the guidelines set for the by
the AOA. This evaluation must be related to the educational objectives of the program and shall
include clinical experiences, intellectual abilities and skills, and attitudes and interpersonal
relationships.
10.1
Evaluation of Faculty
All Residents are required to complete periodic evaluations of the faculty with whom they work.
The number of faculty evaluations each Resident completes will vary depending on service
assignments and/or the size of the attending staff. Evaluations, which are retained in the
Department of Medical Education, are an important component of the professional review of each
supervising and training physician.
10.2
Evaluation of Resident’s Performance
1.
2.
3.
4.
5.
Residents will be evaluated upon the completion of each rotation by the attending on each
rotation. This evaluation shall be signed by the assigned faculty member and the Resident;
and reviewed by the program director and DME.
The Program Director, DME and the Medical Education Committee shall review the
performance of every Resident on a quarterly basis to ensure that educational objectives are
being met.
Prior to early termination of a Resident contract, the institution shall provide the Resident
with appropriate warning and counseling. The assigned faculty member is responsible for
documenting deficiencies and attempting to resolve concerns with the Resident.
In cases of early termination of a Resident contract, the DME shall provide the Resident with
documentation regarding which rotations, if any, were completed satisfactorily. In cases of
early termination or unsatisfactory completion of a Resident contract, the AOA Postdoctoral
Division must be promptly notified and the terminated contract submitted to the AOA.
If the resident is accepted into another resident training program, that program’s DME has
the authority to determine which, if any, rotations from previous AOA-approved programs
will be accepted for advanced standing.
A record of these evaluations will be permanently maintained in the Department of Medical
Education.
If a Resident requires an explanation or interpretation of his/her education records, he/she
should make such a request directly to the Residency Program Director or to the Director of
Medical Education.
Resident evaluations will be based, in part, on at least the following:
1.
Academic Performance:
a.
b.
c.
d.
2.
Whether the Resident has sufficient medical knowledge;
Whether the Resident possesses adequate and appropriate technical skills;
Whether the Resident is able to use medical knowledge and/or technical skills
effectively in providing medical care; and
Whether the Resident has any deficiency that may affect his/her clinical or
academic performance.
Hospital Standards:
a.
b.
Effective 07/01/07
Version 1
Whether the Resident has abided by the Resident Manual, the Medical Staff By
Laws, and the Medical Staff Rules and Regulations;
Whether the Resident demonstrates ability to work cooperatively with others;
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 45
Resident Manual
c.
d.
Whether the Resident has followed the established practices, policies and
procedures of the Hospital; and
Whether the Resident has abided by the Corporate Code of Conduct and
applicable standards of professional responsibility.
Evaluation of Resident’s Performance
10.3
To Appendices
Evaluation of Training Programs
This process is used to monitor the educational process of each training experience.
1.
2.
3.
At the completion of each rotation, the Resident shall evaluate the rotation.
The DME shall evaluate each rotation with the resident quarterly. The DME shall
determine the amount of work being required of the residents to ensure that they
are not overburdened with routine responsibilities and that they have the
opportunity to observe a sufficient variety of cases.
The Medical Education Committee shall evaluate the Resident training programs
quarterly. When necessary, the committee shall approve affiliations within the scope
of the AOA policies and procedures.
Evidence of these evaluations will be maintained in the Department of Medical Education.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 46
Resident Manual
11
MEDICAL RECORDS
The importance of complete and accurate medical records and an orderly and efficient system of
charts control (to assure accessibility) cannot be overemphasized.
At the beginning of the Resident’s service, personal instructions in the use of dictation equipment
and the policies of the Hospital will be given by Medical Records. If a problem arises in
connection with medical records, the staff will be glad to assist you.
11.1
Guidelines for Use of Medical Records
Medical records are privileged and confidential documents and must be safeguarded according to
Hospital Medical Records policies and procedures. The handling of medical records shall be
governed by the following guidelines:
1.
2.
3.
4.
11.2
Medical records must be available to Medical Records personnel day or night. They must:
a. Remain in specified patient care areas.
b. Be readily accessible in case of emergency.
Medical records may be removed from the Medical Records Department only for the following
purposes:
a. For direct patient care, either for admission to the Hospital.
b. For case study or other uses by a Department or individuals authorized to
requisition medical records. Medical records for study or dictation may be
requisitioned by Resident for use only within the Medical Records Department.
Medical records may not be removed from the Hospital except for legal purposes, and
then only in the custody of authorized Medical Records personnel.
Medical records must be kept intact on in-patient floors and in the clinics, and must not be
taken apart or pages removed or rearranged.
Guidelines for Documentation in the Medical Record
The Hospital maintains a “unit” record (containing all inpatient, outpatient, and Emergency
Department information). Residents are reminded that medical records are legal documents, and
the physicians may at some future date be cross-examined in court under oath on the notes
he/she has written. Personal opinions, or non-medical judgments, should not be expressed in the
medical record on any matters except those that pertain to the medical care of the patient.
Rules for Entries into the Medical Record:
1.
2.
3.
4.
5.
6.
7.
8.
ENTRIES MUST BE LEGIBLE.
Entries must be of a permanent nature, such as in black ink or typewritten. (Medical records
written in red, green, or other colors are not readable when photocopied.) Pencil and carbon
notes are prohibited.
Entries must be signed, dated, and timed.
Entries must be complete and accurate.
Entries must be recorded only on officially approved VCOM forms that are provided on the
divisions or in the clinics.
Entries should be made chronologically with minimal blank spaces left between entries to
avoid bulky records.
Chemical, abrasive or other erasures or alterations, that delete the original entry, create an
impression of a falsified record and render the record valueless to the patient or to the
Hospital in the event of litigation. Corrections should be made by drawing a SINGLE LINE
through the part to be corrected and the new entry made in proper sequence, or above or
below the incorrect entry. The reason for the correction, if not obvious, should be noted in
the margin. All corrections should be signed, dated and timed by the individual making the
correction.
Entries should not contain facetious, libelous, or otherwise inappropriate, subjective remarks.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 47
Resident Manual
9.
Entries must be signed, not initialed. Your printed name, Department/Division, PGY level and
pager number should follow each signature, e.g. Jane Doe, PGY II, Med Resident, Beeper
xxx-596-1234.
Guidelines for Documentation in the Medical Record
Top of the Document
11.3
Medical Record Completion Guidelines
1.
2.
3.
4.
11.4
Incomplete medical records remain on the patient division for 24 hours following
discharge to allow for dictation of discharge summaries. Charts should be obtained from
the head nurse or unit secretary (unless removed for follow-up care to the patient). If
the record is still incomplete when sent to Medical Records, it may not be removed until
completed, except when needed for direct patient care.
Final diagnoses and procedures should be dictated with the discharge summary at the
time of the patient's discharge from an inpatient division. The principal diagnosis is the
condition established to be chiefly responsible for occasioning the admission of the
patient to the hospital for care. Other diagnoses are all conditions that coexist at the
time of admission, or develop subsequently, which affect the treatment received and/or
length of stay. Diagnoses that relate to an earlier episode which have no bearing on this
hospitalization are to be excluded.
The Hospital uses a direct-dial dictating system for Operative Reports and Discharge
Summaries and can be used on any phone. Operative reports should be dictated
immediately following surgery. Clinical resumes should be completed immediately
following discharge. Directions for proper dictating procedures will be given to Residents
at the time of their orientation.
Incomplete medical records are considered delinquent 15 days following availability of
the chart for completion in Medical Records. Failure to complete records in a timely
manner will result in the Resident being placed in suspension status. At this time, direct
deposit of paychecks will be stopped. The checks will be sent to the Hospital’s cashier’s
office, and can be claimed only after all available charts are completed and the Resident
has obtained clearance from Medical Records. Be advised that during the course of a
medical career, any hospital to which a former Resident may apply for privileges will
seek verification of training. Standard verification questionnaires request information on
record keeping practices. Delinquent records while a house officer may be an
impediment to obtaining privileges, as well as an embarrassment, throughout one’s
professional career.
Protected Health Information
Medical records are considered Protected Health Information and are privileged and confidential
documents and the information must be safeguarded against unauthorized release according to
Hospital and Medical Records policies and procedures. Information regarding a patient's care and
treatment shall not be divulged without the written consent of the patient, parents or guardians
of minors, or executors of estates of decreased individuals. All medical correspondence shall be
handled by Medical Records including:
1.
2.
3.
4.
5.
All insurance forms.
Request for various medical certificates.
Request for case summaries and other specified medical record information.
Letters to schools, unions, or places of employment.
Birth certificates/Proof of Birth letters.
No Resident shall give out any information relative to the Hospital or concerning any
patient in the Hospital to a representative of the press. Such communications are
issued by Corporate Communications.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 48
Resident Manual
11.5
Medical Staff Rules & Regulations
In addition to being familiar with the content of the Hospital's “Administrative Policy and
Procedure (AP&P)” Manuals, and the System Manual, Residents should review the most current
copy of the Rules and Regulations of the Medical Staff. These are available in the Department of
Medical Education and the Medical Staff Department.
11.6
Physician’s Orders
Orders must be written clearly, legibly and completely in permanent ink and signed by the
attending physician or Resident responsible for the patient's care. All orders written must be done
so on Physician's Order Sheet and must include the date and time written, the physician’s or
Resident’s signature. Supplemental verbal discussion of orders between the physician and nurse
or other professional is encouraged to provide clarity. Orders must be specific for diagnostic or
treatment procedure and include generic name of medication. The time (when appropriate),
frequency, duration, and date to be carried out should be included. For medication orders will be
in concert with Pharmacy P&P Manual.
Physician orders must be written on hospital approved physician order forms according to medical
staff bylaws. Any order discrepancy, or clarification that is required, will be done by clinical staff
with ordering physician in accordance with medical staff bylaws and VCOM Policy and Procedures
for medical orders.
11.7
Service to In-patients
Residents assigned to inpatients units must follow the guidelines of the VCOM Medical Staff Rules
and Regulations. Specifically, Residents must evaluate admissions or transfers to critical care
areas based upon the patient’s condition and within 24 hours in general care divisions. Residents
must evaluate inpatients and write progress notes at least daily. When a patient is seen with an
attending, the Resident should chart that in the progress note.
Residents should answer pages as soon as possible, and respond to emergency consultations and
Emergency Department requests within 30 minutes. Residents are encouraged to consult with an
attending or any time he/she is uncertain about a patient care issue.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 49
Resident Manual
12
INSTITUTIONAL RESOURCES
The importance of complete and accurate medical records and an orderly and efficient system of
charts control (to assure accessibility) cannot be overemphasized.
At the beginning of the Resident’s service, personal instructions in the use of dictation equipment
and the policies of the Hospital will be given by the Department of Medical Records. Should a
problem arise in connection with medical records, the staff of the Medical Records Department
will be glad to assist you at any time.
12.1
Blood Bank
Blood and/or blood components are administered intravenously upon physician's orders. An
informed consent must be signed by the patient or designated caregiver prior to transfusion. The
registered nurse administering blood and blood components shall have knowledge and
understanding of immuno-hematology, blood grouping, blood and its components, administration
equipment and technique appropriate for each component, indications for use, monitoring
parameters, side effects, toxicities, incompatibilities, storage requirements, transfusion reactions,
and potential complications. Type and cross match for ABO and Rh type compatibility shall be
established prior to each transfusion. Positive patient and blood identification must be performed
and documented prior to each transfusion. Collections of blood for type and screen or type and
cross match are drawn within three (3) days of the anticipated date of need. When ordering
blood and blood components obtain and verify physician's orders; confirm type and cross match,
and other pre-transfusion laboratory tests complete blood count [CBC], platelet count; confirm
type of blood or components to be transfused; confirm number of units; date of transfusion; premedication, if necessary; post-transfusion laboratory orders. Observe Standard Precautions.
Obtain blood samples for type and cross match, if necessary. Complete appropriate blood bank
request slip and send blood sample and request slip to blood bank. All possible precautions must
be taken to insure the proper identity of patients to be transfused and of the blood selected for
transfusion. An error in identification of the patient or donor unit is dangerous and can result in a
hemolytic transfusion reaction.
Autotransfusion system will be used by a registered nurse to safely collect and re-infuse
autologous whole blood to the patient who has had orthopedic surgery to replace a total joint
(ex: knee, hip). The autotransfusion system is a self-contained disposable autologous whole
blood recovery system designed to collect and re-infuse blood lost following surgery. The
hemovac vacuum source is used to aspirate the shed blood. The collection system is then
reinfused by using a 40-micron filter and a standard blood infusion set.
Refer to Laboratory Policy and Procedure Transfusion Services, Nursing Policy and Procedures
Blood Administration and Post-Operative Orthopedic Transfusion.
12.2
Child Protection Program
Child Abuse and Neglect:
State laws require that all health care providers, including Residents, report suspected child
abuse or neglect. The social worker shall be alerted by the nursing staff, physician, unit clerk, or
any other staff member or interested party, as to the suspicion of child abuse/ neglect, via
telephone or Meditech, Monday through Friday normal working hours of the department. During
off hours and weekends the Shift Director shall be alerted. Abuse hotline numbers: Virginia 1800-422-4453 or Virginia 1-800-552-7096.
Upon receipt of the referral the Social Worker/Shift Director shall report to the department,
review the medical record of the child involved and observe the child. If the child shows visible
signs of trauma the emergency department shall be notified to take photographs of the child.
The Social Worker/Shift Director shall communicate with the nursing staff and physician as to the
incidence of the child’s admission to the hospital and injuries or illness involved.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 50
Resident Manual
The Social Worker/Shift Director shall notify the appropriate Protective Services Unit and report
the case of suspected abuse/neglect and release photographs and medical information as
necessary.
For complete details, refer to Social Services P&P Manual or the Management P&P Manual.
12.3
Employee Health Service
The Employee Health/Occupational Medicine Service provides a variety of health-related services,
including post-offer pre-placement physical examinations, evaluation and treatment of workplace
injuries and illnesses, exposure surveillance and updating immunizations.
At various times throughout your employment, you will be asked to report to the Employee
Health Service for screening such as the annual PPD skin test for tuberculosis surveillance. You
may also, because of your work duties or area, be asked to have other specific screening tests
and exams, many of which are mandated by state or federal agencies.
The Employee Health Service provides medical evaluations and treatment for work-related
injuries, which include exposure to blood and/or body fluids (e.g., sharps injuries, splashes,
exposures to communicable disease, falls, etc.). It is the responsibility of Employee Health
Service to determine:


When an employee with an injury or infection requires work restriction or work
exclusion
When an employee is ready to return to work after an injury or infectious illness
Employee Health Clinic is a means for evaluating and maintaining the overall good health of its
employees. Employees suffering illness, injury, exposure to toxic substances or a curable or
incurable blood or air-borne communicable disease while on duty must report it immediately. An
Incident Report must be completed for any of the above situations within 24-hours of occurrence
or knowledge of occurrence. In cases of potential exposure to potential blood borne or air-borne
pathogens, an Occurrence Report is completed and followed according to the Infection Control
Manual.
Refer to Human Resources Policy and Procedure Manual.
12.4
Employee Assistance
The Employee Health Clinic is offered to all hospital employees as well as immediate family
members. The Employee Health Clinic is private and confidential. Although there is no cost for
services, there may be fees associated with other services and resources to which you may be
referred.
12.5
Nursing Department
The goal of the Department of Nursing is three-fold: to give quality care to patients, to provide
an exemplary learning climate for students and staff, and to promote a spirit of inquiry in
nursing. The nursing staff is committed to the concept of collaboration in the delivery of quality
patient services and welcomes opportunities to work together with Residents to achieve this goal.
The Department of Nursing at VCOM is decentralized to promote clinical specialization and
accountability for nursing care as close to the point of service as possible.
The Vice President of Patient Care Services directs nursing at VCOM.
Nurse Directors support the Vice President of Patient Care Services in their roles as
managers of individual clinical areas.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 51
Resident Manual
The Vice President of Patient Care Services is the corporate officer responsible for
assuring a consistent standard of nursing care throughout VCOM.
VCOM partners with multiple schools of nursing to provide learning experiences for
student nurses.
12.6
Nutrition Services
The Department of Nutritional Services is responsible for the overall nutritional care of all
patients. Registered, licensed dietitians provide that nutritional care which includes screening
patients to identify those at actual or potential risk, development of care plans to address
problems identified, education of patients for home management of established dietary treatment
regimes, and referral for ambulatory follow-up as necessary. The department is also responsible
for the preparation and distribution of food to all hospitalized patients. A selective menu is
utilized and every effort is made to accommodate special requirements. Commonly used normal
and therapeutic diets are described in the VCOM Diet Manual. Diet Manuals are located on each
nursing unit.
Dietitians are available for consult about individual patient's nutritional status/therapy plan and
should be consulted whenever a patient requires dietary modification other than or in addition to
those described in the Diet Manual. Orders for home-going patient education should be written at
least 36 hours in advance of anticipated discharge of the patient to allow adequate time for full
instruction. Inpatient dietitians can be contacted by calling the Nutrition Services office.
12.7
Pharmacy
The Department of Pharmacy Services has the responsibility for the procurement, storage,
distribution and control of all medications for patients of the VCOM. The Department provides
information and assistance on the clinical use, pharmacokinetics, administration, and adverse
reactions of medications.
Policies and procedures for pharmaceutical services are developed by the Department of
Pharmacy Services, reviewed by the Pharmacy and Therapeutics Committee, approved by the
Medical Executive Committee and appear in the Hospital Policy and Procedure Manual.
Pharmaceuticals are dispensed only to inpatients, outpatients, and patients in the Emergency
Department
The Formulary is maintained, by the Department of Pharmacy Services and the Pharmacy and
Therapeutics Committee. It is a continually revised list of drugs that are the most; safe and
effective for use at VCOM. The Formulary contains a list of available drugs by generic name and
an alphabetic cross-reference of trade names.
Each Resident must sign the DEA registration log in order receive a PIN for the hospital DEA
number. The Department of Pharmacy Services requires an example of your signature for the
purpose of authentication/verification of your prescriptions.
The Department of Pharmacy Services is open Monday – Friday 7am-11pm and on Weekends and
Holidays 7am-5pm. There is a pharmacist on call for all hours the pharmacy is not open.
The Department of Pharmacy Services is responsible for distributing hospital controlled substance
prescription pads. The pads must be obtained during normal hours and require a signature.
Clinical Pharmacy Services provided by the pharmacy include, but not limited to, dosage
adjustment recommendations for patients with renal dysfunction, facilitating the conversion of
patients to oral medications as soon as possible after admission, review of culture and sensitivity
reports for appropriate antibiotic usage, as well as providing drug information for both staff and
patients.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 52
Resident Manual
12.8
Security
Loss of hospital, patient, or personal property under any circumstances should be reported to
Security - ext. ____. Although the Hospital can assume no financial responsibility for personal
losses, every reasonable safeguard will be provided. Thefts or any other incidents should be
reported immediately to Security for investigation. Also, suspicious persons should be reported
immediately for investigation.
Residents should exert a constant interest in the personal safety of patients and in the proper
protection of their property. Please help VCOM provide a safe and secure environment for all
patients, visitors, and employees.
12.9
Rehabilitation Services
The Department of Rehabilitation Services includes: Occupational Therapy (OT), Physical Therapy
(PT), and Speech-Language Pathology (SLP).
The Services include comprehensive and individualized assessment and treatment of inpatients,
skilled care and outpatients. Programs are designed to identify, correct, improve, and/or alleviate
acute or chronic dysfunction and to promote optimal health for orthopedic, cardiac, pulmonary,
congenital, vestibular and neurological disorders. Functional goals may be short-term at each
rehabilitation settings to prepare the patient to move through the continuum of rehabilitation
care to another level and setting.
Referral Process:
1. Inpatient referrals for PT, OT, and SP require a physician’s order in the patient’s medical
record with the dysfunction or impairment for treatment.
2. Outpatient Referrals information should include:
a. Patient Name
b. Physician Name
c. Date of Birth
d. Diagnosis
e. Medical Record Number
f.
Description of the problem to be treated/precautions
Printed Forms are available.
12.10 Social Work
Social Workers are assigned throughout the hospital to assist patients and their families with
personal, emotional, marital, family, or other problems that are often related to illness and their
ability to gain maximum benefit from health care services. In addition to counseling, social
workers collaborate with physicians, nurses, and other health care workers in medical care plans
for patients. With their thorough knowledge of available health and welfare resources in the
community, they can help with arrangements for rehabilitation services, care in the home,
nursing homes, tutoring, specialized infant and children's services, or other post-hospital
assistance. The social worker must be notified in cases of suspected child or elder abuse or in
cases of domestic violence.
Business Hours:
The Social Work Department hours are Monday through Friday 7:30 am – 4:30 pm. During these
hours, social workers are available via individual pagers or through departmental phones at
_____________.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 53
Resident Manual
12.11 Communications/Information Services
Telephone System:
The Communications/Information Services Department is comprised of a complex network of
processor and computer supported telecommunications systems. The system supports direct
incoming and direct outgoing dialing from most telephones, bypassing the hospital operator. To
access an outside line you must dial 9 first.
The Resident’s quarters are equipped with telephones that Residents may use to conduct their
business. The Medical Center’s operators make a determined effort to direct incoming calls to the
correct extension. However, if you customarily cannot be reached at a specific hospital extension,
the operators will use the digital paging system.
The audible overhead paging system is designed for emergency business and used by the
hospital operators only. The hospital operator will not accept messages.
If you have a pager problem or need a new battery the hospital operator will be able to assist
you.
12.12 Transport of Patients
Patients transferred from a patient care area, the mode of transport and necessary equipment
will be determined by each patient’s nurse, based on the patient’s physical condition, activity
restrictions and pre/post procedure care considerations.
Residents needing assistance with transporting patients must refer to the nursing staff on each
unit for assistance.
12.13 Paging System
Signal Calls: The telephone operators at VCOM have been instructed not to call students or
Residents from lectures, conferences, or meetings, except when the call is very urgent.
Therefore, when such a call is made, it is an urgent call insofar as the operator knows and must
be answered at once.
If a Resident is unable to answer the page he/she should have one of the personnel in the area
call the operator, explain the circumstances and take a message.
The emergency codes for the medical center are:
Blue=Coronary or Respiratory Arrest
Red=Fire
Triage Standby=Disaster, External/Internal Incident Command Only
Triage=Disaster, External/Internal
Orange=Hazardous Spill
Black = Bomb Threat
Pink = Infant/child abduction
Green = Robbery/Immediate Threat of Bodily Harm
Yellow = Patient Trauma Alert
Priority 1 = Surgeon response designation
Priority 2 = Surgeon response designation
(These priorities identify types of patients coming in and the response needed by the surgeons.)
The paging system may be used in the follow manner:
Code Blue (Location): This is a call for cardiac arrest and must be answered immediately by all
available personnel. Report immediately to the location mentioned and render services that are
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 54
Resident Manual
needed within your training and skills. If sufficient physicians are available on the scene when
you arrive, return to your regular duty. If you are the first physician on the scene, take charge of
the proceedings until a more senior physician arrives. Remember – Nursing supervisors and ER
Code Team personnel will be of great assistance to you if you are not sure how to proceed.
Resident (by name) STAT (Operator will state what phone or area): The Resident will answer to
that STAT page.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 55
Resident Manual
13
RESIDENT RESOURCES
13.1
Conferences, Rounds, Lectures
There are regularly scheduled Conferences, Seminars, Rounds, Lectures, Demonstrations, etc.,
presented throughout the year under the auspices of the Hospital, each Residency Training
Program and the Department of Medical Education. Notification of these meetings is published in
advance. Refer to Residency Training Program manual for specific didactic programs and
attendance requirements.
13.2
Resident Participation on Hospital Committees
Residents are assigned to monthly medical staff committee meetings and are encouraged to be
active participants if these committees.
13.3
Computer Use and Support
VCOM utilizes MEDITECH as the primary information system in the clinical area. MEDITECH
applications include Nursing Documentation, PCI (Patient Care Inquiry), Laboratory; Order Entry,
Radiology, Admissions, Medical Records, and Pharmacy, among others. There are other
departmental specific clinical applications such as PACS for Radiology. Additional training will be
provided for clinicians required to use departmental systems. All systems are supported twentyfour hours a day. Technical assistance can be accessed by calling the Help Desk at 327-1170 or
the Switchboard by dialing “0”. You may also be assigned an email account and access to the
Internet. Use of email and the Internet are subject to the VCOM Confidentiality Policy (Refer to
Human Resource Policy & Procedure Manual).
The following information is presented as an overview only. Detailed information is available from
Information Services and copies of all policies are available in the Information Services
Department.
Patient Confidentiality and Security
Patients have the right to absolute privacy of their clinical records. All access should be by clinical
care providers only and never by curiosity seekers or friends, neighbors, relatives or co-workers
not involved in the patient’s clinical care. You are privileged to access patient records with which
you have legitimate clinical links. At the same time your user ID and password are assigned, you
will be asked to sign a confidentiality agreement. The agreement verifies your understanding of
what constitutes a breech of access and the consequences of such a violation. All computer
access is through use of an individually assigned sign-on ID and unique password. For security
reasons, your ID or password is never to be shared or borrowed. Use of this user ID establishes
user identity and all transactions are tracked and logged to determine appropriateness of those
transactions. Information Services constantly runs reports to track users and their access. Audit
trails are maintained to allow for periodic audits of clinical transactions, as well as those on the
Internet.
Some patients are designated as “confidential”. When one wishes to access the information for
these patients, a screen warns the user that the patient is confidential and asks if (s)he wishes to
proceed. Extra caution must be exercised in this case.
Access to any patient data is subject to the VCOM Confidentiality Policy (Refer to Human
Resource Policy & Procedure Manual).
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 56
Resident Manual
Process for Obtaining Access
When you arrive at VCOM, the Medical Records Department representative will notify the
Information Services Department of your need for access. When you have signed the
Confidentiality Agreement, you will be assigned your user ID and password. A representative of
Information Services will schedule a training class for MEDITECH and other applications as
required before you are allowed to sign-on. If for any reason your privileges are suspended or
revoked, your computer access will be affected accordingly.
Electronic Signature
VCOM will create an electronic signature for you, which associates each provider with
system/patient activity. Individual PINs for the electronic signature and any other passwords
which are created are to be treated as confidential and are NOT to be shared among other
individuals. Any violation or inappropriate use of personally issued sign-on or electronic signature
codes is considered a breech of confidentiality and is subject to disciplinary action. Immediate
notification should be made to the Information Services Department if you suspect that your code
or password has been lost, stolen, or used by anyone other than its issued user.
MEDITECH Clinical Menu
Access to multiple clinical menu options is available through MEDITECH after completion of the
required security forms and training. Menu options include retrieval of patient clinical results from
radiology and laboratory, designated nursing documentation, medication information, visit history
and demographics.
Security Considerations
The security of the VCOM network is of primary concern. For this reason, various processes are in
place to protect the network, including:

Internet use is limited to job-related access only, and non-related sites are blocked.

Mobile computing and storage devices that contain or access information resources at VCOM
are strictly monitored. They must be approved by Information Services prior to connecting to
the information systems at VCOM. Mobile computing and storage devices include, but are not
limited to: laptop computers, personal digital assistants (PDAs), plug-ins, Universal Serial
Bus (USB) port devices, Compact Discs (CDs), Digital Versatile Discs (DVDs), flash drives,
modems, handheld wireless devices, wireless networking cards, and any other existing or
future mobile computing or storage device. Portable computing devices and portable
electronic storage media that contain confidential, personal, or sensitive VCOM information
must use encryption or equally strong measures to protect the data while it is being stored.

No one is allowed to download anything to or install anything on any VCOM computer.
Details of these considerations may be obtained from the Information Services department
(HIPAA Security Policy and Departmental Policies).
13.4
Food Services
Cafeteria
Monday through Friday – Hours:
Saturday, Sunday – Hours:
A selective menu that includes sandwiches, snacks, salads, and beverages are available during all
open hours. Selections of hot entrees are available during normal meal times.
NOTE:
Residents having breakfast and/or lunch are required to obtain their meals prior to the start of
morning or noon lectures. Once the lecture has started, Residents are not permitted to leave for
meals. This is disruptive and disrespectful to the lecturers.
Vending Machines
Vending machines are available and open 24 hours per day. Items available for purchases are
snacks, and beverages.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 57
Resident Manual
13.5
Interpreter Services
Family members and friends may not translate for a patient when medical information is being
discussed. Federal law requires all language interpreters used by hospitals to be proficient in their
field and competency-tested, so that they can ensure that the medical information being shared
with the patient has been translated accurately. In addition, offering a third party interpreter to
patients allows the patient to keep personal medical information confidential.
13.6
Library Facilities
The Medical Library: A professional librarian is available Monday – Friday between the hours of
8:00 a.m. and 4:00 p.m.
13.7
Meals
Residents are provided a meal allowance while on duty at VCOM.
Residents are responsible for their own meals while at other institutions, if that institution does
not provide meals free of charge or provide meal tickets.
13.8
On-Call Rooms
Every effort is made to ensure acceptable accommodations in a pleasant and restful environment
to Residents while on call. Every room is marked with a standardized sign. Security measures
other than those already in place are also the responsibility of the individual departments.
It is the responsibility of each Resident to inform the Department of Medical Education of any
failed equipment, needs and/or services required or not being tended to.
13.9
Uniforms & Laundry
Edward Via Virginia College of Osteopathic Medicine will furnish each Resident with two lab coats
on the day of orientation and two coats every year thereafter. Residents requiring scrubs must
consult their individual training departments for instructions on obtaining them.
Exception – Any personal effects that are contaminated with patients‘ bodily fluids will
immediately be placed in containers marked CONTAMINATED and handled in the same manner
the hospital cleans all other contaminated linens, etc. These contaminated articles are not to
leave the hospital. The hospital will provide scrub attire for the Resident to wear should it be
needed. This includes socks and shoes.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 58
Resident Manual
14
UNIVERSAL PRECAUTIONS
Universal precautions exist to provide the same high level of infection precaution for all patients.
Body Substance Isolation (BSI) provides a consistent approach to managing body substances for
all patients and is essential to prevent transmission of potentially infectious agents.
The BSI system focuses on body substances (blood, feces, urine, wound drainage, oral
secretions, etc.) from the hands of personnel, primarily by increased blood use and hand
washing. Thus, the system eliminates many of the ritualistic practices associated with traditional
isolation systems while increasing the use of barriers for all contacts with body substances.
The BSI system is consistent with recommendations from the Center's for Disease Control to
consider all blood and body fluids as potentially infectious, regardless of the patient’s diagnosis.
In order to follow these recommendations, use of barriers must focus on the care provider’s
interaction with the patient at the time, rather than on the diagnosis of the patient, which was
the cornerstone of the traditional isolation systems.
It makes more sense to consider all blood and body substances as potentially infectious, rather
than to practice precautions only on patients diagnosed with certain infectious diseases, because
the infection status of all patients’ blood cannot be known for most infectious diseases.
In addition, colonized body sites and secretions are a major reservoir for multiple-drug
resistant organisms easily transmitted from patient to patient on the hands of
personnel. The BSI system also reduces the risk of such transmissions by the
consistent use of barriers whenever any such substances are likely to be in contact
with the caregiver’s hands.
14.1
Basic Elements of BSI
The BSI system includes the following elements and shall be followed by all personnel at all
times, regardless of the patient’s diagnosis.
Use individual judgment in deterring when barriers are needed. Each individual must establish
his/her own standards for consistent use of barriers. These personal standards should be based
on the individual’s skills and interactions with the patient’s body substances, non-intact skin, and
mucous membranes.
1.
Wear gloves when it is likely that hands will be in contact with body substances,
blood, urine, feces, would drainage, oral secretions, sputum, and vomitus.
2.
Protect clothing with a plastic apron when it is likely that eyes and/or mucous
membranes will be splashed with body substances (e.g., when suctioning a
patient with copious secretions).
3.
Wear masks and/or eye protection when it is likely that eyes and/or mucous
membranes will be splashed with body substances (e.g., when suctioning a
patient with copious secretions).
4.
Each physician needs to evaluate his/her own interactions with the patient and
use barriers as appropriate, based on anticipated contact with body substances,
not the patient’s diagnosis of infection.
5.
All physicians need to know their own chickenpox and rubella status. The
Emergency Department screens all new house staff for rubella and encourages
rubella vaccine to those with a negative antibody result. New house staff with a
negative or questionable history for varicella will have a varicella antibody titer
included in their pre-employment blood work and encourage varicella vaccine to
those with negative results. All house staff must participate in the Medical
Center’s annual TB testing program.
All physicians who have frequent contact with blood or body fluids should be
immunized against hepatitis B.
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 59
Resident Manual
14.2
Nurses & Other Direct Care Providers Role in BSI System
Each nurse needs to evaluate his/her own interactions with the patient and use barriers as
appropriate based on anticipated contact with body substances, not the patient’s diagnosis of
infection. Use the guidelines above to make these judgments.
If the patient has a disease that is transmitted in whole or in part by the airborne route, the
nurse is responsible for triage of persons wishing to enter the patient’s room.
If the patient is ambulatory and is soiling the environment with body substances, the patient
should be placed in a single room.
All direct care providers need to know their own chickenpox and rubella status and must
participate in the Medical Center’s annual TB skin testing program.
All direct care providers who have frequent contact with blood or body fluids should be
immunized against hepatitis B.
14.3
Precautions for Patients with Airborne Diseases
a.
b.
c.
Private Room
Stop sign alert on door
Door Closed
When a patient is suspected of or known to have a disease transmitted in whole or in part by the
airborne route, the physician should request a private room and write the diagnosis or “rule out”
diagnosis on the order sheet. This will prompt the nurse to notify the admitting office so that the
patient may be relocated in an appropriate room. The nurse will place a “stop sign alert” on the
door to the patient’s room. The “stop sign alert” instructs anyone about to enter the room to
“wear a mask when entering”.
When the patient is known or suspected of having chickenpox/varicella place a “stop sign alert”
with special Chickenpox Alert on the door of the patient’s room. If the person wishing to enter
has never had chickenpox, he/she should not enter the room with or without a mask, because
masks do not guarantee protection. If you have had chickenpox, you may enter the room without
a mask and provide care using the BSI system.
The airborne route transmits the following diseases in whole or in part. Patients with these
diseases need to be assigned to a private room and have a “stop sign alert” posted on the door.
The door should remain closed.
For disease marked with an asterisk (*), all care providers who are not immune to these diseases
should not enter the room of these patients.
Note: When a patient leaves the hospital room to go to any other area, the patient must ware
masks. For all other entities it would be necessary to place a mask on the patient while
he/she is being evaluated.
Disease
Duration of Airborne
Precautions
** Chickenpox (Varicella)
Until all lesions are crusted.
Epiglottitis, due to
Haemophilus influenza
For 24 hours after start of
effective antibiotic therapy.
**Herpes – zoster/varicella
Duration of illness
Effective 07/01/07
Version 1
Comments
Persons who are not
susceptible do not need to
wear a mask. Exposed
susceptible patients should be
isolated beginning 10 days
after exposure until21 days
after 1st exposure.
Localized lesions in immuno-
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 60
Resident Manual
localized in immunocompromised patient, or
disseminated
14.4
compromised patients
frequently become
disseminated. Because such
dissemination is unpredictable,
use the same precautions as
for chickenpox.
**Measles (rubeola)
For 4 days after start of rash,
except in immunocompromised patients, for
whom precautions should be
maintained for duration of
illness.
Persons who are not
susceptible do not need to
wear a mask. Promptly report
to Infection Control Nurse
x6443
Meningitis
For 24 hours after start of
effective antibiotic therapy.
Call Infection Control Nurse
x6443.
Neisseria menigitidis
(meningococcus), known or
suspect
For 24 hours after start of
effective antibiotic therapy.
Promptly report to Infection
control Nurse x6443.
** Mumps (Infectious
parotitis)
For 9 days after onset of
swelling.
Persons who are not
susceptible do not need to
wear a mask. Call Infection
Control Nurse x6443.
Pertusis (Whooping cough)
For 7 days after start of
effective antibiotic therapy.
Call Infection Control Nurse x
6443.
Pneumonia – Haemophilus in
infants and children any age
For 24 hours after start of
effective antibiotic therapy.
Pneumonia – Meningococcal
For 24 hours after start of
effective antibiotic therapy.
Promptly report to Infection
Control Nurse x6443
Tuberculosis – Pulmonary
confirmed or suspect
In most instances, duration
can be guided by clinical
response and a reduction in
numbers of TB organism on
sputum smear. Usually this
occurs within 2-3 weeks after
chemotherapy has begun.
When the patient is likely to
be infected with INGresistant organisms, apply
precautions until patient is
improving and sputum smear
is negative to TB organism.
Patient must be placed in
properly ventilated room.
Admitting office should be
notified for proper room
placement. Particular
respiratory masks must be
worn when entering TB
isolation room. Prompt use of
effective antitubercular drugs
in the most effective means of
limiting transmission. Call
Infection Control Nurse x6443.
Supplies Needed for BSI
Gloves
Sharps Container
Aprons/Gowns
Eye Protection
Masks
Stop Sign Alert
Chickenpox Alert Sign
Plastic Bags
Barrier Gowns
Effective 07/01/07
Version 1
Disposable non-sterile gloves
Rigid container for immediate disposal of all sharps
Disposable plastic aprons/gloves
Disposable goggles. After use the goggles should be washed by the
patient care provided in the future use.
Surgical Masks to be used if care provided is likely to be splashed in
face by body substances.
One sign is to be placed on the door to the room of the patient with an
airborne disease or a leukopenic patient.
If patient has chickenpox/varicella, place sign with chickenpox alert on
door.
Small clear bags obtained from housekeeping to be used in
transporting procedure trays to Central Supply for sterilization.
Reusable fabric barrier gowns will be distributed on laundry carts.
These gowns are to be used when more extensive covering of clothing
is needed. Gowns are returned to soil linen bags.
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 61
Resident Manual
NOTE: Signs are to be taken down and returned to the storage location when patient no longer needs
airborne precautions. If additional signs are needed, contact Infection Control Office .
14.5
Other BSI Procedures
Soiled linen: All soiled linen is to be put into individual laundry bags, closed securely, transported
in carts, and put down the linen chute or designated areas.
Central Service Reusable Items: All miscellaneous reusable equipment to be returned to the
Central Supply Department is to be placed in a marked basin on shelf located in soiled utility
room.
NOTE: Any fluid filled container that is not disposable should be emptied into hopper on
unit prior to returning to Central Service. All special trays are to be placed in a clear
plastic bag and left in soiled utility room.
Disposal of waste from patient rooms and ICU: Follow infectious waste management
policy.
Communicable Diseases
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 62
Resident Manual
15
EMPLOYEE COMMUNICATIONS
15.1
Open Communication
VCOM encourages employees to discuss any issues they may have with a co-worker directly with
that person. If a resolution is not reached, employees should arrange a meeting with their direct
supervisor. If the concern, problem, or issue is not properly addressed, employees should contact
the Human Resources Department. Any information discussed in an Open Communication
meeting is considered confidential, to the extent possible while still allowing management to
respond to the problem. Retaliation against any employee for appropriate usage of Open
Communication channels is unacceptable.
15.2
House Staff Meetings
In order to keep the communication channels open, the Department of Medical Education
implements a once-a-month house staff meeting. Residents receive communications from the
Department about the agenda and discussion topics every month.
15.3
Bulletin Boards
The Department of Medical Education provides Residents with a bulletin board in the Classroom
where Residents can find organizational announcements, news/events, and discussions about
specific topics. The Residents are responsible for reading necessary information posted on the
bulletin board.
15.4
Suggestions
The Department of Medical Education encourages all Residents to bring forward their suggestions
and good ideas about making VCOM a better place to work and enhancing service to VCOM
customers. Any employee who sees an opportunity for improvement is encouraged to talk it over
with their Program Director and Director of Medical Education. The Department of Medical
Education can help bring ideas to the attention
of the people in the organization that will be
responsible for possibly implementing them. All suggestions are valued.
15.5
Closing Statement
Successful working conditions and relationships depend upon successful communication. It is
important that Residents stay aware of changes in procedures, policies, and general information.
It is also important to communicate ideas, suggestions, personal goals, or problems as they
affect work at Edward Via Virginia College of Osteopathic Medicine to the Department of Medical
Education.
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 63
Resident Manual
16
ACKNOWLEDGMENT
I acknowledge that I have received a copy of the Edward Via
Virginia College of Osteopathic Medicine Resident Manual, and I
do commit to read and follow these policies.
I am aware that if, at any time, I have questions regarding the
Resident Manual, I should direct them to the Administrative
Director of Medical Education or the Director of Medical
Education.
I know that Edward Via Virginia College of Osteopathic Medicine
policies and other related documents do not form a contract of
employment and are not a guarantee by Edward Via Virginia
College of Osteopathic Medicine of the conditions and benefits
that are described within them. Nevertheless, the provisions of
such Edward Via Virginia College of Osteopathic Medicine
company policies are incorporated into the acknowledgment, and
I agree that I shall abide by its provisions.
I also am aware that Edward Via Virginia College of Osteopathic
Medicine, at any time, may on reasonable notice, change, add
to, or delete from the provisions of the company policies.
________________________________
Resident’s Printed Name
___________________________
OGY Level
________________________________
Resident’s Signature
___________________________
Date
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 64
Resident Manual
17
APPENDICES
17.1
Approved Abbreviations
17.2
Non-Approved Abbreviations
17.3
Communicable Diseases
17.4
Directory
17.5
Resident Contract
17.6
Clearance Sheet
Top of the Document
Effective 07/01/07
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 65