HOUSE OFFICER BENEFITS
MEDICAL PLAN Medical Plan Choices program includes medical insurance and Flexible Spending Accounts. Medical election is available the date of hire. Employee contribution is required.
DENTAL INSURANCE: MetLife. Depending on election employee contribution may be required. Effective on date of hire.
VISION INSURANCE: Eye exam and glasses or contact lens. Once every 24 months for adults and once every 12 months for children under 19 years of age. May choose enhancement plan which offers these services once every 12 months.
Depending on election contribution may be required.
Effective date of hire.
LIFE INSURANCE: Coverage of 1 times annual base pay. Effective the first of the month following 90 days of employment. No employee contribution required. In addition employees automatically receive Accidental Death & Dismemberment insurance equal to 1 times annual base pay.
SICK: 10 days per contract year. No carry over and no pay out at termination. Eligible from date of hire. Medical Education will track sick time.
VACATION: 3 weeks per contract year. No carry over and no pay out at termination. Eligible from date of hire.
SHORT TERM Basic plan: No employee contribution required. Benefits are paid on the 15 th
day of continuous disability resulting from any non-occupational surgery, hospitalization or accident. Amount paid is up to 60% of base weekly wage
(40 hours per week), up to $2,000 for a maximum of 24 weeks (must use sick/vacation time for first 2 weeks).
Enhanced: Employee contribution required. Benefits are paid on the 1 st
day of continuous disability resulting from any non-occupational surgery, hospitalization or accident.
Amount paid is up to 60% of base weekly wage, up to
$2,000 for a maximum of 26 weeks (all paid).

LONG TERM
RETIREMENT:
TAX DEFERRED
ANNUITY:
50%
DIRECT DEPOSIT:
Employees are automatically enrolled in this benefit after completing a minimum of 6 months of employment.
Employer pays 100% of this benefit. Benefits are provided after 6 consecutive months of disability and pays 60% of pre-disability earnings.
Cash Balance plan with no employee contribution required.
100% vested in 5 years. Employer contribution based on years of service and employee’s base earnings.
403(b) savings program through payroll deductions that defers Federal and State taxes. Employer will provide a matching contribution up to 4% of employee’s annual base pay. Employer match graded vesting in 2 - 5 years.
Available company is AIG Valic.
No cost service to deposit paycheck directly into bank account.

PGY Level Job Code
I
II
III
IV
V
Chief I
Chief II
Chief III
Chief IV
Chief V
1405
1406
1407
1408
1409
1010
Title
MEDICAL EDUCATION
Effective 7/1/2010
Resident I
Resident II
Resident III
Resident IV
Resident V
Chief Resident I
1011 Chief Resident II
1012
1013
Chief Resident
III
Chief Resident
IV
1014 Chief Resident V
Annual Salary Hourly Rate
$
46,280.00
$
47,694.80
$
49,171.20
$
52,561.60
$
56,014.40
$
47,694.80
$
49,171.20
$
52,561.60
$
56,014.40
$
57,803.20
$
22.25
$
22.93
$
23.64
$
25.27
$
26.93
$
22.93
$
23.64
$
25.27
$
26.93
$
27.79
Meal Allow.
$
1,934.40
$
1,664.00
$
1,664.00
$
1,664.00
$
1,664.00
$
1,934.40
$
1,664.00
$
1,664.00
$
1,664.00
$
1,664.00
Per Pay Meal
Allow
$
74.40
$
64.00
$
64.00
$
64.00
$
64.00
$
74.40
$
64.00
$
64.00
$
64.00
$
64.00
Total Salary with meals
$48,214.40
$49,358.80
$50,835.20
$54,225.60
$57,678.40
$49,629.20
$50,835.20
$54,225.60
$57,678.40
$59,467.20

“R” indicates policy up for review
POLICY APPROVED
ADA Accommodation (HR) 12/31/01
Advanced Cardiac Life Support (ACLS) Certification 10/11/01
Anonymous Contact Flyer
Communication of Medical Education Policy and
Procedures to Residents
Completion of Medical Records by House officers
General Competency Lecture Series
Corrective Action-Due Process Policy and Procedure
Corrective Action Plan Reporting
Counseling and Support Services
05/12/05
03/09/01
12/03/01;
12/13/02
12/12/02
10/10/02
03/9/00
Disaster Response Policy 12/13/07
Disruptive Behavior and/or Harassment (formerly Sexual
Harassment) (HR #105)
Dress Code- Medical Education
Dress Code (HR #407)
12/13/01
03/10/05
Duty Hours, Work Environment and Documentation 03/04/04;
11/10/05
Eligibility and Selection
Evaluation, Promotion and Retention
GME In/Out Rotation Policies and Procedures
Grievance Procedure
01/14/99;
04/09/02
06/13/02
11/14/02
12/10/02
REVISED
04/01/05;
01/01/09
05/12/05;
01/20/11;
03/15/12
01/10/07;
11/22/10;
01/20/11
01/20/11
05/12/05;
03/08/07;
02/23/09;
06/17/10
03/08/07;
09/17/08
04/12/07;
09/17/08
03/08/07;
09/17/08
11/11/04;
06/15/06;
09/17/08;
03/17/11
08/12/10;
03/17/11
01/01/09
06/17/04
04/01/05;
01/01/09
01/26/06;
11/13/08;
07/01/09;
01/20/11
06/16/11
12/13/07;
09/22/08;
07/21/11
01/10/08
09/17/08;
08/09
01/09/03;
02/14/08

Infection Control Policies- Post Exposure Prophylaxis (IF
#602) HIV/HBV/HCV Infected Healthcare Workers (IF
#603), Exposure Control Plan (IF #205), First Responder
Exposure Procedure (IF #604), Infection Control
Guidelines for Healthcare Workers (IF #201)
Internal Review Process
JCAHO: (OHI) Compliance, Provision of Care,
Environment of Care, Ethics, Human Resources,
Improving Performance, Infection Control, Leadership,
Medical Management, Medical Staff, Nursing
Library Access for Residents and Staff Physicians
Medical Library Policy and Procedures
Maternity, Paternity and Adoption Leave
Leave of Absence (HR)
03/02
01/02
10/01, 06/07
01/08
04/11/02;
04/14/05
2004
11/11/02
09/01/01;
09/13/01
01/01/97
Moonlighting 11/19/04
Organizational Code of Conduct (OHI #1114)
PDA (Personal Data Assistant) Policy and Agreement
Vendor Policy
(OHI #1113)
02/15/02
03/11/04
12/13/01
Physician Impairment
Professionalism
Resident Alertness Management & Fatigue Mitigation
Program Annual Review Policy
Program Annual Review Report
Resident File Access, Retention and Verification
Resident Employment Procedures & Credentialing
Residency Closure Reduction
Resident Documentation, Orders and Prescription
Writing
Resident Travel Grant Policy and Procedures
Scholarly Activity
07/13/00
2012
01/19/12
12/10/09
12/10/09
05/09/05
10/13/05;
06/15/06
05/9/02
12/08/05
01/13/05
06/13/02
On going
05/10/07;
02/05/09;
06/11
On going
04/28/04
04/28/04
04/28/04
07/09/00;
12/31/01;
04/01/05;
03/01/09
07/12/07;
07/11/07;
07/21/11
10/07; 2010
08/04/04;
01/14/11
03/01/07;
04/23/08;
01/20/11;
01/02/12
04/11/07;
11/22/10
03/17/11
05/08/08
01/10/08;
03/17/11
08/10/06;
09/22/09;
05/13/10
05/13/10
12/08/05;
01/19/06;
05/13/10

Scrub Policy and Procedures
Sentinel Events
(OHI #1033)
Submission of ACGME Correspondence by Program
Director
Supervision
Transitions of Care
Visiting Residents, Fellows and Interns
**Revised 11/12/12
07/13/00
04/11/02
12/13/07
12/12/02;
10/14/04
02/16/12
07/13/00
10/13/05
01/25/08;
02/04/11
08/12/10
05/08/08
01/10/10;
06/16/11
01/09/06;
09/17/08

ADA Accommodation (Human Resources)
Advanced Cardiac Life Support Certification (ACLS)
Anonymous Contact Flyer
Communication of Medical Education Policy & Procedures to Residents
Completion of Medical Records by House Officers
General Competency Lecture Series
Corrective Action-Due Process Policy
Corrective Action Plan Reporting
Counseling and Support Services
Disaster Response Policy
Disruptive Behavior and Sexual Harassment
Dress Code (Medical Education)
Dress Code (Human Resources)
Duty Hours, Work Environment and Documentation
Eligibility and Selection
Evaluation, Promotion and Retention
GME In/Out Rotation Policy
Grievance Procedure
Infection Control
Post Exposure Prophylaxis (PEP)
HIV/HBV/HCV Infected Healthcare Workers
Exposure Control Plan -Blood Borne Pathogens
Employee Health Services Exposure Procedure
General Guidelines for Healthcare Workers
Internal Review Process
The 2008 Joint Commission Standards (See Oaknet/Departments/Corporate Accreditation)
Compliance
Provision of Care
Environment of Care
Ethics
Human Resources
Improving Performance
Infection Control
Leadership
Medical Management
Medical Staff
Nursing
Library Access for Residents and Staff Physicians

Medical Library Policies
Maternity, Paternity and Adoption Leave
Leave of Absence (Human Resources)
Moonlighting
Organizational Code of Conduct
Personal Data Assistant Policy (PDA)
Vendor Interaction Policy
Physician Impairment
Professionalism
Program Annual Review Policy
Resident Alertness Management & Fatigue Mitigation
Resident Employment Procedures and Credentialing
Resident File Access, Retention and Verification
Residency Closure Reduction
Resident Documentation, Order Writing and Prescription Writing
Resident Travel Grant
Scholarly Activity
Scrub Policy
Sentinel Event
Submission of ACGME Correspondence by Program Director
Supervision
Transitions of Care
Visiting Residents, Fellows and Interns

ADA Accommodation http://oaknet/documents/PolsNProcs/HR/412.pdf

Oakwood Healthcare System (OHS) requires that all residents, including rotating residents, have a valid, current certification in ACLS. This is required to provide excellence in patient care and to meet the standards set by the Joint Commission on
Hospital Organizations (JCAHO). To facilitate these requirements, OHS will provide residents two ACLS courses in June. The CME office will provide exact dates for the current academic year. These courses are offered at no charge to all residents under contract to OHS.
If a resident cannot attend one of these courses, our CME office will provide the resident a list of ACLS provider courses in the area. However, the resident must use their conference funds to pay for these outside courses. Unless courses were closed due to booked courses or special circumstances intervene.
If the resident is more than sixty days past their certification date, they will be suspended without pay until they receive their certification.

MEDICAL EDUCATION
RESIDENT ASSISTANCE
If you have a sensitive issue, grievance or need counseling, assistance is available to you.
Contact:
Larry Fischetti, PhD Office: 734-727-1067
Pager: 1241
Ulliance- EAP Office: 800-448-8326
Anonymous Contacts:
Gregory Mahr, MD Office: 313-982-4351
Bev Beltramo
Pager: 1325
Office: 313-982-5698
Pager: 3675
Lyle Victor, MD Cell: 313-515-4303
All discussions are confidential.
For further information, see
Oaknet-Physicians-Resident Policies-
Counseling & Support

All policies approved through the Graduate Medical Education Committee will be distributed to Medical Education program directors, faculty, residents and staff following formal approval by the Graduate Medical Education Committee.
A copy of each policy will be distributed to program directors, residents, and faculty and posted on Oaknet with email notification to program directors, faculty and residents.

Introduction
This policy is written to insure that the responsibility to complete medical records, including discharge summaries, is accomplished in a timely manner by all residents and interns, who are part of Medical Education at Oakwood Healthcare System in compliance with the Center for
Medicare Services (CMS) and Joint Commission requirements.
Policy
1.
The resident physician responsible for completion of the medical record is that resident indicated on the discharge sheet. In addition, the patient’s record must indicate the resident physician who is responsible for dictating the discharge summary, their pager number and the name of the attending physician responsible for co-signing the summary. For example,
Discharge summary to be dictated by Dr. J. Jones, pager #1234 and co-signed by Dr. S.
Smith. This can be indicated on the discharge sheet or in the progress notes.
2.
The resident should electronically sign patient records daily. Post-operative reports must be completed immediately following surgery. History and physicals must be completed less than 24 hours after admission. Discharge summaries must be completed no more than 48 hrs after the patient is discharged.
3.
All dictations must include the attending co-signer in order for Health Information
Management (HIM, formerly known as Medical Records) to assign the report to the appropriate physician. If an incorrect co-signer is listed, the resident should change the name of the attending co-signer at the time they electronically sign the record.
4.
Questions concerning the resident physician responsible for chart completion by HIM personnel will be addressed by the responsible Chief Resident of each program. The Director of the HIM Department will be apprised of the Chief Resident of each residency. It is the
Chief Resident’s responsibility to identify who is responsible for record completion if the information is not clearly listed in the patient’s record. Medical Education will notify the
HIM Department if a resident is on a leave of absence or vacation lasting more than one week. The Chief Resident will be informed to re-assign these records to the appropriate resident.
5.
Residents must have been involved in the care of the patient for a significant portion of the hospitalization to be reasonably expected to complete the discharge summary. Dictations on patients removed from a teaching service within 48 hours of discharge will be the responsibility of the resident. However, summaries on those patients whose stay on the teaching service was short (less than 48 hours) prior to being removed are the attending physician's responsibility.

6.
Residents rotating from institutions other than another OHS site will not be eligible to dictate with the exception of the Wayne State University affiliated programs. Dictation of patient records will be the responsibility of the OHS resident directly involved in the care of the patient. If no other OHS resident is assigned to the patient then it is the responsibility of the attending physician to complete the record.
Procedures for Suspension of Resident's Privileges
1.
HIM will notify Medical Education weekly via email of the residents who have at least one delinquent medical record. A delinquent record is a record that has not been completed 7 days after discharge of the patient. Residents will receive a text page from the Medical Education
Department informing them of delinquent records that need to be completed as soon as possible. A copy of the delinquent records notice will be given to the appropriate program director. This is considered the first notice of delinquent records. Residents with deficient medical records will be required to contact their program director directly and explain why they have not completed the records according to this policy (above).
NOTE: When completing delinquent records on line instead of in the HIM department, residents should call 313-593-7791 notifying HIM to look for the newly completed record.
2.
Residents with incomplete records 15 days or older will be notified by the program director via text page that they have 48 hours to complete these records. This is considered the second notice of delinquent records. A copy of the delinquent records notice will be given to the appropriate program director.
3.
If records are not completed within this 48-hour period, the program director will pull the resident from their rotation/service until all records are completed. This is the third and final notice of deficiencies.
4.
If any resident medical record deficiencies continue beyond the third notice, a formal corrective action plan will be placed in the resident’s permanent record. In addition, any subsequent deficiencies in the next 12 months will result in the resident appearing before the
GMEC and possible progression of corrective action including probation, suspension or termination.
5.
Resident physicians who are on vacation, at a conference, on a sick leave or ill for more than two days, must inform the program director’s office. If a resident needs to request exemption from these procedures for these reasons, the program must notify HIM.

The General Competency Lecture Series is intended to assist programs in meeting the requirements of the ACGME (IR #IV.B.6.). These requirements require that all residents regardless of specialty will receive instruction in patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice issues. In addition, all residents must receive instruction in physician impairment/substance abuse and the recognition and response to fatigue. These lectures are required for all residents.
In order to meet this requirement all residents must attend these monthly lectures, or view them via videotape or CDROM. Participation of 100% for these lectures is expected for all residents. Monthly attendance data will be provided to program directors so they will be able to monitor their resident’s attendance. If the resident views the videotape or
CDROM, the residency coordinator will enter their name on a monthly log of core curriculum attendees. A copy will be sent to the Medical Education office. In addition, each General Competency Lecture will have a corresponding post-test posted to each resident on Healthstream, the passage of which is required for successful promotion.
General Competency Lecture Topic Areas
Care Management Communication Skills
Cost Containment Issues Community Medicine
Counseling Skills
Domestic Violence
Ethical Issues
Critical Appraisal/EBM
End of Life Care
Epidemiology
Family
Genetics
Healthcare Systems
Medical Informatics
Multi-Cultural Competency
Pain Management
Patient Counseling
Physician Impairment
Preventive Medicine
Professionalism
Fatigue
Human Growth and Development
Law & Public Policy
Medical-Legal Issues
Multidisciplinary Care
Patient Compliance
Patient Safety
Physician/Patient Relationships
Principles of Managed Care
Psychiatric Disorders
Psychopharmacology
Research Design & Statistics
Self-directed Learning
Sports Medicine
Quality Assessment
Research/Scholarly Activity
Socio-Economic Issues
Stress
Substance Abuse Teaching Skills

Medical Education will be notified of any corrective action plans for residents in its GME programs. The attached corrective action plan form (CAP), must be completed and forwarded to the Director of Medical Education (DME) within 72 hours of the time/date it is implemented by the program director. The program director will also forward a copy of the detailed written remediation plan given to the resident with the form. If there are any changes in the action taken with the resident, the DME must be notified within 24 hours. After the CAP is completed there must be a review decision indicated by checking one of the four boxes at the bottom of form and re-submitting to the DME’s office within one week of completion so the action plan can be monitored.
Only probation, suspension and terminations, contract non-renewals will be reported and limited to 5 years after graduation for external references.

Name:
Residency:

Diagnostic Radiology

Family Practice

Internal Medicine

Geriatric Fellow
PGY

1

2

3
Date:

Obstetrics/Gynecology

Podiatric Surgery

Transitional Year

4

5



Academic
Knowledge deficit
Skills deficit
Attitude problem
Disciplinary

Violation of departmental

Unsatisfactory clinical
performance

Unsatisfactory progress
toward educational objectives

Non-participation in
mandatory conferences and/or
seminars

Failure to meet research/
scholarly activity time line

Other

Illegal conduct

Contract violation

Other
Type of Action

Significant Oral warning/Reprimand

Written warning

Non-progression to next PGY level

Probation

Suspension

Non-renewal of contract

Termination
Date/Duration
Impairment

Chemical dependence policies


Violation of GMEC policies
Loss of limited or permanent
license

Failure to meet licensure

Mental impairment

Psychological impairment

Medical impairment standards

Failure to meet expectations of Other
personal and/or professional
growth

Acting in an unethical manner

Review Decision

Complete/Successful

Action Review/Continued
* Must attach detailed, written remediation plan.


Action Reviewed/Discontinued
New Corrective Action plan formulated
Program Director Director, Medical Education

Medical Education
Committee Policy
Draft:
Approved: 6/15/06
Revised:
Personal issues that sometimes emerge during residency include stress due to work problems, conflict between personal demands, family life, and professional workload, and psychological/psychiatric problems. In these and other situations,
Medical Education recognizes the benefit of mental treatment and counseling in supporting residents’ personal and professional growth. Medical Education has identified a number of internal resources and will assist residents desiring confidential treatment outside of the Oakwood Healthcare System (see attached).

In-Network Resources for Residents
Oakwood Employee Assistance Program (EAP )
Oakwood’s EAP provides brief, confidential assessment and treatment services for employees/residents experiencing work or family related stress or substance use concerns at no charge. For individuals requiring longer-term treatment, EAP staff will help facilitate referral to a qualified community provider.
Medical Education may initiate a Supervisor Formal Referral for evaluation and treatment of possible emotional, substance-related, and learning problems. EAP staff may also serve as a liaison between
Medical Education and community providers. Oakwood EAP is located in Suite 235, Village Plaza. Linda
Cunin, ACSW, CEAP, is the Program Director (313-791-4855; 800-327-1127). Additional information is available on Oaknet.
APEX Behavioral Health
APEX is OSHCare’s contracted mental health and substance use provider. APEX has approximately 20 psychiatrists and 70 psychologists, social workers, couples and family therapists on staff at seven locations.
Residents must contact Value Options for approval of mental health/substance use services (877-813-
5362). Jill Blackson, ACSW, is the Project Manager for APEX. She is available to help residents select a therapist or psychiatrist for confidential treatment (734-405-0175, ext 111). To schedule an appointment at the Westland office, call 734-729-3133. The Dearborn office number is 313-271-8170. Web-address is: www.APEXBehavioralHealth.com
. HAP subscribers should call 800-422-4641 or check the website: www.hap.org
.
Medical Education Ombudsperson
Residents with a sensitive concern or grievance may contact the Medical Education Ombudsperson for confidential guidance and support. Residents may also elect to communicate their concerns anonymously.
Ms. Marilyn Kostrzewski (313-593-7692) and Dr. Lyle Victor (313-593-8620; P: 1270) serve in the role.
Medical Education Counseling & Support Team (C&ST)
The Medical Education C&ST serves as an advisor to the Director of Medical Education, residency program directors and faculty, and to residents on issues of work and family stress, mental health and substance use concerns, spiritual and ethical issues, and residency performance problems. Residents may elect to contact members of the C&ST for confidential guidance, short-term counseling, and referral. The
C&ST will not enter into open-ended treatment relationships with residents. Contact persons are as follows:
Larry Fischetti, PhD
Father Richard Leliaert, PhD
Audrey Newell, MD
Linda Cunin, ACSW, CEAP
(734-727-1067; P: 1241)
(734-937-1500 x112)
(P: 2617)
(313-791-4855; 800-327-1127)
Ms. Marilyn Kostrzewski (313-593-7692)
Spiritual Support Services

Reverend Tony Marshall is the Manager of Spiritual Support Services for Oakwood. A number of full-time chaplains and many active volunteers representing a variety of religious traditions provide spiritual support and counseling in Oakwood’s various venues. Reverend Marshall can direct your to a chaplain or lay minister to address your concerns in a manner consistent with your spiritual beliefs and/or religious affiliation (313-593-7202).
Oakwood Staff Development
Oakwood Healthcare System offers a variety of online and scheduled group courses to help employees and residents develop their effectiveness as members of healthcare teams and organizations. These courses can help residents meet expectations in a number of the ACGME General Competencies including Systems-
Based Practice. To review offerings, go to the Oaknet website and click on Training. For online courses, click on the link to HealthStream; for scheduled group courses, click on Oakwood Leadership
Development.
O
UT
-
OF
-N
ETWORK
R
ESOURCES FOR
R
ESIDENTS
For some residents, the added assurance of confidentiality may outweigh the costs of seeking out-ofnetwork assessment, mental health treatment, or substance abuse services. Should Medical Education require an evaluation by an out-of-network provider, Dr. Hannis has arranged for Medical Education to help offset the costs of services. In these situations, Medical Education may request consent for some communication with out-of-network providers; these plans should be made explicit and an agreement reached before entering into treatment. Residents who choose to seek out-of-network assistance on their own accord will be liable for the cost of treatment unless prior agreement for Medical Education support is obtained through their program director or the Director of Medical Education.
Private Mental Health Assessment and Consultation
Roger Lauer, PhD, is a psychologist. His clinic provides neuropsychological assessments, cognitive and learning assessments, and coaching for residents experiencing attentional, learning, and other performance problems. Contact information is as follows:
1955 Pauline Boulevard, Suite 100A
Ann Arbor, Michigan 48103
734-994-9466 www.rogerlauer.com

Joel Young, MD, is a psychiatrist with a special interest in the assessment and treatment of adult attentional and learning problems. His clinic provides psychopharmacologic treatment and cognitive training. Debra
Luria, PhD, RN, a psychologist working with Dr. Young, provides intellectual and neuropsychological assessment services and related counseling. Contact information is as follows:
441 S. Livernois, Suite 205
Rochester Hills, Michigan 48307
248-608-8800 www.rcbm.net
Darren Fuerst, PhD, is a neuropsychologist in the DMC’s Adult Neuropsychology Program. Dr. Fuerst has offices in the University Health Center and the DMC Health Care Center in Novi. Dr. Fuerst provides assessment of cognitive learning, and psychiatric conditions. As needed, he will facilitate referrals for treatment to other mental health providers.
Adult Neuropsychology Program
University Health Center 4-J
4201 St. Antoine
Detroit, Michigan 48201
313-745-8958/313-745-1784
Learning Styles, Test-Taking, and Coaching
As was noted previously, the staff of Oakwood’s EAP facilitates referrals to community providers for assessment of learning difficulties. Tim Dey, MD, is an alternative, independent source of learning assessment and consultation services for residents experiencing academic difficulties. He also provides tutoring to help residents prepare for standardized exams and coaching on issues of professionalism and life goals. Dr. Dey will arrange to meet with residents at his office or other convenient location. (Office: 313-
383-0582)
Conversation and Pronunciation
Residents for whom English is a second language may benefit from extra coaching in correct pronunciation. “Conversation and Pronunciation” is taught by Mary Assel, PhD, Co-Director, English
Language Institute, Henry Ford Community College. Beyond pronunciation, Dr. Assel’s course provides instruction in common English speech idioms. Dr. Assel can be reached at 313-317-1559. Her email address is: massel@hfcc.edu
.
Ms. Judy Raven of the Accent Reduction Institute is a speech and language therapist. Ms. Raven has extensive experience tutoring physicians to improve their English pronunciation and grammar in support of doctor-patient communication. Ms. Raven can meet residents in their work settings. Her organization has also developed procedures for distance learning. Ms. Raven can be contacted at 734-665-2915. The webaddress is: www.lessaccent.com
.

The Dearborn Speech and Sensory Center provides accent reduction services. Lori Shaffer, MA, CCC-
SLP, is a speech and language pathologist and director of the center. Clients are seen individually and in small groups. For information, call 313-359-4659 or visit the center’s website: www.dearbornspeechandsensory.com
.
Substance Use Assessment and Treatment 1
Michigan’s Health Professional Recovery Program (HPRP; 800-453-3784; www.hprp.org) provides confidential assessment and treatment services. For professionals found to be impaired by substance use, confidentiality is maintained while the individual faithfully pursues treatment to discharge. By law, impaired professionals who fail to comply with treatment will be reported to the Michigan Department of
Consumer and Industry Services (HPRP: 800-453-3784). Western Michigan Addiction Consultants
(WEMAC) also provides confidential assessment and treatment services tailored to the medical profession.
The same provisions apply regarding confidentiality and reporting of individuals who are impaired and fail to comply with treatment. Thomas Haynes, MD, is Medical Director of WEMAC (WEMAC: 616-365-
8800).
Note that under the Michigan Public Health Code, licensed health professionals are required to file a report with the Department of Community Health—Bureau of Health Professions if there is reason to believe another licensed health professional has a mental health- or substance use-related impairment that limits his or her ability to practice in a manner consistent with the minimal standards of acceptable and prevailing practice. A referral or self-referral to HPRP satisfies the reporting requirement. If, as a result of an assessment, a health professional is found to suffer impairment, a treatment plan will be proposed. The results of the assessment and all treatment records will be expunged five years after the successful completion of treatment. A report is forwarded to the Department of Community Health—Bureau of
Health Professions only if the referred health professional refuses to comply with an assessment or treatment plan or is deemed to be a threat to public health, safety, or welfare.
1
Note that under the Michigan Public Health Code, licensed health professionals are required to file a report with the Department of Community Health—Bureau of Health Professions if there is reason to believe another licensed health professional has a mental health- or substance use-related impairment that limits his or her ability to practice in a manner consistent with the minimal standards of acceptable and prevailing practice. A referral or self-referral to HPRP satisfies the reporting requirement. If, as a result of an assessment, a health professional is found to suffer impairment, a treatment plan will be proposed. The results of the assessment and all treatment records will be expunged five years after the successful completion of treatment. A report is forwarded to the Department of Community Health—Bureau of
Health Professions only if the referred health professional refuses to comply with an assessment or treatment plan or is deemed to be a threat to public health, safety, or welfare.

Graduate Medical Education
Disaster Response Policy
In the event of a disaster impacting the graduate medical education programs sponsored by
Oakwood Hospitals, the GMEC’s establish this policy to protect the well being, safety and educational experience of residents enrolled in our training programs.
The definition of a disaster will be determined by the ACGME or AOA as defined in their published policies and procedures. Following declaration of a disaster, the hospital’s GMEC, working with the DIO and other sponsoring institution leadership, will strive to restructure or reconstitute the educational experience as quickly as possible following the disaster. As quickly as possible, and in order to maximize the likelihood that residents will be able to complete program requirements within the standard time required for certification in that specialty, the DIO and GMEC will make the determination that transfer to another program is necessary. Once the
DIO and GMEC determine that the sponsoring institution can no longer provide an adequate educational experience for its residents, the sponsoring institution will to the best of its ability arrange for the temporary transfer of the residents to programs at other sponsoring institutions until such time as the sponsoring Oakwood hospital is able to resume providing the experience.
Program Directors will provide residents who transfer to other programs as a result of a disaster with an estimated time that relocation to another program will be necessary. Should that initial time estimate need to be extended, the resident will be notified by their Program Directors using written or electronic means identifying the estimated time of the extension. If the disaster prevents the sponsoring institution from re-establishing an adequate educational experience within a reasonable amount of time following the disaster, then permanent transfers will be arranged.
The DIO will be the primary institutional contact with the ACGME and the Institutional Review
Committee Executive Director regarding disaster plan implementation and needs within the sponsoring institution. In the event of a disaster affecting other sponsoring institutions of graduate medical education programs that Oakwood participates in, the site leadership at Oakwood
Hospitals will work collaboratively with the DIO who will coordinate on behalf of the Oakwood
Hospitals the ability to accept transfer residents from other institutions. This will include the process to request complement increases with the ACGME that may be required to accept additional residents for training. Programs currently under a proposed or actual adverse accreditation decision by the ACGME will not be eligible to participate in accepting transfer residents.
Programs will be responsible for following procedures to protect the academic and personnel files of all residents from loss or destruction by disaster. This will include at least a plan for storage of data in a separate geographic location away from the sponsoring institution.
In addition, during extreme local emergent situations (such as a hospital-declared disaster for an epidemic) that affects resident education or the work environment but does not rise to the level of an ACGME-declared disaster as defined in the ACGME Policies and Procedures and addressed above, certain principles will be followed:

1.
All Oakwood Corporate, Site and Department Emergency Management Policies and
Procedures will be followed per protocols.
2.
All ACGME and AOA Institutional, Common, and specialty-specific Program
Requirements apply in extreme emergent situations for clinical assignments within a training program and the institution.
3.
Residents are, first and foremost, physicians, whether they are acting under normal circumstances or in extreme emergent situations. Residents must be expected to perform as professionals and leaders in health care delivery, taking into account their degree of competence, their specialty training, and the context of the specific situation. Many residents at an advanced level of training may even be fully licensed, and, therefore they may be able to provide patient care independent of supervision.
4.
Residents are also learners. Residents should not be first-line responders without appropriate supervision given the clinical situation at hand and their level of training and competence. If a resident is working under a training certificate from a state licensing board, they must work under supervision. Resident performance in extreme emergent situations should not exceed expectations for their scope of competence as judged by program directors and other supervisors. Residents should not be expected to perform beyond the limits of self-confidence in their own abilities. In addition, a resident must not be expected to perform outside of the scope of their individual license.
5.
Decisions regarding a resident’s involvement in local extreme emergent situations must take into account the following aspects of his/her multiple roles as a student, a physician, and an institutional employee: a.
the nature of the health care and clinical work that a resident will be expected to deliver; b.
resident’s level of post-graduate education specifically regarding specialty preparedness; c.
resident safety, considering their level of post-graduate training, associated professional judgment capacity, and the nature of the disaster at hand; d.
board certification eligibility during or after a prolonged extreme emergent situation; e.
reasonable expectations for duration of engagement in the extreme emergent situation; and, f.
self-limitations according to the resident’s maturity to act under significant stress or even duress.
The program directors’ (PDs) first point of contact for answers to questions regarding a local extreme emergent situation is the GME Office/DIO.
The DIO will contact the Executive Director, Institutional Review Committee (ED-IRC) and/or the AOA via telephone only if an extreme emergent situation causes serious, extended disruption to resident assignments, educational infrastructure or clinical operations that might affect the Sponsoring Institution’s or any of its programs’ ability to conduct resident education in substantial compliance with ACGME Institutional, Common, and specialtyspecific Program Requirements. On behalf of the Sponsoring Institution, the DIO will provide information to the ED-IRC regarding the extreme emergent situation and the status of the educational environment for its accredited programs resulting from the emergency.

The DIO will notify the ED-IRC when the institutional extreme emergent situation has been resolved.
Revised 03/17/11

Disruptive Behavior http://oaknet/documents/PolsNProcs/HR/105.pdf

1.
2.
Preferred attire shall be shirt, tie, and slacks for males. Skirt or slacks for women.
Scrubs (tops and bottoms) may be worn only in labor & delivery, procedure and operating room, on-call and after hours on-call.
8.
9.
3.
4.
Clean white lab coats to be worn at all times.
Scrub clothes are not to be worn coming to and from the hospital at any time.
5.
6.
Hospital ID must be worn at all times on campus.
T-shirts and blue jeans are considered inappropriate at all times.
Public Health policy dictates the following:
7. Women to wear hose or socks. Men are to wear socks.
Footwear should be clean and appropriate. No opened toe shoes.
Foot covers are not to be worn out of appropriate clinical areas.

Dress Code http://oaknet/documents/PolsNProcs/HR/407.pdf

Corrective Action
If the Program Director believes corrective action is necessary to address any difficulties or deficient areas in the Resident's performance noted during the evaluation process or during the course of the Resident's performance of his/her obligations, the Program
Director may take any one or more of the following corrective actions designed to address the difficulty or deficiency:

Informal counseling and opportunities for residents to correct deficiencies should be documented by the program director prior to considering a major corrective action, unless a major work infraction or a violation of GMEC policy is the concern.

Place the Resident on probation, during which time the Resident will be expected to increase his/her effort to improve performance.

Require the Resident to seek counseling and/or psychological support services.

Require the Resident to seek the assistance of an impaired physician committee, or other similar committee or organization within or outside Oakwood, designed to address the needs of impaired professionals.

Require the Resident to spend additional time at the Resident's present level in the
Oakwood Residency Program.

Require the Resident to take a leave of absence with or without pay.

Restrict the Resident's activities outside the Oakwood Residency Program for which the Resident receives compensation.
The Program Director shall notify the Resident in writing of any corrective action taken and shall specify in the notice the period of time during which the corrective action shall remain in effect and how and when such action will be reviewed and/or lifted.
Programs should have the Evaluation Committee review and approve resident corrective action plans. The Evaluation Committee should also review resident disagreements. The reconsideration procedure is only for written corrective action plans, suspensions, probations or terminations.

Summary Suspension
Right to Suspend - Other provisions, the Oakwood Board of Directors, the Resident's
Program Director, or the Director of Medical Education may summarily suspend the
Resident from the Oakwood Residency Program, if in the opinion of the person or entity initiating the summary suspension, such suspension is or may be necessary in order to avoid an adverse effect on patient care. The person or body initiating a summary suspension shall provide the Resident with immediate written notice of the summary suspension, and, if initiated by the Board of Directors, shall also provide the Program
Director and the Director of Medical Education with notice of the suspension.
Effect of Suspension - Immediately upon receipt of a notice of summary suspension, the
Resident shall be relieved of all patient care obligations. The Resident Agreement shall terminate immediately if the Resident fails to request reconsideration of the summary suspension or the summary suspension is upheld after reconsideration.
Termination
Termination by Oakwood - Oakwood may terminate the Resident’s Agreement if
Oakwood determines in its sole discretion that the Resident has failed or is unable to perform his/her duties under this Agreement in accordance with applicable standards of medical practice, has failed to comply with Oakwood policies, procedures, rules or regulations, or has breached this Agreement. Oakwood shall not be required to take any corrective action prior to terminating the Agreement. Through the Director of Medical
Education, Oakwood shall provide the Resident with written notice of the termination, which notice shall specify the date of termination and the reasons for the termination.
Termination of this Agreement shall constitute dismissal from the Oakwood Residency
Program.

Reconsideration
Right to Reconsideration - The Resident may request reconsideration of a summary suspension, termination of their Agreement, or any corrective action taken by Oakwood.
Requests for reconsideration must be made in writing to the Director of Medical
Education within 10 calendar days of the date of notification to the resident of the action.
The request for reconsideration must specify the action which is to be reconsidered. A proper request for reconsideration shall stay any action being reconsidered, except summary suspension. If the Resident fails to request reconsideration of an action, the action shall become immediately final.
Reconsideration Committee - Upon receipt of a proper and timely request for reconsideration, the Director of Medical Education shall appoint a committee to undertake the reconsideration. The Director of Medical Education will act as chairman of the Reconsideration Committee unless the Resident requests that the Director of Medical
Education disqualify himself from appointing and serving as chairman of the
Reconsideration Committee. The request for disqualification must be made in writing at the time the request for reconsideration is made. If the Director of Medical Education disqualifies himself, the Chief of Staff will appoint the Reconsideration Committee and act as its chairman. In addition to the chairman, the Reconsideration Committee will consist of two individuals selected from the Medical Education Committee, two individuals selected from the Medical Staff, two residents, and one individual selected from Oakwood Administration. A majority of the physicians serving on the
Reconsideration Committee shall be from departments other than the department in which the Resident is in training. The individual serving as chairman of the
Reconsideration Committee shall be responsible for appointing members to the committee in accordance with this Section.
Notice of Meeting - The chairman of the Reconsideration Committee shall set a date for the committee to meet that is within fourteen (14) calendar days of the date upon which the Resident submitted the written request for reconsideration. At least seven (7) calendar days prior to the scheduled Reconsideration Committee meeting, the chairman shall provide the Resident and all members of the Reconsideration Committee with written notice of the date, time, and place of the meeting, delivered personally or by certified mail, return receipt requested.

Conduct of the Meeting - The Resident may appear at the Reconsideration Committee meeting, and may ask one medical staff or faculty member to appear at the meeting with him/her to provide counsel and/or to speak on the Resident's behalf. Legal counsel shall not be permitted to attend the meeting with or on behalf of any party or the
Reconsideration Committee. The chairman shall conduct the meeting, and shall request the Resident to present any information the Resident feels is relevant to the committee's reconsideration of the matter. The Reconsideration Committee meeting shall in no manner constitute a hearing. After the Resident has presented his/her information, the chairman shall excuse the Resident and the Resident's medical staff representative, and the committee shall deliberate the matter in private.
Committee Decision - The Reconsideration Committee shall make a decision either to uphold or to overturn the action being reconsidered. The decision of the Reconsideration
Committee need not be unanimous; the majority decision of the committee rules. Within seven (7) days of the committee's meeting, the Reconsideration Committee chairman shall provide the Resident and the Director of Medical Education with the written decision of the committee, which shall include the Committee's rationale for its decision.
Delivery of notice of the decision to the Resident shall be by personal delivery or by certified mail, return receipt requested. The decision of the Reconsideration Committee shall be final. The Resident shall be entitled to only one reconsideration of any summary suspension action, termination action, or any corrective action.

Revised 06/2011
Duty Hours and Work Environment
The Oakwood Hospital GMEC will ensure that our GME programs provide appropriate supervision for all residents, as well as a duty hour schedule and work environment that is consistent with proper patient care, the educational needs of residents and the applicable program and institutional requirements.
Duty Hours:
The Oakwood Hospital GMEC will ensure that each residency program establishes formal policies governing resident duty hours that foster resident education and facilitate the care of patients. The institutional policy on Resident Duty Hours Documentation is attached.
The educational goals of the program and learning objectives of residents will not be compromised by excessive reliance on residents to fulfill institutional service obligations.
However, duty hours will reflect the fact that responsibilities for continuing patient care are not automatically discharged at specific times. Programs will ensure that residents are provided appropriate backup support when patient care responsibilities are especially difficult or prolonged.
Resident duty hours and on-call time periods must not be excessive. The structuring of duty hours and on-call schedules must focus on the needs of the patient, continuity of care, and the educational needs of the resident. Duty hours must comply with the institutional and program requirements that apply to each program.
Work Environment:
Medical Education will provide services and develop systems to minimize the work of residents that is extraneous to their educational programs, ensuring that the following conditions are met:
1. Residents on duty in the hospital will be provided adequate and appropriate food services and private, secure sleeping quarters.
2. Patient support services, such as intravenous services, phlebotomy services, and laboratory services, as well as messenger and transporter services, will be provided in a manner appropriate to and consistent with educational objectives and patient care.
3. An effective laboratory, medical records and radiological information retrieval system will be in place to provide for appropriate to and consistent with educational objectives and patient care.
4. Appropriate security and personal safety measures will be provided to residents in all locations including but not limited to parking facilities, on-call quarters, hospital and institutional grounds and related clinical facilities, (i.e., medical office building).

Revised 06/2011
Compliance Reporting
If residents have any questions or concerns regarding excessive duty hours, their work environment, observed ethical conduct, or compliance with the law, they should contact the External Compliance Hotline at 800-805-2283. The use of this resource is strongly encouraged . Reports can be made anonymously. Attached you will find a complete description of the compliance hotline, which is also available on OakNet and
Oakwood.org. The GMEC will be notified of all calls to 800-805-2283 regarding resident education or GME program issues. The GMEC is required to review each call and recommend action plans to be followed in response to the reports.
Residents with concerns regarding their training or work environment can also utilize the on-line anonymous Med Ed Suggestion Box, which can be found on the Medical
Education page on OakNet. The GMEC is required to review each Suggestion Box entry.
Program directors and/or the Director of Medical Education may be required to present recommended action plans to be followed in response to these reports as well.

Revised 06/2011
2 confidential ways to report concerns regarding ethical business practices, integrity and compliance with laws and regulations


Independent External Hotline
800.805.2283
On the Web www.integrity-helpline.com/oakwood
Business Practices & Compliance Office







Code of Ethics
Organizational Code of Conduct
Investigations & Searches
Compliance Advice & Hotline
Corporate / Administrative Policy & Procedure
Manual
Audit Services
Frequently Asked Questions
Oakwood has a long standing commitment in support of professional and organizational excellence. A cornerstone necessary to maintain professional and organizational excellence is business integrity.
To help each of us practice with integrity and meet the requirements placed upon us, the
Board of Trustees and management have formally established a Corporate Compliance
Program and Business Practices Office. It demonstrates the value Oakwood places on conducting business guided by ethical business practice, integrity, and compliance with law and regulation. The Corporate Compliance Program and its Code of Conduct calls for each of us to act responsibly in our role at Oakwood and to behave consistent with its requirements.
In addition to reading the Code of Conduct at your compliance training session, we ask that you review the Code from time to time and use it as a tool in your daily work life.
By doing this, we believe we can help improve operations and service to our community.
Should you have any questions regarding the Corporate Compliance Program, its Code of Conduct or what is expected of you, feel free to contact your supervisor, any member of management, or the Business Practices Office. To further help you meet what is required by the Code of Conduct, we have also implemented a toll-free Independent
External Hotline, 800.805.2283. We encourage you to utilize any of these resources in the interest of good patient services and achieving excellence.
Revised 06/2011

Resident Duty Hours and Work Environment
I. Purpose/Objective: To provide guidelines and information with regard to tracking resident duty hours.
II. General Information:
A.
ACGME program duty hours requirements:
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.
2.
Duty hours must be limited to 80 hours per week, averaged over a fourweek period, inclusive of all in-house call activities, including all moonlighting hours.
3.
Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call.
One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
4.
Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call, and must include an 8 hour period free of program responsibilities between duty hours’periods.
5.
Duty periods of PGY-1 residents must not exceed 16 hours in duration.
6.
Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested. It is essential for patient safety and resident education that effective transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours. Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty. They must have at least 14 hours free of duty after 24 hours of in-house duty. Documentation must be maintained by the program for any instances where residents, on their own initiative, have stayed beyond the 24 plus 4 hours requirements to provide care to a single patient because of unusual circumstances.
7.
Residents must not be scheduled for more than six consecutive nights of night float.
Revised 06/2011

8.
Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly hour limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one-day-in-seven free of duty, when averaged over four weeks. At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.
B.
All residents will log all duty hours using the New Innovations on-line application.
Residents will enter data on their duty hours at least twice monthly.
C.
The Director of Curriculum and Evaluation will supervise data entry and reporting of this information and provide access to a weekly report for each residency program director of duty hours compliance identifying instances where duty hours requirements are violated. Program directors will take immediate action to respond to any reported violations and provide a monthly summary of duty hours violations and actions taken to the DIO.
D.
Duty hours reports will be reviewed regularly by the GMEC:
1.
Program will be classified “Green” if no duty hours violations have been reported on the ACGME or internal resident surveys or through the New
Innovation time logs in the past year.
2.
A program will be classified “Yellow” if there are either a single duty hours violation reported by greater than 5% of its residents or by more than two residents in a month of time log reporting or any single call is received regarding a program violating duty hours requirements on OAK
LINE or OakNet. An action plan is required and monitored by the GMEC for Yellow residency programs.
3.
A program will be designated “Red” if any duty hours violations are reported by more than 10% of their residents on the ACGME or internal resident surveys, two or more duty hours violations are reported by greater than 5% of its residents, by more than two residents in any two months of time log reporting, by more than four residents in a month of time log reporting, or any two calls are received regarding a program violating duty hours requirements on OAK LINE or OakNet. Red programs will be required to present corrective action plans to the GMEC and the Medical
Executive Committee for monitoring.

Oakwood believes strongly that the selection of high quality residents for its graduate training programs is critical to our mission of providing the highest quality education programs. To this end, in compliance with Accreditation Council for Graduate Medical
2.
3.
Education (ACGME) institutional requirements, applicants must meet one of the following qualifications to be considered eligible for matriculation into our residency programs:
1. graduate of a Liaison Committee on Medical Education (LCME), accredited medical school in the U.S. or Canada, or graduate of an osteopathic school accredited by the AOA, or graduate of medical school outside the U.S. with a valid certificate from the
ECFMG, or
4. graduate of medical school outside the U.S. with a full and unrestricted license to practice medicine in a U.S. licensing jurisdiction
In addition, residents transferring to an Oakwood residency training program must submit a written letter of reference from their current program director which must include a statement of their current status in the program. The Oakwood Program Director must also speak directly with their current program director about this reference.
Oakwood participates in the National Residency Matching Program (NRMP) to select candidates for its residency programs. All applicants for Oakwood residency positions are received through the Electronic Residency Application System (ERAS). Candidates are invited for personal interviews based on their eligibility above and consideration of the selection criteria below. Candidates for our residency programs will be ranked and selected according to a composite evaluation of the following and other criteria. Note the minimum criteria for each program varies. (See program specific criteria)
Internal Medicine
Transitional Year
Obstetrics & Gynecology
Diagnostic Radiology
Family Medicine
Geriatric Fellowship
Sports Medicine Fellowship
Cardiology Fellowship

1.
2.
Passing score on U.S. Medical Licensing Exam (USMLE)
Interview ratings of personal attributes – personality, communication skills, motivation, integrity
3.
4.
Citizenship status- must be a U.S. citizen or permanent resident
Special attributes - medical school honors, research experience, community service
At the conclusion of the recruitment process, a rank order list of candidates is compiled by the residency program director with input from their program’s selection committee.
The rank list is then submitted to the NRMP. Each program established criteria for selection described in their program policies. If positions are not filled with the matching process through NRMP, candidates are interviewed and selected to fill open positions using the same criteria as those used for the matching process.
Oakwood does not discriminate when considering candidates with regard to gender, race, age religion, national origin, disability, veteran status, marital status, weight, or height.

1.
ERAS applications only- Application deadline December 1 st
2.
Full NRMP (Match) participation: a) No pre-match or outside of Match contracts offered b) All ranking information is confidential and will not be shared with candidates
3.
We do not discriminate when considering candidates with regards to age, gender, race, religion, national origin, disability, veteran status, marital status, sexual orientation, height or weight.
4.
ONLY the following applicants are considered eligible for interview: a) Graduates from an LCME accredited medical school in the US or
Canada with minimum passing USMLE score of 176 (75) or greater on Step 1 & Step 2 b) Graduates from a foreign medical school with a valid ECFMG certificate (by matriculation date) with minimum passing USMLE score of 210 or greater on Step 1 & Step 2
5.
Graduation from medical school within the past 5 years
6.
Interview ratings of personal attributes – personality, communication skills, motivation, integrity
7.
Special attributes- medical school honors, community service
8.
One year of U.S. clinical or research experience

1.
ERAS applications only- Application deadline December 1 st
2.
Minimum passing USMLE score of 210 or greater on Step 1 & Step 2 upon first attempt
3.
Graduation from medical school within the past 3 years
4.
Must be a U.S. citizen or permanent resident- Visas are NOT sponsored
5.
Interview ratings of personal attributes – personality, communication skills, motivation, integrity
6.
Special attributes- medical school honors, community service
7.
One year of U.S. clinical or research experience

1.
ERAS applications only- Application deadline December 1 st
2.
Must have a passing score with no more than 1 failure per step
3.
Graduation from medical school within the past 5 years
4.
Must be a U.S. citizen or permanent resident- Visas are NOT sponsored
5.
Interview ratings of personal attributes – personality, communication skills, motivation, integrity
6.
Special attributes- medical school honors, community service
7.
One year of U.S. clinical or research experience

1.
ERAS applications only- Application deadline November 15 th
2.
Minimum passing USMLE score of 200 or greater on Step 1 & Step 2 upon first attempt
3.
Graduation from medical school within the past 3 years
4.
Must be a U.S. citizen or permanent resident- Visas are NOT sponsored
5.
Interview ratings of personal attributes – personality, communication skills, motivation, integrity
6.
Special attributes- medical school honors, community service
7.
One year of U.S. clinical or research experience
8.
Only offered as a 5 year program that includes the clinical year requirement

1.
ERAS applications only- Application deadline December 31 st
2.
Minimum passing USMLE score of 190 or greater on Step 1 & Step 2 upon first attempt unless a student or graduate of one of Oakwood’s official affiliated medical schools
3.
Graduation from medical school within the past 2 years
4.
Must be a U.S. citizen or permanent resident- Visas are NOT sponsored
5.
Interview ratings of personal attributes – personality, communication skills, motivation, integrity
6.
Special attributes- medical school honors, community service
7.
One year of U.S. clinical or research experience

1.
ERAS application or direct application submission to the program are accepted
2.
Applications accepted at any time if all minimum requirements are met
3.
Must be a U.S. citizen, permanent resident or on a J1 Visa
4.
Must be ECFMG certified for foreign medical graduates
5.
If you are a 2 nd year resident, you must have taken USMLE Step 3
6.
If you are a 3 rd year resident, you must have passed USMLE Step 3
7.
Graduation from either an Internal Medicine or Family Medicine residency program
8.
Interview ratings of personal attributes – personality, communication skills, motivation, integrity

1.
ERAS application or direct application submission to the program are accepted
2.
Applications accepted at any time if all minimum requirements are met
3.
Must be a U.S. citizen or permanent resident- Visas are NOT sponsored
4.
Must be ECFMG certified for foreign medical graduates
5.
Graduation from either a Family Medicine, Internal Medicine, Emergency
Medicine or Pediatrics residency program
6.
Must have successfully completed a residency in the aforementioned specialties to be eligible
7.
Interview ratings of personal attributes – personality, communication skills, motivation, integrity

Cardiovascular Disease Fellowship
Minimum Selection Criteria
1.
We do not discriminate when considering candidates with regard to age, gender, race, religion, national origin, disability, veteran status, marital status, sexual orientation height or weight.
2.
Completed residency or advanced cardiovascular training within the last 5 years.
3.
Graduated from a 3 year internal medicine residency.
4.
Must be a U.S. citizen or a permanent resident. Visas are NOT sponsored.
5.
Assessment of personal attributes – personality, communication skills, motivation, and integrity .
6.
Applications for 2013 positions will be taken through ERAS July 2012.

1.
Residents must be evaluated in writing and their performance reviewed with them verbally upon completion of each rotation. During their rotation residents should receive feedback regarding their progress and performance.
Programs should assess resident competencies in all 6 domains with at least one approach in addition to global/end-of-rotation clinical ratings. Recommended methods are direct observation and concurrent evaluation (and other focused assessment methods), 360-degree evaluation involving non-MD members of the care team, patients and their families, checklist evaluation of quality improvement projects, and cognitive tests. Standards that describe different levels of performance and interventions to assist evaluators in the use of standards are expected.
2.
Residents must receive a written summary of the residency program’s evaluation of their clinical competence at least twice a year. This written summary must include a summary of performance compared to PGY level expectations for each of the six general competency areas (patient care, medical knowledge, practicebased learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice).
The residency program on or before November 15th and June 15th will generate written summative evaluations of each resident for each training year. Written performance improvement plans, expected remediation, or formal corrective action plans will be documented. Residents will be notified in writing if they are not eligible for a new contract in the next academic year on or before March 1 unless the resident is in or starts a remediation program after that date. Also, the resident will be notified if their contract is subject to successful completion of a corrective action plan or other remediation.
3.
Residents must maintain ACLS certification to be promoted to the next postgraduate year. Individual programs may require additional training.
4.
Residents must maintain a log of invasive procedures supervised by attending staff. The residency program must review logbooks at the time of the semiannual evaluation.

5.
A permanent record of all semiannual evaluation summaries and procedures logged will be maintained for each resident. The residency program must maintain a summary of counseling provided for residents, as well as any corrective action plans or remediation recommended and their outcomes. Such
records must be available in the resident’s file and accessible to the resident and other authorized personnel (see Resident File Access, Retention, and Verification
Policy).
6.
The program director must prepare a written overall evaluation of the resident’s clinical competence at the conclusion of the resident’s training in that Oakwood residency program (either termination or successful completion) which will be maintained in the resident file.
This summative evaluation must include:

A summary of performance in each of the six general competency areas compared to expectations for that PGY level,

A listing of all procedures logged and a summary of competence with each procedure,

A summary of the residents performance regarding other program expectations such as scholarly activity and quality improvement/patient safety projects, and

Eligibility for board certification or transfer to another program.
7.
In the event of an adverse annual evaluation, the resident must be offered an opportunity to address the stated deficiencies or misconduct with a clinical competence committee constituted by the residency program. Academic due process must be followed as described in sections four (4) through seven (7) of the resident contract.
8.
Upon successful completion of training every resident will receive a certificate verifying success completion signed by the CEO, Chairman, Board of Trustees,
Chief of Staff, Director of Medical Education, Chief of Service, and Program
Director of the residency. A copy of this certificate will be marked “copy” and placed in the resident’s permanent file.

9.
In addition, residents must have taken USMLE Part III by June 30 of their first training year at Oakwood. Residents are required to turn in written confirmation of the results of Part III to their program director. If the resident does not take
USMLE Part III by June 30 of their first year, they will be suspended. Residents on suspension must take USMLE Part III by November 1 of their PGY II year or they will be terminated. Residents who fail USMLE Part III on their first taking will enter a Corrective Action Plan and must pass Part III by March 1 of their
PGY II year or they will be notified of no contract renewal for the PGY III.
Exceptions to this policy can only be granted by the GMEC.
Oakwood Hospital’s Me dical Education realizes the above exceeds some specialty board requirements.
USMLE Part III is required for permanent licensure in most states and Oakwood believes this policy is in the resident’s best long -term interest. If the resident has difficulty passing USMLE Part III, remediation plans should be discussed with the program director.

Fitness for Duty

Introduction
When the Balanced Budget Act (BBA), became law in 1997, it vastly changed the regulations governing the federal Medicare program’s reimbursement of medical education expenses incurred by teaching hospital resident training programs. The BBA regulations have simultaneously reduced those payments and increased the level of documentation required to receive them. Changes in policy, procedures, and monitoring of compliance with these regulations will ensure Oakwood receives the financial support for its medical education programs it is due.
Primary Policy
All rotations by residents in Oakwood training programs will be allowable for medical education reimbursement, as defined by HCFA regulations, unless specifically approved
(as a non-allowable rotation) by the Director Medical Education.
Procedures:
1) Rotation Approval
Oakwood residency programs must obtain approval from the Director Medical
Education for all rotations of residents from Oakwood to other non-Oakwood institutions or sites. Programs and/or medical staff must also obtain approval from the Director Medical Education for rotations of residents from other institutions to Oakwood clinical sites. A Rotation Request Form (RRF) must be completed and submitted to Medical Education administration by May 1 preceding the beginning of the academic year (July-June), in which the rotations will occur. Special cases can be considered for approval if the RRF is submitted
60 days in advance of the proposed rotation. RRF’s will be processed and action taken within 2 weeks of receipt by Medical Education administration.
2) Resident Information Form (RIF)

A RIF must be completed for every Oakwood resident. A RIF must also be completed for every resident rotating into or out of an Oakwood site or residency training program. This form provides the specific information on each resident
(name, social security number, etc.), and the rotation that they are participating in
(Oakwood site, non-Oakwood site, etc) for entry into the GME Track system. All
RIF’s will be completed and entered by the program coordinator into the GME track system by July 1 of the appropriate academic year.
RIF’s for schedule changes that occur after July 1 must be entered 60 days prior to the resident beginning the rotation. A copy of each RIF will be forwarded to Medical
Education administration and the original retained in the resident’s program file.
3) Resident In-rotation Orientation
Residents rotating into Oakwood sites and training programs from other institutions must check-in and receive orientation in Medical Education administration prior to beginning their rotation. Resident information will be verified in the GME Track system, general information will be provided, as well as issuing beepers and ID’s.
4) Resident Information Files
Programs will maintain a reimbursement sub-file in each resident’s program file with a checklist that documents that the following information is present:

Copy of current license

Copy of ECFMG certificate (if applicable)

Resident Information Form

All rotation schedules applicable to that resident

Information on clinical activity occurring during research months

Summary of all elective rotations including name and address of site and supervising physician
A similar file will be maintained in Medical Education administration for residents rotating into Oakwood sites and training programs from other institutions.
Failure to comply with the above referenced policies may result in termination of the rotation by the Director Medical Education. Compliance with the above policy and procedures will be included in staff and program director annual evaluations.

MEDICAL EDUCATION
PROGRAM LETTER OF AGREEMENT &
ROTATION SCHEDULE APPROVAL FORM
MUST BE SUBMITTED FOR ALL ROTATIONS OF OAKWOOD RESIDENTS TO NON-
OAKWOOD FACILITIES AND BETWEEN OAKWOOD SITES NO LATER THAN 60 DAYS
PRIOR TO ANY ANTICIPATED ROTATION. FAILURE TO COMPLY MAY RESULT IN
DENIAL OF ROTATION.
A RESIDENT INFORMATION FORM FOR EACH ROTATING RESIDENT MUST
ACCOMPANY THIS REQUEST.
SECTION I: TO BE COMPLETED BY PROGRAM DIRECTOR
Name of Rotation: _______________________________________________________________
Requesting Residency Program: ____________________________________________________
Home Institution of Rotating Resident/Fellow: _________________________________________
Institution/Site where majority of rotation will occur: ____________________________________
Signed active agreements for rotation is available:

Yes (attached)

No
Number of Residents/Fellows Length of Rotation: for rotation:
PGY I ______
PGY II ______
PGY III ______
PGY IV ______
PGY V ______
(i.e. number of months/academic year)
PGY I Length ______
PGY II Length ______
PGY III Length ______
PGY IV Length ______
PGY V Length ______
Goals & Objectives of rotation: ______________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Official responsible for rotation on-site: ________________________________________________
Title: ________________________________________________
Address: ________________________________________________
________________________________________________
Phone: _(___)____-_______ Fax: _(___)____-_______
Supervising Teaching Physician(s) : ______________________________ Date : ____/____/____
Signature

Evaluations to be completed by supervising physicians:

Yes

No
Evaluations due no later than 30 days after rotation completed:
Policies & Procedures of host institution apply:
Due date:

Yes

No
____/____/____
Requesting Program Director: __________________________ Date : ____/____/___
Signature
Requesting Director of: _______________________________________ Date: ____/____/____
Medical Education Signature
SECTION II: TO BE COMPLETED BY DIRECTOR OF MEDICAL EDUCATION
Agreement on file:

Yes

No
Meets Requirements:

Yes

No
Cap Review Complete:

Yes

No
Approved:

Denied:

Director of Medical Education: ________________________________ Date: ____/____/____
Signature

MEDICAL EDUCATION
RESIDENT ROTATION INFORMATION FORM
LICENSES AND CERTIFICATIONS:
The following information must accompany this form: (NOTE: This information need only be submitted once per academic year for rotations occurring between Oakwood sites)

Michigan Educational Limited License OR Michigan Permanent Physicians License and DEA license

Michigan Controlled Substance License

Proof of current ACLS certification

Copy of ECFMG Certificate (if applicable)

Proof of current TB skin test

Proof of Liability Coverage
Rotation Requested: _________________________Preceptor : ______________________ ______
Resident Name: ____________________________Program: ___________________________
PGY Level: ___ I ___ II ___ III ___ IV ___ V
Pager Number: ___________________ Alternate Number: ____________________
Dates of rotation: ______________________ to __________________________
Month/Day/Year Month/Day/Year
Please estimate the percentage of time the resident will spend during the requested rotation at the following:
Oakwood Hospital and Medical Center
Oakwood Annapolis Hospital
______ %
______ %
Oakwood Southshore Hospital
Oakwood Heritage Hospital
______ %
______ %
Other Hospitals (please indicate): __________________________________ _____%
Location Name
__________________________________ _____%
Location Name

PROGRAM DIRECTOR ATTESTATION
I verify that:
(a )
(b )
(c )
(d )
(e )
The above named Resident/Fellow/Intern is a trainee in good standing in a program, which I direct, and that there have been no licensing, liability, disciplinary or other problems with this applicant.
The above named Resident/Fellow/Intern has received all hazardous material training and universal body fluid precautions training and exposure to blood borne pathogens training as required by the State of
Michigan and Federal Law.
The above named Resident/Fellow/Intern will complete all medical records, for which they are responsible, in a timely manner and in full compliance with all policies and/or requirements established by the hospital and/or Medical Staff and/or attending physician.
The above named Resident/Fellow/Intern is able to perform the duties and responsibilities determined by the preceptor of the defined rotation as listed in the goals/objectives section of the
Rotation Schedule Approval Form.
The above named Resident/Fellow/Intern’s activities at OHS sites and outside institutions will be adequately covered by Professional Liability Insurance under a policy issued to the home institution by the program.
Program Director: _______________________________________ Date: ___/___/___
Signature
Action by OHS Director of Medical Education: _____ Approved _____ Denied
If denied, reason for denial:
___________________________________________________________________
___________________________________________________________________
Director of Medical Education: ______________________________________ Date: ___/___/___
Signature

The purpose of this policy is to define the usual process at Oakwood for residents to communicate substantive issues and concerns to the programs and institution’s administration. It also defines the mechanisms for an official, impartial hearing of concerns that are not resolved through usual, initial communications with administration.
The intent is to provide the due process and an appeal mechanism in instances where this is needed.
1. Residents who have concerns or issues related to the interpretation, application, or breach of any policy, practice, or procedure in their educational program, or
Medical Education in general should: a) first discuss them with their program director, b) if reasonable discussion with the program director does not lead to resolution of the concern the resident(s) should bring the issue to the attention of the Medical Education office, c) if reasonable discussion with the Director of Medical Education does not resolve the issue, a formal grievance may be sent in written form to the
Medical Education Committee.
2. Resident(s) wishing to resolve a specific grievance will forward their complaint in writing (addressed to the Medical Education Committee), to the Director of
Medical Education. The resident(s) concerned, or their colleagues representing them - such as the chief resident(s), will then be scheduled to present a summary of the complaint to the Medical Education Committee at its next meeting. Legal representatives will not participate in or be present during Medical Education
Committee or subcommittee deliberations.
3. If residents desire confidentiality in forwarding the grievance to the Director of
Medical Education or in its presentation to the Medical Education Committee/ subcommittees, they should contact the Medical Education Committee Confidant whose name and number are posted in the Medical Education area and in the resident’s lounge.

4.
5.
6.
7.
8.
9.
Upon hearing the summary of the complaint, the Medical Education Committee will nominate a subcommittee to review that specific complaint. The subcommittee must be made up of Medical Education Committee members and include:
 two residents
 two faculty (one from the program from which the complaint emanated and one not)
 a medical staff physician that is not a Medical Education faculty
 a chairperson who cannot also simultaneously fill one of the above positions
 a non-voting administrative resource person
The chairperson will be nominated and elected by the Medical Education
Committee.
The Grievance Subcommittee will meet within two weeks to consider resolution for the complaint. Residents, program directors, and the Director of Medical
Education will submit documentation they feel is important to the subcommittee secretary prior to the first meeting. The subcommittee chairperson may request additional documentation, as they or the subcommittee feels necessary.
The subcommittee will, at the designated time and place, hear the resident(s) concerned present the details of their complaint and their proposed solutions in full. Other concerned parties may also present their views on the issues to the subcommittees at that time. Having heard the resident(s) and other parties concerned, they will then be excused from the meeting.
The subcommittee will then immediately deliberate behind closed doors, without interference or participation by anyone other than subcommittee members.
The subcommittee will have the fiduciary responsibility to make a final recommendation regarding resolution of the complaint. This will be expected at the time of the first meeting. In rare circumstances, at the chairperson’s discretion, the subcommittee may elect to obtain additional information and meet again in one week to finalize their recommendation(s) for resolution of the complaint.
The final recommendation(s) of the Grievance Subcommittee will be distributed by the chairperson to the Medical Education Committee, the resident(s) concerned, and the Director of Medical Education within 3 work days.

10.
The subcommittee’s final recommendation(s) for resolution of the complaint are not necessarily final and binding:

Those recommendations requiring financial remuneration are subject to review and approval by Oakwood Healthcare System. This review will be executed by OHS administration within two weeks of the subcommittee’s recommendations.
 Resident(s) concerned with the complaint may choose to appeal the subcommittee’s recommendation(s). The appeals process is outlined below.
 In all other cases, the subcommittee’s recommendations are final and binding, and the Medical Education Committee will effect the recommendations of the subcommittee or direct the Director of Medical
Education to do so.
11.
If the resident(s) appeal the subcommittee’s recommendations, they will submit in writing their appeal to the Medical Education Committee, including specific reasons why the feel an appeal is necessary despite the Grievance Subcommittee’s deliberations. The Medical Education Committee will consider this request for appeal and vote to: a) b) retain the subcommittee’s recommendations, or nominate a Grievance Appeals Committee.
If the Medical Education Committee votes to retain the subcommittee’s recommendations, they are final and binding.
12. In case of appeal, if the Medical Education Committee elects to nominate an
Appeals Subcommittee, the constituents will be from the same groups as outlined for the Grievance Subcommittee, but new persons will be nominated first from the Medical Education Committee. If an appropriate member is not available from the Medical Education Committee, nonmembers will be nominated. In addition to the constituents outlined for the Grievance Subcommittee, an administrator from OHS will be nominated to the Appeals Subcommittee, as will a program director or leader from an outside institution.
13. The Appeals subcommittee will follow the same process as outlined above for the
Grievance Subcommittee. The Grievance Appeals Subcommittee recommendations for resolution of the complaint are final and binding on all parties.

Guidelines for Healthcare Workers http://oaknet/documents/PolsNProcs/IC/201.pdf

Exposure Control Plan http://oaknet/documents/PolsNProcs/IC/205.pdf

PEP http://oaknet/documents/PolsNProcs/IC/602.pdf

HIV http://oaknet/documents/PolsNProcs/IC/603.pdf

Employee Health Services Exposure Procedures http://oaknet/documents/PolsNProcs/IC/601.pdf

Purpose:
To conduct regular reviews of all Oakwood Healthcare System (OHS) residency programs to assure their compliance with the ACGME institutional, common program requirements and specialty program requirements of the relevant ACGME RRC. The internal review committee will have completed interviews of the program director, faculty and residents by the mid-point between ACGME Surveys according to the date provided on the notification letter. The Internal
Review Report will be presented to the GMEC by the Designated Institutional Official (DIO) within 60 days of specified internal review date. The GMEC will then request proposed actions from the program director, then establish and monitor action plans resulting from the internal review.
Membership:
An internal review committee will be designated by the GMEC to conduct the review and approve the report for submission to the GMEC. The membership of these committees will be appointed by the GMEC. Membership will include at least one faculty and one resident from within the institution but from programs other than the one being reviewed, as well as one medical staff representative and one administrative representative. The Chairperson of these committees will be the DIO (the Director of Medical Education and chair of the GMEC).
Process:
The Committee will assess the residency program’s compliance with each of the following:
1.
Compliance with the Common, specialty/sub-specialty specific Program, and
Institutional Requirements, including: a.
Professionalism, Personal Responsibility and Patient Safety b.
Transitions of Care c.
Alertness Management/Fatigue Mitigation d.
Supervision of Residents e.
Clinical Responsibilities f.
Teamwork g.
Resident Duty Hours
2.
The educational objectives of the program and its effectiveness in meeting them.
3.
The adequacy of available educational and financial resources.
4.
The effectiveness of the program in addressing citations and concerns from
ACGME letters of accreditation and previous internal reviews.
5.
The effectiveness of program in defining and achieving educational outcomes of the ACGME general competencies.
6.
The effectiveness of the program in using evaluation tools to measure residents’ level of competence in each of the general competencies.
7.
Annual program improvements efforts focused on a) resident performance that use aggregated resident data, b) faculty development, c) graduate performance including performance on certifying examinations, and d) overall program quality including written confidential evaluation of the program by faculty and

residents, and documented faculty approval of a program action plan that addresses the elements above.
8.
Results from internal and external resident surveys, if available.
9.
The program’s compliance with ACGME duty hour’s requirements.

Sources of Data:
1.
Institutional, Common and specialty/subspecialty specific Program Requirements from the ACGME.
2.
Web ADS information on the program including ACGME resident survey information.
3.
The RRC PIF completed by program director.
4.
All program letters of agreement.
5.
Accreditation letters from previous ACGME reviews and progress reports sent to the respective RRC.
6.
Reports from previous internal reviews of the program.
7.
Previous program annual evaluations and resulting action plans.
8.
Resident internal and external survey results.
9.
Interviews with program director, key faculty, and residents at each year level in the program, including at least one peer-selected resident from each PGY level, and other individuals deemed appropriate by the committee.
10.
The checklist for the General Competencies that includes documentation of adequate evidence of a curriculum, complete with goals and objectives, that is used to teach the general competencies. The program director must also provide documented evidence that there are adequate evaluation tools to evaluate residents competences in the six areas based on the goals and objectives. Attached is an example of a checklist for the general competencies.
11.
Duty hours information will be reviewed from the latest ACGME Resident Survey, the latest Oakwood internal resident annual survey, and recent program duty hours’ logs.
12.
Conference schedules with documentation of resident and faculty attendance.
13.
Written program policies/resident manual.
The final report will be prepared by the Chair of the Internal Review Committee and discussed with the Committee members. This report will include all elements listed in the ACGME
Institutional Requirements, including:
1.
the name of the program reviewed
2.
the date of the assigned midpoint and the status of the GMEC’s oversight of the internal review at that midpoint,
3.
the names and titles of the internal review committee members,
4.
a brief description of how the internal review process was conducted,
5.
identify specifically the lists of the groups/individuals interviewed and which residents of those interviewed were peer selected,
6.
sufficient documentation to demonstrate that a comprehensive review followed the
GMEC’s internal review protocol,
7.
a list of citations and concerns from the previous ACGME accreditation letter of notification with a summary of how the program and/or institution subsequently address each item.
8.
A list of areas of major concern or concern regarding compliance with any of the
ACGME requirements.
Changes will be made based on members input and the final report approved by the internal review committee.

The final report will be presented to the GMEC for their review and approval. The GMEC will use this report to monitor deficiencies and appropriateness of the action plans. The approved report, or a summary thereof, will be forwarded to the Medical Executive Committee and the
Board of Trustees. The program director will prepare a response outlining plans to correct the deficiencies outlined in the report and present to the GMEC within 60 days.

EXAMPLE
An Internal Review Checklist for the General Competencies
To be completed as part of a program director’s information for the Graduate Medical
Education Committee Internal Review.
Example of review for an Internal Medicine program:
List the evaluation tools used by the program for the following General Competencies:
General
Competencies
List evaluation tools used or in development by the program
(completed by program director in Internal Medicine at sample hospital)
Other tools designed by program?
Patient Care
Medical
Knowledge
Interpersonal &
Communication
Skills
Developing
OSCE
Chart stimulated recall
Developing
360
°
Professionalism 360 °
Mini CEX
Oral exam
Patient surveys
Checklist
Patient surveys
Written exam multiple choice
Standardized patients
Procedure logs
Practice Based
Learning
Systems Based
Practice
Resident portfolios
Developing resident portfolios
Developing oral exam
Developing
360
°
Record review
The program director is to provide the internal review committee with:
1. Documented evidence of a curriculum with goals and objectives for the general
2.
3. competencies currently implemented.
Documented evidence of the evaluation tools used that he/she has listed.
The status of documenting measures and/or milestones that assess a resident’s
4. competence, improvement plans and progress in these areas.
The status of developing a process that links aggregated resident general competency educational outcomes with program improvement.

Policy
1.
2.
Library hours are:
Monday - Thursday 7:30 a.m. to 7:30 p.m.
Friday 7:30 a.m. to 5:00 p.m.
At times other than those listed above, admittance is granted by calling the
Security Department. Residents should restrict requests to Security only to those needs which cannot be met during regular library hours and are directly related to patient/educational needs of urgent nature. An incident report is created for each entry.
3. After hours visits to the library should be limited to the time needed to acquire the needed research.
4. Residents must individually request access from security. The library should not be opened to other staff without notification to the security office.
5. Permitted individuals to after hours access may not bring in other individuals who are not granted access to the library.
6.
7.
Food or beverage is not permitted in the library.
Only circulating material may be taken after hours. The residents are responsible to notify the security guard of materials that are to be checked out during after hours visits.
8. Access to staff offices, circulation area, and non-public areas are not permitted.
9. Window blinds MUST remain open at all times.
Procedure for After Hours Access
1. To gain admittance to the library after business hours, page the security guard, who will open the library door with a key.
2. Security will record the library users name, along with date and time of admittance. This information will be reported on a regular basis to the Director of
Library Services.
3. Any materials used during the after hours visit should be signed for by the resident and the security guard notified.

4. The shades must remain open at all times after hours for security surveillance.
Note: MDConsult and the library home page with access to multiple medical databases and web links is available 24 hours on all resident area computers and all inpatient care areas.

1. Circulation : All circulating books may be checked out for two weeks, and if needed, renewed for two weeks. After one month, a book must be returned and 48 hours must elapse before checking the book out again. This policy allows other patrons access to the material.
*****NB : No books can be kept out by one person for a full rotation or year. We
only have 1 or 2 copies of any book.
2. Overdue Materials: An overdue fine will be charged for all overdue materials.
3. Replacement Charge: The third monthly notice for an overdue item, will be for replacement cost and handling fees. It will be charged to the individual or his account. (Notices are sent out the monthly)
4. Controlled Reserve: Due to increased loss, susceptible materials will be kept behind the front desk. These books must be requested and signed out. Currently they include, Family Practice and Internal Medicine Board Review books and the green
GME book. Others will be added as necessary.
THEY MAY ONLY BE USED IN THE LIBRARY!!!!
5. After-hours borrowing:
Please leave a signed note on the library’s front desk for
any materials removed from the library, after hours. See the attached after-hours
policy.

General Guidelines:
1. Due to the specific characteristics of residency training and the impact of a resident's absence on patient care and the training of fellow residents, notification of the
Program Director of pregnancy should occur as soon as possible. This should ordinarily be at least 5 months prior to a resident's or spouse's estimated "due date."
2. Specific requirements of each specialty training program governs the amount of time permitted away from continuous residency training per year. Therefore, specific make-up time may be required before the resident advances to the next training level and the projected date of completion of the residency extended.
This can also affect eligibility for Board exams.
3. With adequate advance notice, efforts to rearrange rotations will be directed towards: a) early scheduling of demanding rotations, b) elective rotations near "due date." Adjustments in on-call responsibilities will be negotiated with the Program
Director. The goals will be to maintain patient care, provide a reasonable workload for a pregnant resident, and avoid unacceptable increases in other residents
1. workloads. Specific arrangements may include "make-up call" before or after the leave period.
4. Moonlighting will not be approved by the Program Director during maternity/ paternity/adoption leave.
Maternity Leave:
Time away from residency training for maternity leave can consist of both paid and unpaid leave. The ordinary period of leave for pregnancy and delivery is up to 6 weeks.
2. The resident is eligible to apply for time off under the Family Leave Act (FMLA) which allows the resident up to 12 weeks of time off, under the FMLA. If the resident would like to apply for FMLA , it is important to meet with your program director to determine the effect of the FMLA on the projected date of completion of the training program and human resources to determine how much will be covered under the sick and vacation time.

3. Childbirth is treated the same as disability due to other medical conditions. The determination of disability is made by the resident's personal physician. If the resident would like to apply for a medical leave of absence, they will be required to use accrued sick and vacation time prior to the 14 days not covered by short term disability.
4. The resident must obtain a physician's certification stating that she may return to work without restrictions prior to returning to work.
Paternity Leave:
1. A resident may elect to take up to 5 working days of paid leave within the first four weeks of (the birth) life of his baby or the first four weeks of adoption. If a resident would like paid leave, this time will be composed of available vacation or sick days.
If all available days are expended, this leave may be taken as unpaid leave.
In order to take such leave, the resident must:
A. Give advance notice to the Program Director as in "Guidelines" above.
B. Obtain approval of supervising faculty and Program Director.
C. Arrange coverage for any on-call responsibilities and scheduled out patient responsibilities, (acceptable to the Program Director.)
Adoption/Father as Primary Care Taker:
1. A female resident adopting a child, or a male resident, who will be primary or sole caretaker or a new child may take a maximum of four weeks leave to begin within one week of birth or adoption.
2. The paid portion of this leave will be composed of available vacation or sick days with any remainder being unpaid.
3. The scheduling, notification and leave guidelines are the same as for maternity leave above.

Human Resources Leave of Absence Policy http://oaknet/documents/PolsNProcs/HR/207.pdf

Revised 07/21/2011
3.
6.
7.
4.
5.
1.
2.
8.
Only physicians with permanent licenses are allowed to provide patient care without supervision.
PGY-1 residents are not permitted to moonlight.
Moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program. All significant extracurricular activity (moonlighting, secondary employment, additional education or training), by residents in Oakwood educational programs requires written approval by the program director. Residents must submit a written request describing the activity and track the number of hours per month that they are working outside the educational program. Resident’s should be in good standing in their program.
In programs where moonlighting is allowed, residents can moonlight no more than 80 hours per calendar month of extracurricular activities. Time spent by residents in Internal and External Moonlighting (as defined in the ACGME
Glossary of Terms) must be counted towards the 80-hour Maximum Weekly Hour
Limit. Residents may not exceed ACGME duty hour standards when training and moonlighting work hours are combined.
Program directors must actively track and report these resident activities to Medical Education Committee. Each program will determine rotations during which residents may moonlight.
It is not a requirement for residents to moonlight.
Residents are not allowed to moonlight when simultaneously performing any training duties.
Residents cannot be on call and/or moonlighting more frequently than every third day.
It is the resident’s responsibility to abide by this policy when performing duties outside the training program. The following sanctions may be imposed if the resident violates the above rules: probation, suspension and/or termination from the program.
Residents are only covered by malpractice insurance when performing their resident training duties. Malpractice coverage for moonlighting must be secured through their moonlighting employer or site.

TABLE OF CONTENTS
Documentation and Order Writing on Teaching Services
Verbal Orders for All Teaching Patients
Resident Prescription Writing
Medication Prescribing Guidelines
2
3
4
5

Policy: In admitting patients to the Medical Teaching Services, including the critical care units, the attending physician should delegate order writing to the resident physicians assigned or covering the patient whenever possible. Residents also per their respective job duties document admissions, history and physicals, progress notes and discharge summaries.
Procedure: Residents will perform a complete initial history and physical on all teaching admissions and review the assessment and plan with a more senior resident and the attending physician. Initial orders will be written by the residents. Recommendations of the attending and consultants as noted in the records or transmitted verbally should be discussed and acted upon without delay. Residents must include their beeper number with all signatures on the chart such as orders, history and physicals, progress notes and all other documents requiring signatures.
Attendings who wish orders to be implemented urgently should page the responsible or covering resident to write them. If the resident cannot comply within a short period of time (15 minutes), and if urgent, the attending physician may write the orders and include an order to call the resident to review them and the associated progress note as soon as possible.
It is expected that there will be a few brief initial orders written by the attending or the emergency department physician to initiate the referral to the teaching service. It is further expected that on occasions when urgent orders, or highly specialized orders (i.e., chemotherapy), or orders related to a specific invasive procedure by a consultant, that the attending or consulting physician may write some orders. However, under most circumstances, residents should write the teaching patients’ orders based on written or verbal interactions with the attending and consulting staff or supervising senior resident.

Verbal orders shall:
1. Only be given for emergent or urgent indications by a resident when another patient care emergency or urgency precludes immediate access to the patient and the chart.
2. BE SIGNED AND DATED BY THE NEXT MORNING. All residents on an inpatient service rotation must log onto Last Word the first thing everyday and sign all verbal orders.
3. Only be for patients known to be on the teaching service - the resident must verify this prior to giving any verbal order.
4. It is the responsibility of the resident who issued the verbal order to insure it is signed and dated by the next morning.
5. The appropriate on-duty resident each day will check all teaching charts on the services they cover to sign and date all remaining unsigned verbal orders.
6. Residents with two or more verbal orders not signed/dated will be asked to appear before the Graduate Medical Education Committee.
7. Repeated failure to comply with this new policy may result in corrective action including suspension, probation, or termination.
Cc: Medical Staff Office
Nursing Administration
Nursing Stations
Attending Staff

1.
Residents must follow the Oakwood policy entitled “Medication Prescribing
Guidelines” (attached).
2.
Residents may only write prescriptions for patients they have evaluated in clinic or during hospital encounters that are documented in the medical record.
3.
All residents will be provided a pharmacy stamp for all outpatient prescriptions and inpatient orders at the beginning of their residency. If the stamp is lost, stolen, or broken residents will be charged a $10 fee for replacement. This fee may not come from the resident’s benefit allowance. It is imperative that you use this stamp on all outpatient prescriptions. You must also sign the prescription. The stamp is not a replacement for your signature. If you do not utilize this stamp, or have the information on the stamp in legible writing on all your prescriptions, the
DEA can refuse to give you, or can revoke, your DEA license.

Medication Prescribing Guidelines http://oaknet/documents/PolsNProcs/Medication/117.pdf

Organizational Code of Conduct http://oaknet.ohsnet.ad.oakhealth.net/flipbooks/2010-code-of-conduct/index.html

1.
Medical Education will process the reimbursement for the resident purchase of a PDA, smart phone, or laptop. The resident may use their book, travel or membership allowance funds to reimburse the cost of the items. If there are insufficient funds in the residen t’s allowances, the resident is responsible for the remaining cost.
2.
Resident will be responsible for maintenance and technical support of the PDA, smart phone or laptop.
3.
Oakwood Healthcare Inc. and Medical Education will not be responsible for phone services or any other services associated with these devices. These services shall be the responsibility of the resident.
4.
Lost or broken devices will be the responsibility of the resident.
5.
Residents must complete the attached Resident PDA Program Form for Reporting
Taxable Income form in order to receive reimbursement for the item (form located on
“F” drive) and Resident Handbook Policies.
Revised 12/16/10

Form for Reporting Taxable Income
Dear Employee,
The Internal Revenue Service considers your PDA reimbursement as taxable wages in the year the reimbursement was received. Oakwood Healthcare
System will pay, on your behalf, all withholding taxes generated by the reimbursement.
Example :
Award Value
Social Security Taxes
Medicare Taxes
Federal Withholding Taxes
$250.00
24.43
5.71
98.50
State of Michigan Withholding 15.37
Total Amount Added to Form W-2 $394.01
The taxable amount will be added to the wages on your W-2 at the end of the year. If you have any questions regarding the Employee PDA program please contact me at (313) 791-4839.
Sincerely,
Lillian F. Sayles, CPP
Corporate Payroll Manager
Oakwood Healthcare System
________________________________________________________________
Department Manager : Please complete the following data and forward the completed form to Lillian Sayles in the Payroll Department at Village Plaza (Site
#44). A copy of the completed form must also be sent over with all check requests for reimbursement of PDA expenditures:
Description of Reimbursement:
_________________________________________________
Monetary Value of PDA $____________ Date of
Purchase____________________

Employee’s
Name____________________________________________________
Employee ID#__________________________
Business Unit___________________ Department
Number___________________
Employee Signature:
____________________________________
Department Manager (please print):
_____________________________________
Department Manager Phone Number:
____________________________________
Revised 12/16/10

Vendor Interactions
I. Purpose
To establish guidelines for resident and faculty interactions with industry representatives at Oakwood sites.
II. Policy
Interactions with industry occur in a variety of contexts, including marketing of new pharmaceutical products, medical devices, research equipment and on-site training of newly purchased devices. Although many aspects of these interactions are positive and important for promoting the educational and clinical mission of
Medical Education, these interactions must be ethical and cannot create conflicts of interest that could endanger patient safety, data integrity, and the integrity of the education programs. Any interaction with industry and its vendors should be conducted so as to avoid conflicts of interest.
1.
Residents and faculty should not accept of gifts of any substantial value from industry vendors.
2.
Textbooks, modest meals and other gifts are appropriate only if they serve an educational function.
3.
Residents and faculty may not accept gifts or compensation for listening to a sales talk by an industry representative.
4.
Residents and faculty may not accept gifts or compensation for prescribing or changing a patient’s prescription.
5.
Residents and faculty must consciously separate clinical care decisions from any perceived or actual benefits expected from any company.
6.
It is unacceptable for patient care decisions to be influenced by the possibility of personal financial gain.
7.
Vendor support of educational conferences involving the resident may be used only if the funds are provided directly to the institution, not to the resident or faculty. The program director should determine if the funded conference or program has educational merit.
8.
The resident will be informed by teaching faculty of the potential conflicts of interest during interactions with industry vendors.
9.
Residents, faculty and programs must also comply with the Oakwood Vendor
Interaction Policy and must pay special attention to gift and meal limit values in that policy (sections IV.I.4., IV.K., IV.L., IV.M., IV.P., and IV.R.).
See OHI Vendor Interaction Policy at http://oaknet/documents/PolsNProcs/OHI/1113.pdf

Refer to human resources policy on Fitness for Duty .
Resident acknowledges and agrees that his/her acceptance into the residency program is conditioned on resident submitting to a drug test prior to beginning their residency program. Refusal to submit to drug testing will result in the immediate termination of their agreement.
If the test is positive, the resident shall be given the opportunity to discuss the test results and to submit information demonstrating authorized use of the drug(s) in question. A substantiated positive drug test will result in immediate termination of their agreement.
The foregoing notwithstanding, resident will be required to submit to alcohol/drug testing whenever reasonable cause exists to believe that the resident’s ability to fulfill his/her obligations under their agreement may be impaired by alcohol and/or drugs. A positive test result will be handled in accordance with the guidelines set forth in Oakwood’s
Human Resources Policy and Procedure Manual.

Fitness for Duty http://oaknet/documents/PolsNProcs/HR/417.pdf
Fitness for Duty Checklist http://oaknet/Documents/Forms/HR/FitnessforDutyObservationChecklist.pdf

Medical Education
Resident Professionalism Policy
Purpose: Adherence to the pertinent ACGME Common Program Requirements as defined below:
IV. Educational Program
IV.A. The curriculum must contain the following educational components:
IV.A.5. ACGME Competencies
IV.A.5.a) The program must integrate the following ACGME competencies into the curriculum:
IV.A.5.f) Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
Residents are expected to demonstrate:
IV.A.5.f).(1) compassion, integrity, and respect for others;
IV.A.5.f).(2) responsiveness to patient needs that supersedes selfinterest;
IV.A.5.f).(3) respect for patient privacy and autonomy;
IV.A.5.f).(4) accountability to patients, society and the profession; and,
IV.A.5.f).(5) sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
VI.
VI.A.
Resident Duty Hours in the Learning and Working Environment
Professionalism, Personal Responsibility, and Patient Safety
VI.A.1. Programs and sponsoring institutions must educate residents and faculty members concerning the professional responsibilities of physicians to appear for duty appropriately rested and fit to provide the services required by their patients.
VI.A.2. The program must be committed to and responsible for promoting patient safety and resident well-being in a supportive educational environment.
VI.A.3. The program director must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.
VI.A.4. The learning objectives of the program must:
VI.A.4.a) be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events; and,

VI.A.4.b) not be compromised by excessive reliance on residents to fulfill non-physician service obligations.
VI.A.5. The program director and institution must ensure a culture of professionalism that supports patient safety and personal responsibility. Residents and faculty must demonstrate an understanding and acceptance of their personal role in the following:
VI.A.5.a) assurance of the safety and welfare of patients entrusted to their care;
VI.A.5.b) provision of patient- and family-centered care;
VI.A.5.c) assurance of their fitness for duty;
VI.A.5.d) management of their time before, during, and after clinical assignments;
VI.A.5.e) recognition of impairment, including illness and fatigue, in
VI.F. themselves and in their peers;
VI.A.5.f) attention to life-long learning;
VI.A.5.g) the monitoring of their patient care performance improvement indicators; and,
VI.A.5.h) honest and accurate reporting of duty hours, patient outcomes, and clinical experience data.
Teamwork
Residents must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty.
Curriculum Requirements:
A. Professionalism:
The Department of Medical Education and Oakwood residency programs share responsibility for resident education in the elements of Professionalism as defined in the
ACGME Common Program Requirements. The didactic component begins with the residency Orientation and continues throughout residency during General Competency and residency program conferences. This teaching must incorporate the following elements:

The professional responsibilities of the physician including: o Appearing for duty appropriately rested and fit to provide the services required by their patients; o Assurance of the safety and welfare of patients entrusted to their care; o Attention to life-long learning; and, o Recognition of impairment, including illness and fatigue, in themselves and in their peers.

Ethical principles of care and ethical decision-making including: o Respect for patient autonomy, beneficence, non-malfeasance, and justice; and,

o Identifying and weighing competing ethical principles.

Sensitivity and responsiveness to a diverse patient population including: o Patients differing by gender, age, culture, race, religion, disability status, and sexual orientation; o Provision of patient- and family-centered care to a diverse patient population; and, o Use of Interpretive Services.
In their clinical teaching, faculty supervisors must emphasize the professional responsibilities of the physician; identify relevant ethical principles of care; model ethical decision-making; and model care that is sensitive and responsive to the needs and views of a diverse patient population.
B. Quality Improvement, Patient Safety, and Teamwork:
Resident instruction must incorporate didactic and experiential components, be continuous throughout residency, and include the following elements:

Participation in interdisciplinary clinical quality improvement and patient safety programs;

Monitoring of resident patient care performance improvement indicators;

Training in a structured Handover process;

Completion of the LifeWings curriculum;

Communication with other healthcare providers as appropriate to the delivery of care within a specialty;
To ensure effective modeling of interprofessional communication and teamwork,
Department of Medical Education faculty must also complete the LifeWings curriculum.
C. Culture of Professionalism:
The Department of Medical Education and Oakwood residency programs must ensure resident immersion in a culture of professionalism that supports patient safety and personal responsibility through instruction and faculty modeling in Service Excellence including:
 Oakwood’s Core Values of Compassion, Respect, Excellence, Diversity,
Ownership;
 Oakwood’s Code of Conduct; and,

Resident articulation and periodic review of a Service Excellence Pledge (form attached).
2
2 Also available on Oaknet. Click on Programs, then Service Excellence. Drop down to item “4. Behavioral
Standards
.” Click on “Values in Action” poster and “Personal Pledge Form.” Print and complete “Personal
Pledge Form.”

D. Supportive Educational Environment:
The Department of Medical Education and Oakwood residency programs must ensure that resident training occurs in a supportive educational environment that incorporates the following elements:

Educational programming with a specific focus on residents’ personal and professional well-being;

Monitoring of resident wellness, Duty Hour compliance, fatigue, and impairment;

Transitioning of patient care when resident fatigue poses a threat to patient safety; and,

Avoidance of excessive reliance on residents to fulfill non-physician service obligations.
Evaluation:
A. The Department of Medical Education Monitoring:
The Department of Medical Education will monitor resident attendance at Orientation and General Competency lectures and completion of the LifeWings curriculum. The
Department of Medical Education will conduct 360-degree surveys of resident
Professionalism using the attached instrument.
3 Medical Education will also provide individual residency programs with information regarding resident conference attendance and results of the 360-Degree Professionalism Survey for entry and updating on the attached Resident Professionalism Review form. Additionally, Medical Education will conduct 360-Degree Professionalism Surveys on faculty using the same instrument and will forward results of the survey to programs and faculty.
B. Residency Program Monitoring:
During resident semiannual reviews, program directors must address resident participation in Professionalism instruction and professional behavior as evidenced by their 360-degree survey results. These semiannual reviews must include discussion of the resident’s Service Excellence Pledge as evidence of residents’ maturing commitment to carrying out professional responsibilities and adherence to ethical principles.
Semiannual reviews must articulate a Professionalism Plan for the following six-month period including required or elective instruction, other elective activities, e.g., recording an ethics journal, and specific activities to address areas identified on the 360-degree survey as needing improvement.
3 Accreditation Council for Graduate Medical Education. ACGME Pediatrics program requirements.
Accessed at: http://www.acgme.org/RRC/PedNet

Personal Pledge Form http://oaknet/documents/services/SE/Behavior_Standards_Personal_Pledge.pdf

360-Degee Professionalism Survey
The 360-Degree Professionalism Survey was developed by the Accreditation Council on
Graduate Medical Education and the American Academy of Pediatrics. The survey asks that you make a judgment whether or not the physician consistently displays a set of attitudes and behaviors that define Professionalism. You may base your judgment on your interactions with the physician as well as observations and reports of the physician’s interactions with patients, families, and other members of the healthcare team.
Additionally, the physician’s medical chart notes and other records may provide useful indications of the physician’s professionalism in formulating your judgment.
The survey asks that you evaluate the physician’s behavior with respect to each of eight
Professionalism components. Rate a particular component as
“Meets Expectations”
if the physician displays attitudes and behaviors you would judge as professional and appropriate to the role of a physician and with the consistency you would expect.
Conversely, rate a particular component as “Needs Improvement” if the physician displays attitudes and behaviors you would judge as unprofessional and inappropriate to the role of a physician. You may also rate a particular component as “Needs
Improvement” if the physician displays professional and appropriate attitudes and behaviors, however, the consistency is less than you would expect. On the back of the survey form, please provide a description of the attitudes and/or behaviors you evaluated as “Needs Improvement.”
Endorse the
“Cannot Assess”
response if you feel you have insufficient information with which to form a judgment.
Your responses will remain anonymous—identifying information will be removed prior to sharing the results of the 360-Degree Professionalism Survey.

360-Degree Professionalism Survey
Components of Professionalism
Meets
Expectations
Needs
Improvement
1. Honesty-Integrity
Is truthful with patients, peers, and in professional work (e.g., documentation, communication, presentations, research).
2. Reliability-Responsibility
Is accountable to patients and colleagues. Can be counted on to complete assigned duties and tasks. Accepts responsibility for errors.
3. Respectful of Others
Talks about and treats all persons with respect and regard for their individual worth and dignity; is fair and non-discriminatory. Routinely inquires about or expresses awareness of the emotional, personal, family, and cultural influences on patient well-being and their rights and choices of medical care; is respectful of other members of the health care team. Maintains confidentiality.
4. Compassion-Empathy
Listens attentively and responds humanely to patient’s and family members’ concerns; provides appropriate relief of pain, discomfort, anxiety.
5. Self-improvement
Regularly contributes to patient care or educational conferences with information from current professional literature; seeks to learn from errors; aspires to excellence through self-evaluation and acceptance of the critiques of others.
6. Self-awareness-Knowledge of limits
Recognizes need for guidance and supervision when faced with new or complex responsibility; is insightful of the impact of one’s behavior on others and cognizant of appropriate professional boundaries.
7. Communication-Collaboration
Works cooperatively and communicates effectively to achieve common patient care and educational goals of all involved health care providers.
8. Altruism-Advocacy
Adheres to best interest of the patient; puts best interest of the patient above selfinterest and the interest of other parties.
*Accreditation Council for Graduate Medical Education. ACGME Pediatrics program requirements. http://www.acgme.org/RRC/PedNet
2001. Accreditation Council for Graduate Medical Education, 2001.
Cannot
Assess

Please provide a description of the attitudes and/or behaviors you evaluated as
“Needs Improvement.” Your responses will remain anonymous. Identifying information will be removed prior to sharing the results of the 360-Degree
Professionalism Survey.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_____________ _________________________________________________________

R ESIDENT P ROFESSIONALISM R EVIEW
Part I: Complete Part I as part of the resident’s initial Resident Professionalism Review. List completed required and elective activities by noting the date and, as appropriate, title of the activity. Append New Innovations reports. Update Part I during subsequent semiannual resident reviews (attach a separate Part I if needed).
I.
Department of Medical Education Orientation Lectures
Date: ______________ Professionalism
Diversity
Interpretive Services
Date: ______________
Date: ______________
II.
Department of Medical Education Seminars and Workshops
Alertness Management-Fatigue Mitigation
LifeWings Course
Date: ______________
Date: ______________
III.
Professionalism/Ethics Case Conferences
_________________________________________
_________________________________________
IV.
Annual Resident Wellness Day
_________________________________________
_________________________________________
V.
Quality Improvement/Patient Safety Committee
_________________________________________
_________________________________________
Date: ______________
Date: ______________
Date: ______________
Date: ______________
Date: ______________
Date: ______________

VI.
General Competency Lectures and Workshops
_________________________________________
_________________________________________
_________________________________________
Date: ______________
Date: ______________
Date: ______________
VII.
Other Activities: Ethics Journaling, Narrative Writing, Training Modules, Workshops
_________________________________________ Date: ______________
_________________________________________ Date: ______________

Part II: Complete Part II as part of the resident’s initial Resident Professionalism Review.
Sign and date below and provide the resident with a copy of Part I and Part II of the
Resident Professionalism Review.
I.
Service Excellence Pledge
The resident must define a “Service Excellence Pledge.” The resident should review
Oakwood’s “Values in Action” (available on Oaknet), select a value to address, i.e.,
Compassion, Respect, Excellence, Diversity, Ownership, and review the corresponding
Behavior Standards. The resident must complete and attach a “Personal Pledge Form” identifying specific actions he/she will perform to demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
II.
Professionalism 360-Degree Survey
Enter the results of the most recent 360-degree Professionalism survey. Highlight strengths and areas identified as needing improvement.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
III.
Professionalism Plan
Together with the resident, compose a Professionalism Plan for the ensuing six-month period. Include required and elective instruction in Professionalism, behaviors the resident will display in fulfillment of his/her Service Excellence Pledge, and steps he/she will take to address Professionalism components identified on the 360-degree survey as needing improvement.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________________________________ _________________________
Date Resident Signature
_________________________________________
Program Director/Supervisor Signature
_________________________
Date

Part III: Complete a separate Part III to record subsequent Resident Professionalism Reviews.
Sign and date below and provide the resident with a copy of Part I and Part III of the
Resident Professionalism Review.
I.
Service Excellence Pledge
In the space below, document actions taken by the resident in fulfillment of his/her Service
Excellence Pledge.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
II.
Professionalism 360-Degree Survey
If stipulated in the previous Professionalism Plan, list resident actions to address
Professionalism components identified on the prior 360-degree survey as needing improvement. Enter the results of the resident’s most recent 360-degree survey. Highlight strengths and areas identified as needing improvement.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

III.
Professionalism Plan
Together with the resident, compose an updated Professionalism Plan for the ensuing sixmonth period. Include required and elective instruction in Professionalism, behaviors the resident will display in fulfillment of his/her Service Excellence Pledge, and steps he/she will take to address Professionalism components identified on the most recent 360-degree survey as needing improvement.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________
Resident/Faculty Signature
________________________________
Date
____________________________________
Program Director/Supervisor Signature
________________________________
Date

OAKWOOD MEDICAL EDUCATION
ANNUAL PROGRAM REVIEW POLICY
PURPOSE:
To establish a formal, systematic process to annually evaluate the educational effectiveness of each Residency Program, in accordance with the program evaluation and improvement requirements of the ACGME and the GMEC.
POLICY:
Representative personnel from each Residency Program will be organized as a Program
Evaluation Committee to review the program's overall goals and objectives and the effectiveness with which the curriculum has achieved those objectives during the academic year. In addition, accomplishments and remaining needs in faculty development will be assessed. The meeting(s) of the Program Evaluation Committee will be documented in the form of written minutes. The group will prepare an explicit plan of action, to specify initiatives to improve program performance identified as a result of the review process. The action plan will be presented to the entire program faculty and the
GMEC.
PROCEDURE:
1. The annual review will be conducted on or about October 15th of each year, unless rescheduled for other programmatic reasons.
2. Approximately two months prior to the review date, the Program Director and
Program Evaluation Committee will:
 establish and announce the date of the review meeting
 identify at least two (2) representative members of the program faculty to participate in the review
 identify at least two (2) program peer-selected residents to participate in the review; one shall be a junior and the other a senior resident
 identify an administrative coordinator to assist with organizing the data collection, review process, and report development
 identify other important or desirable participants as determined by the program director
 solicit written confidential evaluations from the entire faculty and resident body for consideration in the review
 authorize the administrative coordinator to compile the materials, listed below, to be used in the review
3. At the time of the initial meeting, the Committee will consider:

 degree of achievement of action plan improvement initiatives identified during the last annual review
 correction of citations and concerns from last ACGME program survey and the last GMEC internal review of the program
 residency program overall goals and objectives
 faculty members’ confidential written evaluations of the program
 the residents' annual confidential written evaluations of the faculty
 the residents' annual confidential written evaluations of the program
 resident performance and outcome assessment, as evidenced by:
- performance of program graduates on the certification examination
- aggregated data from general competency assessments
- in-training examination performance
 faculty development needs and effectiveness of faculty development activities during the past year

ACGME and/or other available resident survey results
 any other issues that might come before the panel
4. Additional meetings may be scheduled, as needed, to continue to review data, discuss concerns and potential improvement opportunities, and to make recommendations.
Written minutes will be taken of all meetings .
5. As a result of the information considered and subsequent discussion, the Committee will:
 identify any deficiencies in the program, and prepare an explicit plan of action to address them using the standard program action plan reporting form
 develop recommendations for improving the residency program, through enhancement of identified strengths
6. The final report and action plan will be approved by each member of the Committee, reviewed and approved by the program’s teaching faculty, and documented in faculty meeting minutes. A report will be provided to the GMEC, and discussed at a full meeting of the GMEC.

RESIDENCY PROGRAM ANNUAL PROGRAM REVIEW REPORT OUTLINE
Date of Review Meeting(s):
Participants:
Program Director: Other:
Faculty Member: Faculty Member:
Junior Resident(s): Senior Resident(s):
Summary of Faculty Confidential Annual Written Evaluations:
Summary of Residents’ Confidential Annual Written Evaluations of the Faculty:
Summary of Residents’ Confidential Annual Written Evaluations of the Program:
Data Considered by Program Evaluation Committee: (check each one used)
___Status of issues identified in last Annual Program review
___Medical residency program goals and objectives, teaching activities, and evaluation tools
___Faculty development needs/activities
___Resident performance:
___performance of program graduates in certification examination
Other:
___aggregate data from general competency evaluations
___in-training exam performance
Summary of Findings:
1) Residents’ Performance
2) Faculty Development
3) Graduates’ Performance
4) Program Quality
Deficiencies in the Program:
Program Strengths to be Reinforced:
Action Plan Priorities for this Academic Year: (copy of Action Plan attached)
Approved by: (signed by each member of review panel)
Date action plan reviewed with and approved by faculty (also note in faculty meeting minutes):

Medical Education
Resident Alertness Management/Fatigue Mitigation Policy
Purpose: Adherence to the pertinent ACGME Common Program Requirements as defined below:
VI. Resident Duty Hours in the Learning and Working Environment
VI.A. Professionalism, Personal Responsibility, and Patient Safety
VI.A.1. Programs and sponsoring institutions must educate residents and faculty members concerning the professional responsibilities of physicians to appear for duty appropriately rested and fit to provide the services required by their patients.
VI.A.5. The program director and institution must ensure a culture of professionalism that supports patient safety and personal responsibility. Residents and faculty must demonstrate an understanding and acceptance of their personal role in the following:
VI.A.5.c) assurance of their fitness for duty; and,
VI.A.5.e) recognition of impairment, including illness and fatigue, in themselves and in their peers.
VI.A.6. All residents and faculty members must demonstrate responsiveness to patient needs that supersedes self-interest. Physicians must recognize that under certain circumstances, the best interests of the patient may be served by transitioning that patient’s care to another qualified and rested provider.
VI.C. Alertness Management/Fatigue Mitigation
VI.C.1. The program must:
VI.C.1.a) educate all faculty members and residents to recognize the signs of fatigue and sleep deprivation;
VI.C.1.b) educate all faculty members and residents in alertness management and fatigue mitigation processes; and,
VI.C.1.c) adopt fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, such as naps or back-up call schedules.
VI.C.2. Each program must have a process to ensure continuity of patient care in the event that a resident may be unable to perform his/her patient care duties.
VI.C.3. The sponsoring institution must provide adequate sleep facilities and/or safe transportation options for residents who may be too fatigued to safely return home.

Procedures:
A. Education:
Residents and faculty must review the Department of Medical Education’s half-day course on Alertness Management and Fatigue Mitigation and complete a quiz. After completing the introductory requirement, residents and faculty must complete the online
SAFER curriculum module and quiz on an annual basis.
4
B. Use of Alertness Management/Fatigue Mitigation Processes:
Residents and faculty must demonstrate effective use of Alertness Management/Fatigue
Mitigation processes, which should include the following:

Rest breaks and strategic napping before and during night-float and extended duration shifts (e.g., between the hours of 10:00 pm and 8:00 am) as indicated by physician fatigue and as permitted given the requirements of patient care and safety;

Faculty, supervising resident, and team member consultation regarding the ability to provide safe, effective patient care, the need for back-up call, and use of the back-up call system; and,

Oakwood Healthcare System, Inc., and the Department of Medical Education will ensure that each hospital site has adequate rest/sleep facilities for resident and faculty use and ready access to safe transportation options for providers who may be too fatigued to safely return home at no cost to the provider. Taxi vouchers are available through the Director, Care Management at pager #2187.
C. Monitoring of Physician Alertness and Fatigue:
Residents and faculty must demonstrate systematic monitoring of physician alertness and fatigue as evidenced by assessment during morning and evening rounds, night-float shifts, and/or extended duration shifts (greater than 16 hours). Programs should monitor physician alertness and fatigue as follows:

Faculty and supervising residents will observe team members routinely for signs of excessive fatigue and sleepiness;

Faculty and supervising residents will monitor resident alertness and fatigue and should respond as described in the attachment Monitoring and Responding to
Resident Fatigue employing routine completion of the Check-Ins form with team members and using validated tools, i.e., the Visual Analogue Sleepiness Scale and the Psychomotor Vigilance Test;
5
4 The Alertness Management Seminar (slides) and Resident Fatigue Management (video) are available on Oaknet. Go to Departments, Medical Education, and click on Video Lectures.
Residents can find these topics under General Competencies. Faculty should look under Faculty
Education. The SAFER curriculum is also available at these sites. Quizzes are posted on New
Innovations.
5 The Psychomotor Vigilance Test can be accessed online at: www.sleepdisordersflorida.com/pvt1.html


Residents observing signs of excessive fatigue among colleagues will raise their concerns with faculty or supervising residents who will assess and intervene as required to ensure safety;

Residents who feel excessively fatigued have the professional responsibility to notify faculty or supervising residents—without fear of reprisal; and,

Faculty should incorporate behaviors listed in the attached Suggested Template for Inpatient Supervision and Alertness Management/Fatigue Mitigation into their inpatient rounding.
D. Department of Medical Education Monitoring:
The Department of Medical Education must monitor resident alertness/fatigue and intervention through:

Periodic assessment of resident and faculty alertness/fatigue using aggregate data from the Check-Ins form including the Visual Analogue Sleepiness Scale and
Psychomotor Vigilance Test; and,

Periodic assessment of resident and faculty chronic sleepiness using the Epworth
Sleepiness Scale (attached), the frequency of which should not exceed six assessments annually.
E. Program Documentation of Alertness Management/Fatigue Mitigation
Strategies:
Residency programs must document physician use of rest breaks, strategic napping, back-up call, and safe transportation options and provide summarized data to the
Department of Medical Education at regular intervals using the attached Reporting Form for Program Resident Alertness/Fatigue Mitigation Procedures. The Department of
Medical Education will review this information along with monitoring data from validated instruments for evidence of effective alertness management, fatigue mitigation, and physician safety during Annual Program Reviews and Program Internal
Reviews.
Also see the Oakwood Fitness for Duty Policy and Fitness for Duty Observation
CheckList for concerns regarding resident impairment. Residents with recurrent fatigue problems may be asked to have a medical evaluation as well as other interventions to return the resident to full program responsibilities.

Monitoring and Responding to Resident Fatigue
Faculty and supervising residents must demonstrate systematic monitoring, assessment, and intervention with respect to resident alertness and fatigue. Monitoring should be ongoing. Formal Check-Ins (see attached) should occur as needed. Ideally, Check-Ins would be performed during direct face-to-face contact though some may be conducted telephonically or through other electronic modalities.
High Risk Times for FatigueSigns of Fatigue Include
Related Symptoms
Involuntarily nodding off
Waves of sleepiness
Repeated blinking break
Lethargy
Irritability shift
Midnight to 6 am
Early hours of day shift
First night shift or call night after a
Change of service
First 2 to 3 hours of a shift or end of
Early in residency or when new to Mood lability night call
Impaired ability to perform simple cognitive
or psychomotor tasks
Slowed response/reaction time
Inattention to details
Difficulty focusing attention and with
short-term recall
Double- and triple-checking one’s work
Impaired situational awareness
(leading to over-reliance on rote memory)
Tardiness or absences at work
Response
Faculty or supervising residents who observe evidence of excessive fatigue, should approach the resident, assess level of fatigue, and, as needed, intervene to protect the well-being of the resident and patients. Interventions for residents found to be at risk to self and others due to excessive fatigue based on a Check-In assessment include:
 Signing out the resident’s pager to another provider

Taking a rest-break or strategic nap

Releasing the resident from further patient care responsibilities and accessing back-up schedule

Requiring a rest break before commute home or arranging for a taxi voucher for safe transportation


U-V light exposure

Caffeine
Check-Ins
Circle Interventions
Rotation/Service ____________________________________________________
Faculty or Supervising Resident Signature ________________________________
Pager Number __________________ Date_____________________________
Morning Rounds : Suggested questions for on-call or night-float residents :
Were you able to take a rest-break or strategic nap ?
Are you feeling excessively tired or fatigued at this point?
(If Yes, ask resident to complete and return VASS and/or PVT.*
Attach VASS/record PVT on back of this form.)
Do you feel you are safe to drive home?
(If No, ask resident preference for rest before commute or taxi voucher for
safe transportation—contact Director, Care Management @ pager #2187.)
Morning Rounds : Suggested questions for incoming residents:
Do you feel you are alert and ready to provide safe, effective patient care?
(If No, ask what steps resident could take to mitigate fatigue, e.g., sign out Resident 1
Resident 1
Resident 2
Resident 3
Yes
Resident 1
Resident 2
Resident 3
Yes
Resident 1
Resident 2
Resident 3
Yes
pager , take a rest break or strategic nap , or access back-up schedule .) Resident 2
Resident 3
Evening Rounds : Suggested questions for on-call or night-float residents:
Yes
___
___
___
No
___
___
___
No
___
___
___
No
___ ___
___ ___
___ ___
Do you feel you are alert and ready to provide safe, effective patient care?
(If No, ask what steps resident could take to mitigate fatigue, e.g., sign out pager , take a rest break or strategic nap , or access back-up schedule .)
Resident 1
Resident 2
Resident 3
If you become excessively tired or fatigued, what steps could you take to Resident 1
Mitigate your fatigue? ( sign out pager , take a rest break or strategic nap , Resident 2 the back-up schedule ) Resident 3
Yes
___
___
___
No
___
___
___
No
___
___
___
___
___
___
___
___
___
________
________ or access
________

* The Psychomotor Vigilance Test can be accessed online at: www.sleepdisordersflorida.com/pvt1.html
Visual Analogue Sleepiness Scale
Pager: ______________ Date: _______________ Time: _______________
Place a mark on the line below to describe how alert or sleepy you feel at this moment.
Note that the scale is anchored on the left with the phrase: “Sleepy as ever”
Also note that the scale is anchored on the right with the phrase:
“As wide awake as I can be”
___________________________________________________
Sleepy as ever As wide awake
as I can be
*Psychomotor Vigilance Test
Average RT __________ Circle: 1. Vigilance and Alertness are Excellent 2.
Alertness may be Suboptimal
________________________________________________________________________
Visual Analogue Sleepiness Scale
Pager: ____________ Date: ______________ Time: ________________
Place a mark on the line below to describe how alert or sleepy you feel at this moment.
Note that the scale is anchored on the left with the phrase:
“Sleepy as ever”
Also note that the scale is anchored on the right with the phrase:
“As wide awake as I can be”
__________________________________________________________
Sleepy as ever
*Psychomotor Vigilance Test
Average RT __________ Circle: 1. Vigilance and Alertness are Excellent
2. Alertness may be Suboptimal
As wide awake
as I can be

Morning Rounds :
Attendance:
Suggested Template for Inpatient Supervision and
Alertness Management/Fatigue Mitigation
Check-In:
Sitting Rounds:
Day, On-Call, and Night-Float Residents
Other Learners
Supervising Faculty (Direct Supervision)
Fitness for Duty
Alertness/Fatigue
Arrange transportation as needed
New Admissions
Emergent Issues
Plan for Walking Rounds and Patient Care
Review “Always Events” and Policy regarding Attending
Contact*
Record Hand-Over in EMR
Patient Assessment and Modify Care Plans Walking Rounds:
Evening Rounds :
Attendance:
Check-In:
Sitting Rounds:
Day, On-Call, and Night-Float Residents
Other Learners
Supervising Faculty (Direct; Indirect with Direct Supervision
Immediately Available, i.e., in-house; Indirect with Direct
Supervision Available, e.g., conference call)
Fitness for Duty
Alertness/Fatigue
Arrange transportation as needed
New Admissions
Emergent Issues
Plan for Walking Rounds (as needed) and Patient Care
Review “Always Events” and Policy regarding Attending
Contact
Record Hand-Over in EMR
Patient Assessment and Modify Care Plans (as needed) Walking Rounds:
Night Coverage :
Attendance:
Rest Break:
Night Residents
Other Learners
Supervising Faculty (Direct; Indirect with Direct Supervision
Immediately Available, i.e., in-house; Indirect with Direct
Supervision Available, e.g., conference call)
40-Minute Break (allowing 20-minute nap)
Between 10:00 pm and 8:00 am
Sign-out Pager

*Always Events to be defined by GMEC/Medical Education

Situation
Epworth Sleepiness Scale
Pager: _____________ Date: _____________ Time: ______________
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you.
Use the following scale to choose the most appropriate number for each situation:
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Chance of Dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g., a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
________
________
________
________
________
________
________
In a car, while stopped for a few minutes in traffic ________
To check your sleepiness score, total the points. Check your total score to see how sleepy you are.
Total score: _________________________
9 - 10 Borderline Chronic Sleepiness
11 -13
14 – 17
> 17
Mild Chronic Sleepiness
Moderate Chronic Sleepiness
Severe Chronic Sleepiness

Reporting Form for Program Resident Alertness/Fatigue Mitigation Procedures
Program: _________________________________
AM:
PM:
Site: _____________
Months (circle): Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year: ____
Total number Check-Ins: ________
______
______
After-hours: ______
Total Number of interventions reported: ________
Breaks: _______
Naps: _______
Taxi: _______
Other:
Visual Analog Sleepiness Scales: _________
_______
Number below bottom ¼ of scale:
_______
Percentage below bottom ¼ of scale: _______
PVTs recorded: _________
Number in fatigued range:
_______
Percentage in fatigued range:
_______
Epworth Sleepiness Scales: _______
Number with total score 11 or higher: _______
Percentage with total score 11 or higher:
_______

REQUIREMENTS FOR THE CREDENTIALING OF RESIDENTS
TABLE OF CONTENTS
2
Employment Procedures
General Information
4
Initial Appointments
Reappointment
Mental/Physical Impairments
Release of Information Policy
Temporary Appointments
Non-Renewal of Resident Appointments
Terminations
Foreign Medical Graduates
Criminal Background Checks
Initial Appointment Checklist
Reappointment Checklist
Program Director Recommendation
Resident Reappointment Recommendation
Supplemental Applications
OHI Licensure/Certification Policy
Informed Consent/Release of Information
22
24
25
16
17
19
27
31
34
5
8
9
10
11
12
14

1.
2.
3.
4.
5.
6.
Resident will sign the resident agreement and return to their residency program coordinator. The coordinator will obtain appropriate Medical Education administration signature and mail one original to the resident and keep one original for the residents file, (see attached agreement).
An international medical graduate (IMG) must have a green card, a green card work permit (this is given to an IMG who has applied and is waiting for their green card), permanent residency or a J1 visa. They must have a J1 visa by July
1 st
or their contract is null and void, (see attached addendum to contract.)
All IMG’s must have a valid ECFMG Certificate and provide a copy to begin the residency program.
All employees of the corporation are required to have a physical. This is done during their orientation. A physical consists of a urine drug screen, urine dip, TB test (x2)*, respiratory fitt test, eye exam, blood draw, injection of hepatitis series*.
* If you have had a TB test or hepatitis B vaccine done within the last year, please bring documentation with you or send it with your H&P packet.
Orientation is usually the last 2 ½ weeks of June. Orientation is mandatory for all incoming residents. An example list of orientation lectures is attached. If an incoming resident is unable to attend orientation, they must see the education program coordinator to receive pertinent information and schedule for necessary information, i.e., physical, beepers, DEA #, etc.
Residents must be licensed by the State of Michigan before they are able to begin their residency. If they are a first or second year resident they will receive a limited educational license. An application is mailed to all incoming residents in
March. The resident fills out the application, returns it to their residency program, who then sends it with payment to the State of Michigan. Once the paper copy is received, a copy is given to the education program coordinator. If a resident is a third year or has had 2 years previous training as a resident they may apply for a permanent license. These applications may be obtained by calling the State of
Michigan or contacting the education program coordinator. Once the paper copy has been received they need to provide a copy to the education program coordinator. If you don’t have your license by July 1 st
, you cannot begin your residency program. If you haven’t renewed your license by the end of the 60 day grace period, you will be suspended without pay until you are licensed.

7.
8.
Residents will sign up and choose their benefits on the first day of orientation.
All residents must be ACLS certified and maintain certification throughout their residency. See ACLS policy in policy section 5A.

REQUIREMENTS FOR THE CREDENTIALING OF RESIDENTS
PURPOSE : Oakwood Healthcare is committed to provide the public with well-trained physicians who possess the traits of high moral character and standards. The purpose of this policy is to help ensure a safe environment for patients, employees, and the general public by establishing required credentials for all residents training at our institutions.
SCOPE : This policy applies to all residents receiving offers of employment from any facility or entity associated with Oakwood Healthcare on or after the effective date shown above. It also applies to residents rotating at Oakwood facilities from other institutions. This policy does not apply to residents who are moonlighting at Oakwood. Moonlighting is a special privilege granted through the appropriate hospital Medical Staff Credentials Committee process.
AUTHORIZATION : Applicants for training experiences at Oakwood institutions must provide a signed release-of-information request establishing Oakwood’s right to secure the information necessary to fulfill this policy.
GENERAL INFORMATION



All residents must be credentialed in accordance with the following requirements prior to assuming patient care responsibilities.
All required materials must be submitted to the Medical Education Office no less than 60 days prior to the effective date of the resident's appointment/reappointment.
The Credentials Coordinator will review the materials and: o Submit them to the Medical Education Committee for approval OR o Notify the appropriate program director of deficiencies that prevent approval (i.e., missing documents, copies vs. originals, etc.). The application will be submitted to the Medical Education Committee as soon as the deficiency is corrected.
 Upon approval by the Medical Executive Committee, the Chairman of the
Medical Education Committee will send an appointment letter to the resident and program director.
 It is the responsibility of the program director to notify the Medical Education
Committee of any changes in a resident's clinical privileges (additions, reductions, restrictions, termination, etc…). Notification must be submitted, in writing, when the change becomes effective as an amendment to the current appointment.

REQUIREMENTS FOR INITIAL RESIDENT APPOINTMENTS
Educational Program Responsibilities:
1. Letter from the program director requesting appointment of new resident member,
including:
 Specific residents staff title (resident, fellow, etc.),
 For fellows, division/subspecialty designation,
 Dates of appointment -- limited to one year only , and
 Statement regarding the applicant's physical and mental health.
2. Resident supplemental application form, completed by the applicant:
 Responses to all sections must be complete.
 MUST include picture.
3. Curriculum Vitae:
 All periods from graduation to present must be specified.
 For any periods not accounted for on the CV, the applicant is responsible for providing details. If, during any of this time, the applicant was not in training or employed, he/she must document his/her activities in writing. (This is often true for foreign medical graduates who take time off to study for board exams or to secure ECFMG certification.).
4. Documentation of medical education:
 Original Dean's letter (now titled Medical Student Performance Evaluation -
MSPE). Note that 'Dean's letters' often are written prior to graduation and, therefore, do not contain the date of graduation.
 Original Transcript.
 Document a. or b. above must specify date of graduation (exception - see #10 below).
 Foreign medical graduates often are unable to secure original documents in a timely manner for credentialing purposes. Therefore, if necessary, notarized copies of original Dean's Letter and Transcript will be accepted.

5. Documentation of all periods of graduate medical education (residencies and
fellowships). Acceptable documentation includes:
 Notarized copy of training certificate, or
 Letter of recommendation from program director specifying inclusive dates of training and level successfully completed.
6. Verification of all non-training clinical activities:
 Original documentation from locations of non-training employment/practices

(hospitals, practices, etc.). See General Reference Form .
Statement from applicant for any period since medical school graduation not covered under #5 or #6a.
7. Two letters of recommendation:
 Must be originals,
 At least one must be provided by person with/for whom applicant has worked during past year. One may include the Program Director’s reference (See #1 above). Must be from the prior program director if applicant is coming from another training program.
8. Proof of Michigan licensure, temporary or permanent, if applicable:


Must be official transcript or original valid license with expiration date.
License Verification Form must be completed.
(see OHI policy on licensure/certification)
9. Original documentation from all residency training programs of liability coverage and
claims history for applicants beyond the PGY 1 level:
 Statement from all past carriers on past claims/actions occurring during the past ten years must include inclusive dates of coverage.
 'Certificate of insurance' for current liability insurance coverage, including inclusive dates of coverage.
 'Certificate of insurance' for future liability coverage if applicant will be covered by non-Oakwood carrier during appointment.
10.
Copy of USMLE transcripts.

11. For foreign medical graduates:
 Copy of valid ECFMG certificate . Pay particular attention to English test date.
(See Guidelines for Appointment of Foreign Medical Graduates to Resident
Positions )
Residency Office Responsibilities:
12. For June/July intern (PGY 1) appointments:



Applications should be submitted by September 1st . Non-compliant residents will face suspension after November 1 st .
Proof of graduation directly from the medical school.
Original documentation of liability insurance coverage and claims history.
13. Secure Supplemental Application (confidential questions) and Release Statement
from applicants.
14. Secure Recommendation letters (sent with employment packet), one signed by
program director/another from a supervisor of the applicant.
15. Secure temporary Michigan medical training licenses.
16. Query the AMA database, and the National Practitioner Data Bank (NPDB) if
currently a resident.
17. Secure statement of applicant’s physical and mental health from Occupational
Medicine including drug screen results.
Prior to authorizing that applicant may begin working:
18. Secure results of pre-employment drug screening from Occupational Health.
19. Secure results of Criminal Background Check from Human Resources.
(See Checklist for Initial Resident Appointments )

REQUIREMENTS FOR RESIDENT REAPPOINTMENTS
Residency Office Responsibilities:
1. Resident Reappointment Recommendation Form :
 Applications should be submitted by May 1 st .
Non-compliant residents will face suspension after July 1st .
 Complete all requested information.
 Signature of program director required .
 Dates of appointment -- limited to one year only .
2. Supplemental Application for Residents Reappointment completed by the applicant:
 All questions must be completed.
 For any questions responded to with YES (except #1a), additional documentation
 must be provided as specified.
Must include original signature of applicant.
3. Annual Evaluation of Applicant:
 Program Evaluation Forms will be provided for each resident/fellow currently enrolled. The latest summative evaluation of the resident will be provided.
 All evaluations must be provided with the reappointment request.
4. Proof of Michigan licensure, temporary or permanent:


Must be a copy of the current license indicating expiration date.
License Verification Form must be completed.
(see OHI policy #518 on Licensure/Certification)
5. Secure malpractice claims history from Risk Management.
6. Provide transcript of USMLE scores
(
See Checklist for Resident Reappointment )

TEMPORARY RESIDENT APPOINTMENTS
1. Temporary appointments will be provided to NEW residents members when
circumstances prevent approval of credentials materials by the effective date of
appointment.
2. In most circumstances, all documentation required for appointment is required to
provide a temporary appointment. However, in extremely special circumstances
(determined by the Chair, Medical Education Committee), minimum credentials
requirements for consideration of temporary appointments are:
 Letter from program director requesting and explaining necessity for temporary
 appointment,
 Supplemental Application,
Application form,
 Copy of current Michigan license, showing expiration date, and
 'Certificate of Insurance' for current liability coverage, showing coverage limits
 and dates of coverage, where necessary.
Query results from AMA database and NPDB.
3.
All requests for temporary appointment will be reviewed and acted upon by the
Medical Education Committee.
4. Temporary appointments may be granted for no longer than 60 days . If, at the end of
the temporary appointment, credentials materials have not been presented as required
for approval by the Medical Education Committee and the Medical Executive
Committee, privileges will be terminated.
5. Temporary appointments will not be granted in lieu of full reappointments.

NON-RENEWAL OF RESIDENT APPOINTMENTS
In accordance with ACGME Institutional Requirements, residents who will not be reappointed (released from the program) must be notified in writing by the Program
Director at least four months prior to the end of the current appointment. However, if the primary reason(s) for non-renewal occur(s) within the four months prior to the end of the appointment, the Program Director must provide residents with as much written notice of the intent not to renew as circumstances will reasonably allow, prior to the end of the appointment. Making this determination should follow procedures set forth in the policy
“Evaluation, Promotion, and Retention of Residents”. In situations of this type, the
Director of Medical Education and the Medical Education Office should be notified as soon as possible and copies of letter of appointments provided to the Medical Education
Office.

TERMINATION OF RESIDENT APPOINTMENTS
1. The Medical Education Committee must be notified, in writing , when any resident is
terminated prior to the end of their current appointment period. The termination letter,
from the program director, must be accompanied by:
 A copy of the program director’s termination letter, and
 An evaluation of the resident's performance up to the date of termination. (See
also #3 under Requirements for Resident Reappointment )
2. The Medical Education Committee must be notified, in writing , when any resident’s
member resigns at the end of the current appointment period and will not be
reappointed. The termination letter, from the program director, must be accompanied
by:
 A copy of the residents member's resignation letter and
 An evaluation of the resident's performance up to the date of termination. (See
also #3 under Requirements for Resident Reappointment )

POLICY AND PROCEDURES FOR MENTAL/PHYSICAL IMPAIRMENT
Procedures for dealing with residents who may be impaired are outlined in the Resident
“Policy for Counseling and Support Services”, contained in the Resident Handbook or available in the Medical Education Office. In addition, the following procedures may apply:
* When reasonable question exists whether a clinician's mental or physical ability to practice medicine in any area privileged by Oakwood has been compromised to any degree, the program director or the Medical Education Committee may request a third party assessment of the clinician's condition.
* The Medical Education Committee or program director will notify a clinician in writing that a mental or physical examination is being requested and the reason for the request.
The letter will give the clinician an option of at least two health care providers from which to choose to conduct the examination. The cost of the requested examination will be borne by the clinician, unless otherwise agreed in writing.
* The physician conducting the examination will be required to submit a written report to the Medical Education Committee and/or the program director. If the report goes to the program director, then the program director must forward the report with his/her recommendations for privileging, based on the report, to the Medical Education
Committee. If the Medical Education Committee receives the report, then the Committee will share the report with the program director and request recommendations from them.
* Should the Medical Education Committee decide there is no reason for concern, then the report will be filed with that decision in the clinician's credentials file, and no further action shall be required.
* Should the Medical Education Committee decide to revoke or limit the clinician's privileges, this decision shall be subject to review in accordance with resident grievance procedures. Should revocation or limitation of privileges stand, before the clinician can request appointment anew or reappointment, a letter from a treating physician of the clinician must certify that the clinician is mentally and physically capable of practicing medicine. The Medical Education Committee may request an independent examination to verify the clinician's status in accordance with the procedures set forth above.
* Should the Medical Education Committee decide to grant privileges, but stipulate that they be for a term less than the standard one year and/or require that the physician's condition and performance be monitored, then before granting reappointment, a letter

from a physician following the clinician's condition and giving the clinician's health status must be presented to the Medical Education Committee. The Committee may request an independent examination to verify the clinician's health status in accordance with the procedures set forth above.
(See OHS Policy #417 Fitness for Duty)

GUIDELINES FOR RELEASE OF PRIVILEGING/CREDENTIALING
INFORMATION
PERSONS PERMITTED REVIEW OF FILES:
* A resident may review his/her credentials file.
* A program director may review the credentials file of any resident in that program.
* The Chair of the Medical Education Committee may review the file of any resident
whenever the purpose is related to his/her role in the privileging/credentialing process.
* Staff of the Medical Education and Residency Offices may review credentials files as
necessary to carry out their job responsibilities.
* Internal auditors for the Medical Staff and the Medical Center may review files after a
written request stating the purpose of the audit has been reviewed and approved by the
Graduate Medical Education Committee or the Chair of the Graduate Medical
Education Committee if determined to be urgent.
* Outside auditors for accreditation organizations, contractors or other government
organizations may review files after a written request has been reviewed and approved
by the Graduate Medical Education Committee or the Chair of the Graduate Medical
Education Committee if determined to be urgent.
RULES FOR REVIEW OF CREDENTIALS FILES:
* Files may not be taken from the Residency Office. Authorized reviews of files will
take place in the office.
* A staff person from the Medical Staff and Residency Office must be present while any
file is being reviewed.
* No information may be removed or copied from a file.
* Requests to remove or copy portions of a file must be approved by the
Graduate Medical Education Committee or the Chair of the Graduate Medical
Education Committee if determined to be urgent.

REQUESTS FOR INFORMATION FROM INSIDE THE INSTITUTION:
* Any person or part of Oakwood Healthcare may receive a listing of residents by
program and specialty upon written request so long as such listing is to be used for
Oakwood purposes.
* No other credentials file information will be sent without a written request stating the
purpose of the information until the Graduate Medical Education Committee or the
Chair of the Graduate Medical Education Committee has reviewed and authorized
such request.
REQUESTS FOR INFORMATION FROM OUTSIDE THE INSTITUTION:
* Any resident may request in writing that specific privileging/credentialing information
from his/her file be released to a designated third party.
* Information requested under court order will be released only after review and
approval by the Graduate Medical Education Committee or Chair of the Graduate
Medical Education Committee and legal counsel.
* Privileging/credentialing information will NOT be released to any others without
specific review and authorization by the Graduate Medical Education Committee or
Chair of the Graduate Medical Education Committee if determined to be urgent.
RULES FOR RELEASING PRIVILEGING/CREDENTIALING INFORMATION:
* All requests must be in writing with a copy of the request being placed in an
individual's file and a master file.
* All authorizations/approvals must be in writing and filed with the request in an
individual's file and the Medical Education Office master file.
* All information being sent out will be reviewed by the Program Director and the
Director of Medical Education before being sent out to insure that no unauthorized
or irrelevant information is included.
* The information sent out will be stamped CONFIDENTIAL on each and every page.

GUIDELINES FOR APPOINTMENT OF FOREIGN MEDICAL GRADUATES
TO RESIDENT POSITIONS
The primary requirement for the appointment of foreign medical graduates to resident positions is possession of a valid ECFMG certificate. The ECFMG (Educational
Commission for Foreign Medical Graduates) is authorized by the U.S. Information
Agency to sponsor foreign medical graduates in U.S. graduate medical education training programs. It is their responsibility to assure institutions that foreign medical graduates have medical knowledge and English language skills comparable to U.S. medical graduates. A Standard Certificate is issued to foreign medical graduates by the ECFMG upon fulfillment of certain credentials requirements and the successful completion of both medical (USMLE) and English tests. In reviewing an applicant's credentials for appointment, the following should be noted regarding the ECFMG Certificate:
 Verify that the expiration date of the English Test is valid. Upon initial certification, the English Test remains valid for two years. During that time, if the foreign medical graduate secures a U.S. position, the ECFMG will re-issue the certificate as Valid Indefinitely. Therefore, check the date to insure that it is or will be valid beyond the desired appointment date.
 New certificates often take up to two months to be printed. In lieu of a certificate, the ECFMG will provide a letter to the foreign medical graduate. In this case, make certain that the letter states that all requirements have been met and that the certificate will be issued.

CRIMINAL BACKGROUND CHECK REQUIRED FOR RESIDENTS
POLICY
1. Oakwood Healthcare requires a criminal background check as part of
the credentialing process for all residents.
2. Background checks will be performed only after the applicant has received an offer of
employment.
3. All employment offers are contingent upon satisfactory results of a criminal
background check.
4. Criminal background information released to Oakwood will be used only for
purposes of assisting in making hiring or other employment decisions.
5. If a background check identifies issues which may preclude employment, the case will
be referred to the Graduate Medical Education Committee for review and action or the
Chair of the Graduate Medical Education Committee.
PROCEDURE
1. Application: The Application for Appointment includes an inquiry about criminal
convictions. Applicants who refuse to complete this section or do not answer
truthfully and completely, will not receive offers of employment, or employees
will have their employment terminated. Any Resident Agreement already signed
will be cancelled.
2. Waiver/Consent: The Application for Appointment will include a Consent Form
for a Criminal Background Investigation. Refusal to provide adequate/correct
information or to provide consent for investigation will result in withdrawal of offer
of employment.
3. Inquiry:
a) The background check will be initiated by Human Resources as part of the routine
credentialing of residents prior to appointment.
b) A copy of the informed consent form will be faxed to the company authorized to
perform the background check.
c) A confidentiality agreement must be signed by the receiving company. The
authorized company will be instructed to provide results to authorized
individuals only.
4. Convictions:
a) If an applicant truthfully discloses conviction(s) on the application, an evaluation
of each conviction will be made before making a conditional offer of employment.
b) The existence of a conviction does not automatically disqualify an individual from
eligibility for employment. Relevant considerations may include, but are not
limited to the date, nature and number of convictions; the relationship the
conviction bares to the duties and responsibilities of the job; and successful efforts

toward rehabilitation. Any decision to reject or accept an applicant with a
conviction is solely at the discretion of Oakwood.
c) If the background check identifies a criminal conviction not disclosed on the
employment application, the applicant will be notified and the offer of employment
withdrawn.
d) If Oakwood becomes aware that a current employee has not completed the
application truthfully, he/she will be subject to disciplinary action up to and
including termination.
5. Results:
a) Confidentiality : Reasonable efforts will be made to ensure that results of criminal
background checks are kept as confidential as possible with a limited number of
persons authorized to review results. (Refer to #3 (d) above).
b) Access to Results : The Director of Medical Education will review all criminal
background checks concerns. If adverse information deemed to be relevant to the
applicant’s suitability for employment is contained in the background check, the
Director of Medical Education will notify the applicant in writing and will refer
the report the Medical Education Committee. The Graduate Medical Education
Committee or the Chair of the Graduate Medical Education Committee will make
all decisions relative to employment.
c) Information Available Through Background Checks : The criminal background
check will include a record of all arrests and convictions. In almost every case,
only conviction information will be considered. If the check reveals information
that could be relevant to the suitability for the job, the Medical Education
Committee may request additional information from the applicant.
d) Ability of Applicant to Review Information: The applicant may review the
criminal background check received by Oakwood by contacting the Director of
Medical Education in writing .
e) Right to Respond to Adverse Report: The applicant will be asked to review any
adverse information and to provide a written response to the Medical Education
Committee. When appropriate, the resident may be asked to meet with the
committee in person to answer questions.
f) Right to Change and/or Terminate Policy: Reasonable efforts will be made to
keep employees informed of any changes in the policy. However, Oakwood
reserves the right, in its sole discretion, to amend, replace, and/or terminate this
policy at any time.
Approved by:
Medical Education Committee
June 2003

CHECKLIST FOR INITIAL RESIDENT APPOINTMENT
DUE DATE SEPTEMBER 1st
Applicant's Name: __________________________________
1.
4.
2.
3.
5.
Program: __________________________________
Date Received: __________________________________
*Note that this form lists key words for required documents. Specific requirements are detailed in narrative section entitled "Requirements for Initial Appointment".
Have Need Comments
Residency Office Responsibilities:
PD Appointment Letter
Title (including subspecialty)
Inclusive Dates (1 year max)
Health Statement Comments/Issues
Application w/ original signature
Picture
Curriculum Vitae
Original Dean's Letter certifying date of graduation
Original Transcript
Original documentation of all training
____ ____ ____________________
____ ____ ____________________
____ ____ ____________________
____ ____ ____________________
____ ____ ____________________
____ ____ ____________________
____ ____ ____________________
____ ____ ____________________
____ ____ ____________________
completed at other institutions ____ ____ ____________________

6.
Original verification of all non-training clinical activities
Two original letters of
____ ____ ____________________
7.
recommendation ____ ____ _______________________
*NOTE: One letter from proposed or prior program director and other from supervisor or medical school.
8. Copy of Michigan license
(temporary or permanent) ____ ____ _____________________
9. Copy of USMLE scores
10. For Foreign Medical Graduates:
____ ____ ______________________
Notarized copy of valid ECFMG cert. ____ ____ ______________________
11. Verification of MD degree
(medical school diploma) ____ ____ _____________________
12. Supplemental application release statement
____ ____ _____________________
13. License Verification Form ____ ____ _____________________
14. AMA Profile ____ ____ _____________________
15. Valid ACLS/BLS Card ____ ____ _____________________
16. Job Description ____ ____ _____________________
17. Confidentiality Agreements ____ ____ _____________________
18. Orientation Documentation ____ ____ _____________________
19. Proof of Liability Coverage ____ ____ ________________________

Prior to authorization to begin work:
20. Human Resources Employment Application
____ ____ _____________________
21. Visa or Work Authorization if applicable ____ ____ _____________________
22. Health Statement- Human Resources
(Employment Clearance)
23. Drug Screen Results
____ ____ _____________________
____ ____ _____________________
24. Criminal Background Check ____ ____ _____________________

CHECKLIST FOR RESIDENTS REAPPOINTMENT
DUE DATE MAY 1st
Applicant's Name: __________________________________
Department:
Date Requested:
__________________________________
__________________________________
3.
4.
5.
6.
Program Responsibilities:
1. Residents Reappointment
recommendation
2. Inclusive Dates (1 year max)
Signature of Program Director
Supplemental Application Form
Have Need Comments
____ ____ _____________________
____ ____ _____________________
____ ____ _____________________
____ ____ _____________________
Documentation for YES responses ____ ____ _____________________
Original signature ____ ____ _____________________
7. Summative evaluation ____ ____ _____________________
8. Copy of Michigan license
(Temporary or Permanent)
9. License Verification Form
____ ____ _____________________
____ ____ _____________________
10. Transcript of USMLE Scores ____ ____ _____________________
11. Valid ACLS/BLS Card
12. Proof of Liability Coverage
____ ____ _____________________
____ ____ _____________________

13. Procedure Log ____ ____ _____________________
14. Healthstream Transcript
15. Professional Growth Record
18. Claims History
____ ____ _____________________
____ ____ _____________________
16. Current Performance Appraisal ____ ____ _____________________
17. Secure evaluation forms for residents changing departments ____ ____ ______________________
____ ____ ______________________

PROGRAM DIRECTOR
LETTER OF RECOMMENDATION FOR RESIDENT APPOINTMENT
Date: ____________________
To: Medical Education Committee
Oakwood Hospital and Medical Center
Dear Sirs/Madams:
I am recommending appointment of _________________________________________ to the position of Oakwood Resident PGY: I II III IV V (circle one).
This resident meets the ________________________________ Program’s eligibility and selection criteria as per program and GMEC policy.
The dates of appointment should be ____ /____/_______ to ____ /____/_______ .
A statement of this applicant’s physical and mental health is attached.
Thank you for your consideration of this applicant.
Yours Truly,
Program Director: _______________________ ___________
Signature Date
Approved by the Graduate Medical Education Committee:
Director of Medical Education: __________________________ ___________
Signature Date

RESIDENT REAPPOINTMENT RECOMMENDATION
Reappointment Period
__________________________________________________________
Resident Member's Name
_____________________________________________________
Program (including subspecialty)
________________________________________________
Title _________________________________________
Year in This Program (not PGY level) ___________
Current program (if different from above)_____________________________________
Current year of training _________
I have reviewed this resident member's performance and progress in the training
program with him/her, in accordance with institutional policies and the specific
ACGME (or other accrediting agency) requirements for this program. Also
attached is a copy of the program’s annual evaluation form in support of this
reappointment request.
I find this resident member's performance to be:
Acceptable and recommend him/her for reappointment. _____
_____ Unacceptable and have instituted corrective action (see attached CAP).
I am confident that these actions will resolve the problem and recommend him/her for reappointment with the stipulation that patient care responsibilities be limited as set forth in his/her corrective action plan.
_____ Unacceptable where deficiencies do not permit recommendation for reappointment.

In addition, I have reviewed this resident member’s clinical competence and acquisition of the skills identified for this level of training in the program curriculum and recommend that:
_____ He/she be advanced to the next level of training with patient care
responsibilities commensurate with his/her training and experience with
increasing independence as appropriate for his level and training.
_____ he/she be retained at the current level of training with patient care
responsibilities limited as set forth in his/her corrective action plan for the
following reasons:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
The condition of this resident’s physical and mental health is:
_____ Satisfactory for patient care responsibilities.
_____ Some physical and/or mental health issues which are being
accommodated in the following manner:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Signature, Program Director:
Date: ________
_______________________________
Signature, Department Chief:
Date: _______________
________________________________
Department: ___________________________________
Approved by the Graduate Medical Education Committee:
__________________________________
Director of Medical Education
_________________
Date

Attach photo here
SUPPLEMENTAL APPLICATION FOR RESIDENT APPOINTMENT
Please print legibly or type all information. MUST ATTACH CURRENT
PHOTOGRAPH.
Name___________________________________ Social Security No.________________
Work Address_____________________________________________________________
Telephone________________________
Home Address_____________________________________________________________
Telephone________________________
Current Program __________________________________________________ Current
Title___________________________
New Program (if changing)_________________________________________ New
Title_______________________________
Please respond to the following questions. If you answer YES to any of these questions, except for question #1, you must provide a full explanation of the details on a separate sheet, including date, place, reason, and disposition of the matter, as well as other, relevant information.
1. Health Status:
YES NO

If you perform invasive procedures, have you complied with the
U.S. Public Health Service recommendation to know your health
status regarding blood borne pathogens such as hepatitis B and
human immunodeficiency virus?
____ ____

Do you currently suffer from any physical, mental, or emotional
problems which affect, or is likely to affect, your ability to perform
your duties as a residents member or which may place a patient at risk?
____ ____

4.
5.
3.
2. may place a patient at risk?

Do you take any medication or drugs (including alcohol or any form of drug, legal or illegal) which affect, or is likely to affect your ability to perform your duties as a residents member or which
YES NO
____ ____
Have you ever been denied clinical privileges by or appointment ____ ____ to any health care facility or managed care entity?
Has your membership status or clinical privileges by another health care provider or managed care entity ever been revoked, suspended, reduced, or not renewed?
____ ____
Has your membership in a local, state, or national medical society or other professional society ever been suspended, terminated, or denied?
Has any state licensing board revoked, suspended, limited, or denied a certificate or license to you or taken any other disciplinary action?
____ ____
____ ____
6.
Please attach a copy of your current medical license.
Have you ever voluntarily relinquished your professional license (including DEA), any or all clinical privileges, or membership in a medical society or association:
7.
a) While under investigation by the health care entity, or ____ ____ b) In return for not conducting such investigation or
proceeding.
Has your narcotic license ever been revoked, suspended, or limited in any way?
8.
Have you ever been denied a DEA registration number or been issued a restricted registration?
If currently registered, give number and state of issue.
____ ____
____ ____
____ ____
Controlled Substance Number ____________________ Expiration __________
License Number ________________________ Expiration __________


Has a lawsuit ever been settled on your behalf?

Has a verdict ever been rendered against you in a
malpractice lawsuit?
9. Malpractice information:

Have you ever had a malpractice claim filed against you or is a claim currently pending against you?
YES NO
____ ____
____ ____
____ ____

Have you ever been denied professional liability coverage?
____ ____
If yes, to any, please provide claimants name, date of suit, allegations, and any payments made on a separate piece of paper and attach.
10.
Have you ever been suspended, excluded, or debarred ____ ____ from participation or otherwise, sanctioned or had civil monetary penalties levied against you by a Medicare,
Medicaid, or other Federal program? Do you have outstanding payments with Medicare?
11.
Have you ever been convicted, entered into a plea bargain, or pled Nolo Contendere to a felony, crime of moral turpitude, healthcare fraud or other crime related to governmentally financed healthcare programs, or criminal abuse or neglect of patients?
12.
Do you currently have clinical privileges at any other institution(s)?
____ ____
____ ____
Should the answer to any of these questions change, I understand that I am under a continuing obligation to notify my Program Director and the Graduate Medical
Education Committee of such change or changes in writing so long as I remain a member of the residency program.

I hereby make application for appointment/reappointment to the residency programs of the
Oakwood Healthcare System. I understand and agree that I, as an applicant for Resident membership, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications. I fully understand that any significant misstatements in or omissions from this application constitute cause for denial, modification, or revocation of my appointment and/or clinical privileges. I confirm that all information submitted by me in this application is true to my best knowledge and belief.
Further, should reasonable question exist regarding my physical or mental ability to perform the privileges granted, I agree to undergo a mental or physical examination if requested and, if this shows evidence of mental or physical impairment, to provide evidence that the impairment does not interfere with my professional competence.
I agree to the release of my credentialing and privileging information by the Credentials
Committee and its staff office for such purposes where authorized by such contract and/or endorsed by the Health System in accordance with established policy. My credentialing and privileging information may be released only for the purpose of my being credentialed under an institutional contract or for credentialing by an arm of the University, unless otherwise explicitly authorized by me in writing. All reasonable efforts will be made to maintain the confidentiality of my information and to preserve any legal privilege afforded the information.
If granted clinical privileges, I agree, as a Resident in the Oakwood Healthcare System, to abide by the established practices, procedures, and policies of the Medical Centers and those of its programs, clinical departments, and other institutions to which I may be assigned. Further, I pledge to maintain an ethical practice, abiding by the ethical principles set forth by the American Medical Association, with my patient’s interest at the center of the care I render to him or her.
Signature of Applicant________________________________________________
Date of Application__________________

INFORMED CONSENT/RELEASE FOR
CRIMINAL BACKGROUND INVESTIGATION
I hereby authorize the Oakwood Healthcare System Office of Medical Education, or any qualified agent of Oakwood Healthcare, to obtain the following in connection with my appointment as house officer: criminal background information including copies of my past and present law enforcement records. This criminal background investigation is being conducted for the purpose of assisting the Oakwood Healthcare Resident Credentials and GME Committees in evaluating my suitability for appointment to the residency. The release of information pertaining to this criminal background investigation is expressly authorized.
I understand that information contained in the criminal background report may result in the withdrawal of my offer of training. I also understand that any such withdrawal may be appealed to the Graduate Medical Education Committee.
I understand that I have a right to review the information that the Oakwood Healthcare System
Medical Education Committees receive in this criminal background investigation by putting a request in writing, and that I may respond to the information.
I understand that all reasonable efforts will be made by Oakwood Healthcare to protect the confidentiality of this information.
I further understand that the results of the criminal background check will be reviewed by the
Oakwood Healthcare System Medical Education Committees. If negative information is contained in my report, I understand that I will be notified by the respective Director of Graduate
Medical Education and will be asked to provide information in writing to the Medical Education
Committee. In the case of a negative decision by the Graduate Medical Education Committee, I understand that I may appeal any decision subject to the “Due Process Policy” as outlined in the
Resident Handbook.
I hereby release those individuals or companies from any liability or damage in providing such information. I agree that a photocopy of this authorization may be accepted with the same authority as the original. I hereby further release Oakwood Healthcare and its agents and employees from any and all claims, including but not limited to, claims of defamation, invasion of privacy, wrongful termination, negligence, or any other damages of or resulting from or pertaining to the collection of this information.
________________________________
Signature of Applicant
______________________
Date
_____________________________
Print Name

1. Each graduate medical education program sponsored by the institution will maintain a file concerning each resident or subspecialty resident/fellow (trainee).
2. During training, the file will contain all written evaluative information concerning the resident including:

Record of rotations/training experiences/procedures



Written evaluations
Periodic summative evaluations
Other material judged appropriate by the program director
3.




The file will be regarded as confidential and will be kept in a secure location.
Only the following will have access:

Program Director & Director of Graduate Medical Education or their designee
Programs Resident Evaluation Committee
Others whom the program director or Director of GME deem to have a legitimate need for the information
Administrative Staff
Others as authorized in writing by the trainee
4. The following will be printed on the exterior of the file:

This file contains confidential information

Access to this file and the information contained therein is governed by the record access and retention policy
5. The trainee shall have access to his/her file under direct supervision of a designated staff member of the residency program office.
6. For residents who have completed the program successfully and who will be
7. recommended for Board certification, the following will be retained permanently:

Summative evaluation


Records of trainee’s rotations, training experiences, and procedures
Record of disciplinary actions required to be reported to state licensing
 agencies
Other records per the program director
Record Access and Retention
For residents who do not complete the training program at the standard required for Board certification, the entire file will maintained as a permanent record.

8. The resident files are to be reviewed bi-annually by the Medical Education office staff. The following material will be checked for in all resident files:














Application
AMA verification
Contract
Current license
ECFMG certification
ACLS certification
ECFMG certificate
Mid-year evaluation
Procedure logs
Summary
USMLE part I
USMLE part II
USMLE part III (if applicable)
Visa (if applicable)
The following items will be maintained for reimbursement purposes in a sub-file for each resident file, (a similar file will be maintained in Medical Education administration for residents rotating into Oakwood sites and training programs from other institutions):

Copy of current/latest license





Copy of ECFMG certificate (if applicable)
Resident information form
All rotation schedules applicable to that resident
Information on clinical activity occurring during research months
Summary of all elective rotations including name and address of site and supervising physician
9.
Information from all residents’ general competency assessments in all six areas
(patient care, medical knowledge, practice based learning, interpersonal and communications skills, professionalism, systems-based practice) will be included in the residents file with a summary of faculty reviews of progress and recent actions.
File Retention
10. Resident files are maintained in individual residency programs. Once a resident has graduated or left the program, their file is kept in the department for three years. After three years, their file is sent to storage.

11.
Once a verification of residency form has been received, the resident’s file is sent for (if over 3 years), or pulled from the filing cabinet. It is then given to the individual residency program director for signature on the form provided or on a letter, if required.
12. A copy of the form/letter, along with the request and authorized release form signed by the resident, and any other information sent, is placed in the resident’s file and put back in the filing cabinet or sent back to storage.
Verification Fee
13. Due to the increasing number of requests for verification and evaluation of completed post-graduate training, the Oakwood Healthcare System Medical
Education department is requiring a handling fee of $25.00 for any graduate who has been out of the program more than three years.

Licensure Verification Policy http://oaknet/documents/PolsNProcs/HR/518.pdf

Oakwood Healthcare, from time to time, may reevaluate the types and sizes of its residency programs. An advisory group including stakeholders from residency programs, medical staff and administration, will review pertinent information and make recommendations regarding such closures or size reductions to the Medical Education
Committee and Oakwood administration. Final decisions are the responsibility of
Oakwood’s Governing Board and its Executive Council.
If Oakwood determines that it is necessary to reduce the size of a residency program or to close a residency program, Oakwood shall inform the DIO, GMEC, program director and residents within 60 days of the final decision. In the event of such a reduction or closure,
Oakwood 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 reduction in the number of residents, Oakwood shall make every effort to assist the residents in identifying a program in which they can continue their education.
Revised 03/17/11

Purpose: The Policies and Procedures for Resident Travel Grants establishes and defines the circumstances under which the Department of Medical Education will financially support the expenses incurred for travel to professional conferences to present scholarly projects conducted during residency at Oakwood Healthcare. The availability of travel funds is not guaranteed .
1.
The Research Committee will consider each request at their monthly meeting.
The resident will provide a copy of the abstract, letter of acceptance, and completed form with budgetary estimates as soon as possible after notification of acceptance.
2.
The project must have been presented to the Research Committee and approved previously.
3.
The committee will consider the status of the meeting, the difficulty in getting accepted to present, the projects standing with the IRB, as well as budgetary considerations in their decision.
4.
If a second author has made a significant contribution to the work, the Committee will decide on a case-by-case basis on that author’s attendance.
5.
Budgetary considerations will consider the availability of appropriate funds in the following order:

The available funds in the Resident’s account.

The available funds in the Medical Education Research fund.

The available funds in the residents program’s General fund.

The available funds in Medical Education’s General fund.
6.
Travel will be supported within the following parameters:
The meeting must be within the continental US. Please refer to Oakwood Healthcare
System Travel Policy on Oaknet.
Funds will be provided for:

Up to advance (at least 3 weeks) coach class plane fare. Mileage for travel by car up to the coach fare amount. Rental cars are not covered.

Registration fee for conference. Early or pre-registration, late registration fees not covered.
 2 nights stay in hotel. The conference’s lowest price blocked rooms for meeting presenters, deemed reasonable for conference location.


2 days of meals for presenter only (meal costs are expected to be reasonable) with itemized receipts. Meals provided by the conference sponsors will not be reimbursed. Alcoholic beverages are not reimbursable.
7.
The Faculty Research Mentor and Program Director must sign the application form to indicate their support for the travel and their agreement that the estimated costs are reasonable and appropriate. Then the application must be brought to the
Research Committee for approval before travel is taken.
8.
One grant will be made to a single resident per academic year and only covers the primary author/presenter. If the primary author cannot attend; then a presenting co-author can use funds to present in their place.
9.
Funds are not available to residents whom have graduated.
10.
Once travel is completed, the resident must complete an “Itemized Expense
Statement for Approved Travel” with all original receipts attached (registration fee, lodging, meals, airfare, etc.) provide their signature, and attach a copy of the appropriate pre-approvals (based on the source of funding) in their Resident
Travel Grant Application. The resident should submit this to their program coordinator within 14 calendar days for reimbursement processing.
11.
Exceptions to this policy will be made only with advanced approval by the
Medical Education Research Committee.

(Resident’s Funding Account must be Exhausted)
Resident: __________________________________Beeper: ________________
Program & Year:
_____________________________________________________________________
Abstract Title:
_______________________________________________________________________
Title of Meeting/Location:
Dates to be held:
_____________________________________________________________________
Estimated Costs (See policy & Guidelines):
Round trip coach fare or mileage:
Meeting registration fee:
$__________
__________
Two nights hotel stay:
Meals for 2 days:
__________
__________
I agree that the funds requested are appropriate for the applicant’s attendance at this meeting.
___________________________________________
Faculty Research Mentor Signature
(prior to submission)
___________________________________________
Program Director Signature
(prior to submission)
Travel grant approved by Research Committee:
_________________________________
Initialed & Dated
_______________________
Date
________________________
Date

Resident’s General Program Funding Available: ______Yes _____ No
Medical Education General Fund Available: ______ Yes _____ No
Approved by: _______________________________________
For Medical Education Administrative Use:
Date received: _______________
Date submitted for reimbursement: ________________
Funding Source: _______________________________

The intent of this policy is to describe requirements for residents’ scholarly activity at
Oakwood Healthcare System. It is understood some requirements may exceed those of the ACGME or specific specialty committees.
1. All residents who train at Oakwood for more than one year are expected to participate in, complete, and present the results of a scholarly project to successfully complete their graduate program of study. Oakwood Healthcare
System will support these efforts with appropriate resources, including guidance from the Research Director and available funds to cover expenses approved by the
Research Committee. Residents must meet the expectation for completion of various steps in the project by the end of their respective post-graduate years as specified in the resident research project timeline for that program.
2. All academic projects (i.e., case studies, case series, chart reviews, educational websites, experimental & quasi experimental studies, new curriculum, observational studies, review articles, survey research and/or projects nested within randomized control trials), intended to fulfill the residents research requirements as defined by Medical Education and the specific residency program
(note that some residency programs may have different requirements) must be presented to the research committee for review.
3. All residents must complete a research project that has been reviewed by the following: resident’s mentor, program director, Medical Education Research
Committee, and the Institutional Review Board (unless otherwise exempted) in order to successfully complete the training program.
4. Projects must be presented to the Research Committee prior to seeking IRB approval. Certain exceptions may exist for projects nested within larger ongoing trials or other forms of programmatic research. Under these circumstances the resident must submit to the Research Committee once a project has been defined with the intent to fulfill the residents research requirements even if IRB approval has already been sought and/or the protocol methods are essentially fixed. This must occur before the project can be approved for formal credit, or before it is submitted to Oakwood’s Resident Research Day.

5.
6.
Projects not presented to the Research Committee will not be eligible for
Oakwood’s Resident Research Day, or be eligible for additional Medical
Education monies to support costs of conducting the research, travel associated with presenting the research, or time/costs associated with preparation of visual displays associated with the research.
Residents who do not complete and present a scholarly project by the end of their residency training will have the following including in all letters of reference regarding privileges or positions requested of any residency director (program, associate or assistant), for that individual:
“All requirements of the residency program have not been met. Specifically, [program] has a requirement for completion of a research project during the resident’s training and this has not been fulfilled.”

Introduction:
In response to residents need for scrubs, the following policy and procedures are effective immediately. All areas within the hospital requiring sterile procedures will be provided hospital owned and laundered ceil blue scrub apparel.
All hospital owned and laundered scrubs will remain on the hospital premises. Scrubs should not be worn into the hospital and you should not leave the hospital in your scrubs.
Please change into and out of scrubs at the hospital.
Scrub Dispensing Machines:
The scrub dispensing machines are located in outpatient surgery, operating room, and labor/delivery. You may use any of these areas to check out or check in scrubs. Make sure your ID badge is programmed for ALL of these areas.
Security department on the first floor will program your card for three pairs of scrubs.
Once these have been dispensed no more will be issued until at least one set is returned.
In order to receive proper credit for return, all scrubs must be returned to the auto-valet return unit using your ID badge.
Individuals who have not returned their issued scrubs within 30 days will be billed for the scrubs checked out to them.
This policy is intended to meet your needs for scrubs and to reduce the annual loss rate for scrubs. Please cooperate with this policy and we should be able to accomplish both.
Please see Dress Code policy section E.

Sentinel Event http://oaknet/documents/PolsNProcs/OHI/1033.pdf

Submission of ACGME Correspondence by Program Directors
1.
The Institutional Requirements of the ACGME require that the GMEC provide oversight of all significant program changes and that the following must be reviewed and approved by the GMEC prior to the submission to the ACGME by program directors: a.
All applications for ACGME accreditation of new programs; b.
Changes in resident complement; c.
Major changes in program structure or length of training; d.
Additions and deletions of participating sites; e.
Appointments of new program directors; f.
Progress reports requested by any Review Committee; g.
Responses to all proposed adverse actions; h.
Requests for exceptions of resident duty hours; i.
Voluntary withdrawal of program accreditation; j.
Requests for an appeal of an adverse action; and, k.
Appeal presentations to a Board of Appeal or the ACGME.
2.
The DIO must review and cosign all program information forms and any documentation or correspondence submitted to the ACGME (or its RRC’s) by program directors. This must specifically include any documentation or correspondence submitted to the ACGME (or its RRC’s) related to the program change requests listed above.
3.
In the absence of the DIO, the Director of Curriculum & Evaluation, or the administrator assigned to cover the DIO in his absence, shall have designated authority to sign required documentation or correspondence submitted to the
ACGME (or its RRC’s) that is due prior to the DIO's return, or within the covering administrator’s reasonable expectation of the need for submission.

Revised 06/2011
1.
All resident patient care activity must be supervised by an attending physician with the appropriate clinical privileges at Oakwood. All operative and major invasive procedures require the presence of an attending physician in the operating room or interventional/cath lab with the resident, except during wound closures. The management of each patient’s care is ultimately the responsibility of the attending physician.
2.
Residents and faculty members should inform patients of their respective roles in each patient’s care.
3.
Residents’ service responsibilities must be limited to patients for whom the teaching service has diagnostic and therapeutic responsibility, except in rare circumstances such as Code Blue or other emergency situations. (Teaching
Service is defined as those patients for whom residents routinely provide care)
4.
Residents must write all orders for patients under their care, with appropriate supervision by the attending physician. In those unusual circumstances when an attending physician or subspecialty resident writes an order on a resident’s patient, the attending or subspecialty resident must communicate his or her action to the resident in a timely manner.
5.
Each physician of record has the responsibility to make management rounds on his or her patients and to communicate effectively with the residents participating in the care of these patients at a frequency appropriate to the changing care needs of the patients.
6.
Residents or other appropriate supervisory physicians (e.g., subspecialty residents, fellows, or attendings) with documented experience appropriate to the acuity, complexity, and severity of patient illness must be available at all times on site to supervise first-year residents.
7.
The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members. a) The program director must evaluate each resident’s abilities based on specific criteria. When available, evaluation should be guided by specific national standards-based criteria. b) Faculty members functioning as supervising physicians should delegate portions of care to residents, based on the needs of the patient and the skills of the residents.
Revised 06/2011

c) Senior residents or fellows should serve in a supervisory role of junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow.
8.
To ensure oversight of resident supervision and graded authority and responsibility, the program must use the following classification of supervision: a) Direct Supervision – the supervising physician is physically present with the resident and patient. b) Indirect Supervision with direct supervision immediately available - the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision. c) Indirect Supervision with direct supervision available - the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision. d) Oversight – The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
9.
GME programs must provide for progressive development and responsibility for their residents while ensuring safe and appropriate care for patients. Programs must demonstrate that the appropriate level of supervision is in place for all residents who care for patients. A policy will be provided by each GME program describing the process faculty and program directors use to make decisions regarding residents’ readiness to assume progressive responsibility. In conjunction with this policy, each residency program will provide written descriptions of the role, responsibilities, and patient care activities for each postgraduate year level resident. These will include specific reference to who may write orders, what chart entries must be co-signed by the attending physician, what procedures may performed, and the mechanisms used for resident supervision. Programs must post residents credentials for performing procedures without direct supervision on OakNet.
10.
Programs must set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members, such as admissions, the transfer of a patient to an intensive care unit, discharge or end-oflife decisions.
11.
The department’s QA Committee will regularly submit to program directors reports on the residency program’s clinical quality issues. Program Director’s will submit to the Medical Education Committee annually a review of the residency program’s clinical quality issues to include: a) a summary of random chart audits conducted to ensure the above policies and procedures are being followed
Revised 06/2011

b) a review of any substantive quality of care issues involving the program identified during that period and the resulting action plans and follow-up c) specific patient safety initiatives that have been undertaken, and d) any actions taken in regards to resident performance in their program.
12.
The ACGME Institutional Requirements, and the Common Program
Requirements, specify that resident supervision must be assured at all times.
Programs must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient’s care:
Program Directors or their designees should always be available by page to the residents for supervision in the case that they are unable to contact faculty or medical staff for supervision. They must notify the page operator and the Medical
Education office of the designated “back-up” physician supervisor for the residents in their absence. The Director of Medical Education or their designee is available at all times through the page operator as a final back-up, in case faculty, program director or designee cannot be contacted for some reason.
These procedures will ensure that there is always a physician available to the residents for consultation and supervision of their patient’s clinical care. Program
Director should communicate with all of faculty and house staff outlining the procedures that will ensure 24 hours a day, 7 days a week, availability of supervision to residents for their clinical care activities. They should immediately notify the page operator of their availability status, or the designated emergency back-up physician for their program.
Finally, an e-mail or memorandum should be sent to the Medical Education office and the page operator, when the program director or their designee is delegating responsibility to another physician in case of vacation or leave.
13.
Faculty and residents will be provided annual education on resident supervision policies.
14.
Compliance with resident supervision policies will be monitored by the GMEC.
This will include the regular review of resident supervision compliance through: a) Review of posted program policies, job descriptions and credentialing at least annually b) Annual resident survey data (both internal and ACGME resident surveys) c) Internal reviews of residency programs.

I.
Purpose/Objective: To provide information and guidelines with regard to transitions of care within OHI residency programs.
II.
ACGME Transitions of Care Common Program Requirements:
VI.B.1. Programs must design clinical assignments to minimize the number of transitions in patient care.
VI.B.2. Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety.
VI.B.3. Programs must ensure that residents are competent in communicating with team members in the hand-over process.
VI.B.4. The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient’s care.
III.
General Information a.
In order to comply with the Common Program Requirements and implement safe and effective processes by which patients’ care is handedover, each residency program is required to demonstrate specific policies, education and practice that, at the minimum, incorporate the following: i.
A rotation or assignment structure that minimizes the number and frequency of handovers.
1.
And an accessible schedule that clearly delineates who is caring for whom. ii.
Ongoing education for faculty and residents that addresses: 1) how to better understand handover risk, 2) how to best communicate to one another, 3) how to best work as a team, and 4) what it means, professionally, to hand over a patient and their care. iii.
Processes that are:

1.
Standardized
– handovers must use a uniform, electronic template, conducted in a designated space, at a designated time, without interruptions. The handover process should be face-to-face, guided by checklists, interactive questioning and read-backs.
2.
Supervised – handovers must be supervised by qualified senior residents or faculty at a level of involvement and frequency to ensure effectiveness and safety.
3.
Monitored and improved – residency programs must put in place a way to monitor or “test” the effectiveness of their structure, education and processes to ensure safe and effective hand-overs. a.
For example: audits, OSHE (observed, structured handoff exercises), videotaped analysis, feedback and follow-up (review in M&M for example), faculty review of sign-out paper s.

Purpose:
This policy is intended to verify and credential the qualifications of interns, residents and fellows who rotate at OHS. This process also guarantees that OHS will receive appropriate reimbursement and insures that all rotations have professional liability insurance.
Procedure:
1. Residents/Fellows, Interns from non-Oakwood residency programs must complete the Rotation Application Form 60 days prior to start of desired rotation, according to directions on page 1 of the application (attached).
2. Resident will complete Part I and forward to their Program Director. Program
Director will complete Part II and mail to Medical Education by mail or fax as indicated on front of application.
3. Resident must also furnish copies of these documents 60 days before rotation begins: a) Michigan License (permanent or educational) b) Proof of ACLS certification c) Copy of ECFMG certificate (if applicable) d) A current resume e) Michigan controlled substance license
4. The Medical Education office will review the materials submitted and inform residents and their program directors if the requested rotation has been approved.