Policies and Procedures Manual

About GME

Graduate Medical Education is the phase of formal medical education beginning at graduation from medical school and ending after the educational requirements for one of the medical specialty certifying boards have been completed. The objective is to prepare physicians for the independent practice of medicine.

State licensing boards have varying requirements for post-MD clinical training, and almost every medical school graduate now spends from three-to-seven years in postgraduate training. The term "residency" is commonly used to describe this training period. At the conclusion of the residency period, some individuals enter an additional year of training as chief resident. Others enter a fellowship in one of the discipline's subspecialties. A fellowship usually encompasses a one to three-year period, and often includes time for research.

The resident physician is both a learner and a provider of medical care. The resident is involved in caring for patients under the supervision of more experienced physicians. As their training progresses, residents gain competence and require less supervision, progressing from on-site and contemporaneous supervision to more indirect and periodic supervision. Throughout their training, residents also serve as teachers and join with faculty members to educate medical students and more junior residents in the hospital setting.

Programs are accredited by the Accreditation Council for Graduate Medical Education (ACGME), which, in turn, acts on the recommendations of 26 Residency Review Committees (RRCs), each of which serves a medical or surgical specialty. Specialty certifying boards establish the educational criteria that residents must achieve to be eligible for board certification. These criteria include the length of time for education and training and, to a significant degree, the content of the training program. These are detailed in the Special Requirements for each specialty's residency programs and complement the Common Program Requirements promulgated by the ACGME.

Mary Hitchcock Memorial Hospital (MHMH), as part of Dartmouth-Hitchcock Medical Center, assumes accountability for the quality of the GME training programs it sponsors. While each program assumes responsibility to ensure integrity under the purview of their RRC, institutional oversight is maintained by the MHMH Graduate Medical Education Committee (GMEC). The GMEC is principally comprised of program directors and has representation from the resident group, program coordinators, the Department of Nursing and Hospital Administration. The Committee meets eleven times a year on the second Monday of the month. The GME Office (hereafter in this manual referred to as GME) implements institutional policies and procedures approved by the GMEC. GME maintains house-staff and accreditation records, facilitates internal reviews of educational programs, serves as liaison with the ACGME, coordinates benefit programs for house staff, and supports the administration of individual programs.

Statement of Commitment to Graduate Medical Education

Dartmouth-Hitchcock Medical Center (DHMC) is an integrated academic medical center consisting of four distinct entities: Mary Hitchcock Memorial Hospital, Dartmouth-Hitchcock Clinic, Veteran Affairs Medical Center (WRJ, VT), and Dartmouth Medical School. Mary Hitchcock Memorial Hospital is the sponsoring institution of record for all accredited graduate medical education (GME) training programs and has supported such programs since 1895.

As the sponsoring institutions for GME, Mary Hitchcock Memorial Hospital and the integrated partners comprising DHMC commit to ensuring that all ACGME-accredited programs remain in substantial compliance with the ACGME's institutional and program-specific requirements. Furthermore, DHMC strives for continuous improvement in the effectiveness of all its GME programs via ongoing assessment of educational and medical practice. In this way, DHMC leads transformation of graduate medical education in our region, helps set new standards at the national level, and supports our vision of achieving the healthiest population possible.

DHMC's four component institutions pledge appropriate resources to support GME trainees and their educational environment, including an organized administrative system to oversee all residency and fellowship programs through the activities of our Graduate Medical Education Committee and the Associate Dean for Graduate Medical Education. In addition, DHMC is dedicated to the proposition that advancement of patient care is supported by a strong educational environment and as such, is specifically committed to the ongoing development and support of a strong teaching faculty.

DHMC's commitment to conduct and support graduate medical education programs furthers our combined missions of providing the highest quality care to our patients and educating future generations of physicians to serve our community, the Northern New England regions, and beyond. The governing authorities; the administration; and teaching faculty and staff of Dartmouth-Hitchcock Medical Center endorse this statement of institutional commitment as developed by the Graduate Medical Education Committee.

ACGME Competencies

MHMH is committed to providing house staff with an educational environment that allows a resident or fellow to demonstrate to the satisfaction and understanding of the faculty, the following attributes and objectives as set forth by the ACGME.

Each residency program enables its residents to develop competencies in six areas. Toward this end, programs define the specific knowledge, skills, and attitudes required, and provide educational experiences as needed, in order for their residents to demonstrate the competencies.

As specified in the ACGME Common Program Requirements, all DHMC training programs have integrated the general competencies into written curriculum and evaluations related to education and clinical care. Programs use resident performance data as the basis for program improvement and provide evidence for accreditation review. Programs are expected to use external measures (e.g., clinical quality indicators, patient surveys, employer evaluations of graduates, national and specialty standardized measures) to verify resident and program performance levels.

The six core competencies and sub-competencies, as defined by the ACGME are as follows:

Patient Care

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

Communicate effectively and demonstrate caring and respectful behavior when interacting with patients and their families.
Gather essential and accurate information about their patients.
Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment.
Develop and carry out patient management plans.
Counsel and educate patients and their families.
Use information technology to support patient care decisions and patient education.
Perform competently all medical and invasive procedures considered essential for the area of practice.
Provide health care services aimed at preventing health problems and maintaining health.
Work with health care professionals, including those from other disciplines, to provide patient-focused care.
[as further specified by each ACGME Review Committee]

Medical Knowledge

Residents must demonstrate knowledge about established and evolving biomedical, clinical epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to:

Demonstrate an investigatory and analytic thinking approach to clinical situations.
Know and apply the basic and clinically supportive sciences which are appropriate to their discipline.
[as further specified by each ACGME Review Committee]

Practice-Based Learning and Improvement

Residents must demonstrate the ability to investigate and evaluate their patient care practices, to appraise and assimilate scientific evidence, and continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to develop skills and habits to be able to meet the following goals:

Analyze practice experience and perform practice-based improvement activities using a systematic methodology;
Obtain and use information about their own population of patients and the larger population from which their patients are drawn;
Locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems;
Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness;
Facilitate the learning of students and other health care professionals;
[as further specified by each ACGME Review Committee]

Interpersonal and Communication Skills

Residents must demonstrate interpersonal and communication skills that result in effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to:

Create and sustain a therapeutic and ethically sound relationship with patients;
Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills;
Communicate effectively with patients, families and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds;
Communicate effectively with physicians, other health professionals, and health related agencies;
Work effectively as a member or leader of a health care team or other professional group;
Act in a consultative role to other physicians and health professionals; and,
Maintain comprehensive, timely and legible medical records, if applicable.
[as further specified by each ACGME Review Committee]

Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles and a sensitivity to a diverse patient population. Residents are expected to demonstrate:

Compassion, integrity, and respect for others;
Commitment to ethical principles;
Responsiveness to patients needs that supersedes self-interest;
Respect for patient privacy and autonomy;
Accountability to patients, society and the profession; and,
Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
[as further specified by each ACGME Review Committee]

Systems-Based Practice

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to effectively call on other resources to provide optimal health care. Residents are expected to:

Work effectively in various health care delivery settings and systems relevant to their clinical specialty;
Partner with health care managers and health care providers to assess, coordinate;
Practice cost effective health care and resource allocation that do not compromise quality care;
Advocate for quality patient care and assist patients in deal with system complexities;
Work in interprofessional teams to enhance patient safety and improve patient care quality; and
Participate in identifying system errors and implementing potential systems solutions.
[as further specified by each ACGME Review Committee]

Eligibility & Selection

This section contains information on the qualifications to be eligible for appointment as a resident or fellow, and criteria used in applicant selection.

Eligibility Requirements

Applicants must meet one of the following qualifications to be eligible for appointment to ACGME-accredited residency and fellowship programs at DHMC:

Graduates of medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME) and successful completion of any pre-requisite accredited training specified by ACGME Residency Review Committees. Some programs require successful passage of board exams (or good faith effort to pass) for promotion through subsequent years of fellowship.
Graduates of colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA) and successful completion of any pre-requisite accredited training specified by ACGME Residency Review Committees.
Graduates of medical schools outside the United States and Canada who meet one of the following qualifications:
- Have a currently valid certificate from the Educational Commission for Foreign Medical Graduates prior to appointment, or
- Have a full and unrestricted license to practice medicine in a US licensing jurisdiction in which they are in training, and
- Successful completion of any pre-requisite accredited training specified by ACGME Residency Review Committees.
Graduates of medical schools outside the United States who have completed a Fifth Pathway program* provided by an LCME-accredited medical school and successful completion of any pre-requisite accredited training.

* A Fifth Pathway program is an academic year of supervised clinical education provided by an LCME-accredited medical school to students who meet the following conditions: (1) have completed, in an accredited college or university in the United States, undergraduate premedical education of the quality acceptable for matriculation in an accredited United States medical school; (2) have studied at a medical school outside the United States and Canada but listed in the World Health Organization Directory of Medical Schools; (3) have completed all of the formal requirements of the foreign medical school except internship and/or social service; (4) have attained a score satisfactory to the sponsoring medical school on a screening examination; and (5) have passed either Parts I and II of the examination of the National Board of Medical Examiners or Steps 1 and 2 of the United States Medical Licensing Examination (USMLE).

Additionally, upon matching with Dartmouth-Hitchcock Medical Center, applicants must meet all of the following requirements:

Applicant must consent to a criminal background check.
Applicant must pass a pre-employment drug screening.
Applicant must meet eligibility requirements to obtain and maintain a training license in the State of New Hampshire.

The New Hampshire Board of Medicine requires demonstration of passing scores on one of the following sets of examinations:
- USMLE Steps 1 and 2 CK, CS
- COMLEX Level 1 and 2 CE, PE
- NBME Parts 1 and 2
- FLEX Parts I and II
- NBOE Parts I and II
- LMCC
Foreign medical graduates must also supply proof of ECFMG certification.

It is recommended that you have passed these examinations and/or obtained ECFMG certification no later than January 1st of the year in which there is an anticipated June or July residency start date. It is imperative that applicants meet these requirements in order to be appointed and begin training on time.

Note: New Hampshire training licenses shall be confined to activities performed in the course of the qualifying residency or graduate fellowship training program, shall expire automatically upon the licensee's separation from the residency or graduate fellowship training program for any reason, and may be issued on a restricted or conditional basis.
Non-citizens must have Permanent Resident Status, current Employment Authorization Card or be eligible to obtain the appropriate visa as outlined in the DHMC Graduate Medical Education Visa Policy no later than the date of hire.
Applicant must be fully competent in written and oral English.

Selection Process

It is the policy of Mary Hitchcock Memorial Hospital at Dartmouth-Hitchcock Medical Center to sustain house staff selection processes that are free from impermissible discrimination.

In compliance with all federal and state laws and regulations, no person shall be subject to discrimination in the process of house staff selection on the basis of race, national origin, gender, religion, age disability, marital or parental status, status as a Vietnam-era veteran, sexual orientation, or gender identity.

Selection of House Staff

Applications, along with required supporting documentation, are submitted according to the appropriate procedure outlined on the Program web page (i.e. Submission of paper application or via Electronic Residency Application Service).
Applicants meeting eligibility requirements outlined by the Institution and the Program will be invited for a personal interview. Interview days include (but are not limited to) interviews with faculty and residents, program orientations, tours of the medical center, attendance at conferences, etc.
Each program will apply its own criteria for evaluating and ranking candidates. Those criteria may include, but are not limited to:
- Review and confirmation of eligibility requirements
- Performance on standardized medical knowledge test.
- Verbal and written communication skills.
- Letters of recommendation from faculty.
- Dean's letter.
- Medical school transcript.

The recruitment and appointment of residents and fellows to training programs sponsored by Mary Hitchcock Memorial Hospital is based on and in compliance with the institutional, common and specific program requirements of the Accreditation Council for Graduate Medical Education (ACGME). The process of application, eligibility, selection and appointment of residents or fellows to a program is the responsibility of the Department Chairperson, the Program Director, and/or departmental faculty.

All residents that are offered and accept positions must consent to a pre-enrollment criminal background check and pass a pre-enrollment drug screening.

Mary Hitchcock Memorial Hospital has no requirement that residents must sign a non-competition clause as part of the Resident/Fellow Agreement of Appointment.

Visa Policy

Non-citizens, in addition to meeting eligibility requirements set forth in the Graduate Medical Education Accredited Residency and Fellowship Program Eligibility Requirements policy, must either have Permanent Resident Status, an Employment Authorization Card or be eligible to obtain one of the following employment visas (J-1, F-1OPT or H-1B Transfer) as outlined in the visa policy.

All eligible fees related to obtaining appropriate visa or work authorization status including USMLE transcripts or other examination credentialing, licensure and or legal fees are the full responsibility of the applicant or resident or fellow.

ECFMG Certification

The Educational Commission for Foreign Medical Graduates (ECFMG), through its program of certification, assesses whether international medical graduates are ready to enter residency or fellowship programs in the United States that are accredited by the Accreditation Council for Graduate Medical Education (ACGME).

ECFMG and its organizational members define an international medical graduate as a physician who received their basic medical degree or qualification from a medical school located outside the United States and Canada. To be eligible for ECFMG Certification, the physician's medical school and graduation year must be listed in the International Medical Education Directory (IMED) of the Foundation for Advancement of International Medical Education and Research (FAIMER). To verify that a particular medical school and graduation year are listed, access IMED.

Citizens of the United States who have completed their medical education in schools outside the United States and Canada are considered international medical graduates; non-U.S. citizens who have graduated from medical schools in the United States and Canada are not considered international medical graduates.

ECFMG Certification assures directors of ACGME-accredited residency and fellowship programs, and the people of the United States, that international medical graduates have met minimum standards of eligibility required to enter such programs. ECFMG Certification does not, however, guarantee that these graduates will be accepted into programs, since the number of applicants frequently exceeds the number of available positions.

ECFMG Certification is one of the eligibility requirements for international medical graduates to take Step 3 of the three-step United States Medical Licensing Examination (USMLE). Medical licensing authorities in the United States require ECFMG Certification, among other requirements, to obtain an unrestricted license to practice medicine.

For information about certification requirements, examination requirements, medical education credentials etc, please refer to the ECFMG 2011 Information Booklet, available online in PDF format.

Recruitment Documentation Policy

Scope

The policy applies to all DHMC residency and fellowship programs.

Purpose

To ensure that all residency and fellowship applicants who interview at the Dartmouth-Hitchcock Medical Center:
- receive a copy of the Eligibility Guidelines documentation (as distributed by the GME office annually).
- receive a copy of the Selection Process documentation (as distributed by the GME office annually).
- are provided with a written, sample Agreement of Appointment.
To ensure that all programs utilize a standard format for documenting the provision of the above named documents.
To ensure that all programs utilizing ERAS apply the standard, institutionally approved filters prior to the review of any applicant files.

Policy Guidelines

Responsibilities

The Program Director/Coordinator is responsible for:
- Supplying a copy of the eligibility requirements, selection process, and sample Agreement of Appointment to all resident and fellow applicants who interview at DHMC.
- Obtaining a signature from each applicant noting their receipt of the above documents.
- Maintaining this documentation in the program office and providing it to GME during the Internal Review file audit.
- Applying the institutionally approved ERAS filters as described in this policy.
The Office of Graduate Medical Education is responsible for:
- Providing annual updates to all programs of the following documents:
  - Eligibility Requirements
  - Selection Process
  - Sample Appointment Agreement
- Review of the required documentation as part of the Internal Review process.
- Providing updated information on the institutionally approved ERAS filters.

General Guidelines

All training programs must ensure that each resident and fellow applicant has received a current copy of the eligibility requirements, selection process and sample appointment form.
All programs must document applicant receipt of the above noted documents utilizing the signature page provided by the GME office. Either a multi signature page or single signature page may be used to document this requirement.
All programs utilizing a paper application must use the application form provided by the GME office.
All programs using ERAS must apply the institutionally approved filters within ERAS.
The following filters must be in place prior to the review of any applications files in ERAS:
- Birth Date
- Birth Place
- Citizenship/Visa Status
- Gender
- Limitations
- Photograph
- Race/Ethnicity
- Social Security Number
Once an applicant has accepted an interview, programs are asked to use the scheduled to interview filter prior to unlocking photographs of the scheduled applicants. Photographs must then be locked again prior to removing the scheduled to interview filter in order to view other applicants in the system.

Agreement of Appointment

A sample of the Resident & Fellow Agreement of Appointment form.

Sample Agreement of Appointment (PDF)

Programs & Benefits

An overview of available benefits, including stipends, insurance, and assistance programs.

Stipend Levels

Stipend levels are paid commensurate with the responsibility of training position. All house staff at the same Graduate Level will be paid at the same Stipend Level. Only RRC defined prerequisite years of training for the current training program are applicable towards the Stipend Level. Incentive pay for house staff joining any training program is not allowed.

GME Stipend Levels

Post-Graduate Year	Stipend
GL1	$48,415
GL2	$51,025
GL3	$53,680
GL4	$56,230
GL5	$58,840
GL6	$61,440
GL7	$64,105
GL8	$66,670

Health & Welfare Benefits

The 2011 Guide to LiveWell Benefits is your resource to find information about the medical, dental, long term disability, life insurance, and flexible spending account benefit plans. You received this document at open enrollment (or in your new hire packet). This document also covers topics such as who is eligible for benefits, whose benefits are taxable, and when you can make benefit changes. If you have questions after reviewing this document, please call the Dartmouth-Hitchcock Benefits Administration Office at 653-1400

Medical Insurance

The House Staff health care plan is an employer paid PPO plan, administered by Anthem BlueCross BlueShield.

Spouses, dependants, domestic partners and their minor children are covered for most services at the $0 (zero) deductible level for in-network services. Coverage begins on the date of hire. Coverage continues to the end of the month that you finish your training, plus one month. After that you may elect COBRA coverage or wait until your new medical coverage begins.

Example: Termination date is June 14. You would continue your coverage with D-H through the end of July. COBRA would become effective on August 1.

Dental Insurance

Basic Dental Option for employee only is at no cost to you and is provided by Northeast Delta Dental. If you choose to enroll your dependents into the dental plan there is a cost associated with the coverage level you choose. Coverage begins on the date of hire.

Life Insurance

All House Staff are insured for one times their stipend, rounded to the next higher $1,000, subject to a maximum of $50,000 through term insurance from The Hartford. Supplemental Life/AD&D is available in increments of .5 times your base salary to a maximum of $500,000 without evidence of insurability. Premiums for this supplemental coverage are the responsibility of the resident/fellow and will be deducted from your bi-weekly paycheck. Dependent Life/AD&D coverage is available for your spouse/dependants; please review the enrollment booklet for specifics on coverage limits and premiums. You will be required to designate your beneficiaries on-line when you enroll in your benefits. You may change your beneficiary at any time during the training year.

Sick Leave/Short Term Disability

You have 90 days of paid short term disability per training year at your full stipend through GME. Any illness lasting more than 2 weeks will require an application for the salary continuation plan (short-term disability coverage) which is administered by The Hartford. Your Program Coordinator will give you the forms you need to apply for this benefit when you report your leave of absence.

Long Term Disability

Long-term disability benefits may begin on your 91st day of disability. Application for long-term coverage through The Hartford is recommended by the 60th day of illness if you anticipate being out for more than 90 days due to a qualifying disability.

Medical benefits may be continued for House Staff on approved leaves of absence for up to a total of 12 months beginning from the first day of the leave.

Health Care Reimbursement Account

The Health Care Reimbursement Account (HCRA) is offered under the Flex Plan to provide you with a tax-effective way to pay for medical and dental services outside of the Medical and Dental Plans. Since some health care services are not covered due to deductibles, or other benefit limitations, or only partially covered, employees and dependents usually pay for them out of their own pocket. HCRA establishes a reimbursement account that can be an important part of your annual budget planning as it allows you to set aside funds, before paying taxes which may be used to pay for some or all of these expenses.

Dependent Care Assistance Account

The Dependent Care Assistance Program (DCAA) is offered under the Flex Plan to provide a tax-effective way to pay for dependent care expenses resulting from the employment of an employee and spouse. DCAA allows you to set aside funds, before paying taxes, to cover certain dependent care expenses.

Malpractice Insurance Coverage & Risk Management Program

The Dartmouth-Hitchcock Clinic (DHC), Mary Hitchcock Memorial Hospital (MHMH), and Dartmouth College (DC/The Geisel School of Medicine) participate in a self-insured malpractice insurance program that was created in 1977. By pooling financial resources, they are able to obtain professional and comprehensive general liability insurance to cover medical center employees such as physicians (including physicians admitted to professional graduate training programs as residents or fellows), nurses, medical students, other clinical and non-clinical employees, and volunteers. As a Resident or Fellow, you are covered under this insurance program for activities within the scope of your employment. Over the years, the program has been effective from both a risk-funding and a claims-management perspective. The combined program facilitates cooperation among those it insures by utilizing a joint defense of claims. When a claim is asserted against more than one of the institutions and/or its insured's, potentially divisive forces are avoided by coordinating the defense of all co-defendants rather than each institution attempting to minimize its separate liability.

Related pages

Frequently Asked Questions

What are my responsibilities as an individual insured under the program?

As an individual covered under the insurance program, you have several responsibilities, including:

Prompt reporting of events to Risk Management
Participation in follow-up of events or patient complaints, which may include meeting with a Dartmouth-Hitchcock Risk Manager or our claims management staff from Atlantic Risk Management.
Interaction/consultation with Risk Management staff when questions or concerns arise

How do I reach Risk Management?

Risk Management assistance is available 24/7. The office is on the main DHMC campus on the 2nd floor of the Doctors' Office Building and is open from 8AM - 5PM (Monday - Friday) and you can call us at 603-650-7864. A Risk Manager is also on-call after hours via pager through DHMC Communications.

Do I only report adverse events to Risk Management? What about near-misses?

One of the most useful risk management tools, and one that is sometimes neglected, is the thorough investigation of "near-misses." As any liability claims manager can attest, before a catastrophic event occurs, the same set of circumstances may have been in place multiple times without triggering such an event. Your risk management program encourages the investigation and discussion of "near-misses." This is the best way to address problems related to the idiosyncrasies of a particular institution before a catastrophic event occurs.

Do I need to report a bad outcome if it was a known risk/complication which was fully discussed and documented in the informed consent process?

Yes. Any loss of function at the time of discharge and any iatrogenic injury that extends the hospital stay, requires additional treatment, or results in readmission (even if the loss or injury is a known risk/complication of the treatment provided) should be reported to Risk Management.

What form of malpractice insurance coverage is provided?

The Dartmouth-Hitchcock insurance policy is written on a "modified claims-made" basis which means it covers claims or adverse incidents actually reported to the insurance program during the policy year, resulting from services rendered after inception of an employee's coverage under this program. It is "modified" because it also covers the "tail." The primary limits are $1 million per claim and $3 million aggregate.

What happens when a Resident or Fellow leaves the program?

Residents or Fellows who leave Dartmouth-Hitchcock employ will continue to be covered for the "tail", i.e., claims made subsequent to their departure, but only for covered claims arising out of medical incidents that occurred during the period of the individual's participation in the Dartmouth-Hitchcock insurance program.

Will the policy cover me for claims incurred before I began my Residency or Fellowship at MHMH?

No. Claims related to a service rendered prior to the individual's employment here should be covered by the insurance carried by that employee at the time the service was rendered. Employees who previously had a claims-made policy from another insurance company should procure appropriate "tail coverage" from that carrier before entering this insurance program. Individuals whose prior policy was an occurrence policy do not need to purchase tail coverage. Check with your prior employer/insurance company if you do not know which type of coverage was provided.

Does the insurance program cover me for any eventuality in my practice?

The insurance program covers you for allegations brought against you only while you are practicing within the scope of your employment. Activities outside of your employment ("moonlighting") are covered only as described below. Allegations of sexual misconduct, if found to be true, cannot be covered.

Are all the institutions that participate in the New England Alliance for Health (NEAH) insured under the Dartmouth-Hitchcock insurance program?

None of the NEAH hospitals or organizations is insured under the Dartmouth-Hitchcock insurance plan.

Are Residents or Fellows covered while "moonlighting" at institutions that are not insured under the program?

No. A Resident or Fellow is not covered while moonlighting outside the Dartmouth-Hitchcock organization. It is important that anyone contemplating moonlighting makes sure they have adequate professional liability coverage, either through the other institution or by their own purchase of an individual policy.

Please be aware that this document is not the actual insurance policy. To review the complete terms and conditions of this program please contact the Executive Director, Dartmouth-Hitchcock Risk Management Program at (603) 650-7864.

House Staff Groups

The DHMC House Officer Association

Mission Statement

The House Officer Association exists to improve the overall experience at Dartmouth-Hitchcock Medical Center. Areas of focus include:

Improve the educational experience of residents and fellows at DHMC
Optimize house staff well being both in and out of the hospital
Improve overall patient care by optimizing resident involvement and performance
Ensure resident/fellow involvement at the hospital level thru participation in hospital committees

Membership

Each ACGME accredited residency/fellowship program should have between one and two voting representatives on the HOA.
Representatives will be selected by each department, either by selection or election, based on interest in each particular department.
Representatives will serve for a term of one year. Representative may serve more than one term if so chosen by their respective department.
Each designated representative will have voting rights on the HOA. 60% attendance is required to retain voting privileges. If a voting member is unable to come to a meeting, they should designate a person to vote in their absence.
Any DHMC interns, residents, or fellows are invited to attend all HOA meetings and contribute to the meetings. They will not however have voting privileges.
The President will be elected by the HOA and will serve a term of one year. This term will start in January and go for 12 months. This will allow for the past president to help with the transition before leaving the institution.
The President will select a vice president and other directors based on individual interest as outlined above. Residents/fellows will serve in the positions at the discretion of the President.
The membership director of the HOA will be responsible for ensuring equal representation among the various departments.

Meetings

Meetings will be held monthly at the discretion of the leadership, typically on the 4th Tuesday of the month.
The meeting schedule will be published and distributed to all departments with the anticipation that members of the committee be relieved from clinical duties whenever possible to attend meetings
The meeting agenda will be open for additions until 24h before the meeting starts. It will then be distributed by email before the meeting.
All meetings are open to all house staff.

Purpose

To foster communication between house officers and the administration and staff at DHMC and associated hospitals.
To foster communication among house officers from different hospital departments.
To provide a means by which house officers can actively participate in the formation and change of policy that affects patient care. Specifically, this will be achieved by active participation in quality improvement projects, membership and various hospital committees, etc.
To provide a means to monitor the quality of benefits provided to house officers.
Optimize the educational experience by house staff
Contribute to house staff wellness by providing resources and opportunities for healthy living inside and outside of the hospital setting.

Residents' Revolving Loan Fund

The Hitchcock Foundation established the Residents' Revolving Loan Fund in 1959 to assist Residents and Fellows at the Medical Center with emergency or unforeseen expenses. All repayments and interest on loans are returned to the Revolving Loan Fund, thus the Fund and its benefits are perpetuated for future applicants.

Most loan fund applicants already have substantial loan balances related to their education and in some cases additional debt for a car, credit and charge cards. While a loan from the Hitchcock Foundation may be modest by comparison, it is adding to your debt burden and hence your application should be a careful and reasoned decision. It is also and an opportunity to review your current income and expense including debt service.

The Regulations for the Resident's Revolving Loan Fund, a Summary Worksheet of Income and Expense and a Revolving Loan Fund Application can be found on the Hitchcock Foundation Residents' Revolving Loan Fund information page.

If you plan to apply for a loan from the Hitchcock Foundation, your Income and Expense Worksheet must be completely filled out and enclosed with your Application. Those interested in a more detailed income and expense worksheet, please contact (603) 653-1230. Completed Applications and your financial summary should be forwarded to The Hitchcock Foundation, Colburn Hill.

If you have questions, please call (603) 653-1230. They also have a list of individuals who provide financial counseling should you desire help or require counseling under the terms of the Revolving Loan Fund Regulations.

Additional Benefits

Vacation

House staff at all levels are allowed three weeks time off per training year, 15 business days and six weekend days.

On-Call Meals

Call night allowances will be initially distributed in July to those house staff required to be in the hospital overnight. The amount is determined by taking your number of in-house calls x the current nightly meal allowance. Your allowance can be used as you wish, but it is designated as call-night allowance and once it is gone, there will be no more until the next training year begins. GME receives a listing of your charges each month. If you feel you were not given enough call night money, please discuss it with your chief resident and have them call GME to discuss any shortages.

* If you have any problems with the hospital cafeteria or Cravin's concerning your meal card, do not discuss them with the cashiers; call Graduate Medical Education at 5-5748.

Coats/Scrubs

Two lab coats are provided to all house staff at the beginning of training, and two additional coats are available each following year. We offer 100% cotton, unisex-sized coats in coat sizes ranging from 30 to 56. Coats are embroidered with the DHMC logo, and name and specialty. Laundry services are provided for coats, call room liniens, and scrub attire in areas where hospital laundred scrub attire is mandated. Laundered coats for house staff are found in the call room kitchen area. Coats not embroidered with a name on them must be marked with "GME" and last name in permanent laundry marker on the inside collar of their coats, just above the label. Coats not properly marked will not be returned to the call room, may be lost and will not be replaced by GME.

Education Fund

Each resident is given $300 per training year to be used for items of an educational nature such as textbooks, educational retreats and subscriptions, membership in educational societies, Step 3 exam fees, towards the purchase of a PDA or laptop computer. The money is deposited into your program's Hitchcock Foundation Account in October of each year. You may submit receipts for approved educational expenses and request reimbursement through your program.

Parking

Free parking space is available throughout the Hospital premises and off-site locations are provided. Security and Parking maintains shuttle bus services to lots 9, 20, and between DHMC campus sites. The Security shuttle bus continues to return riders to Lot 20 from 6:00 p.m. to 11:00 p.m. from the East entrance. After 11:00 p.m. call the Security Department at beeper 9381 for a ride to Lot 20.

Child Care

DHMC has an on-site Child Care Center designed to care for the children of employees and house staff. It includes eight classrooms, two large indoor play areas and two separate outdoor playgrounds. Adjacent to the Medical Center, it can accommodate children from six weeks to kindergarten. A highly qualified staff provides professional care from 6:30 a.m. to 8:00 p.m., Monday through Friday. There is a sliding fee scale based upon your income and payroll deduction is available. Those interested in this care should apply as early as possible by calling (603) 643-6504.

Getting Home Safely

At times you may be too tired to safely drive home from work. Arrangements have been made with the Big Yellow Taxi Co. to take you home and deliver you back to work the next day if necessary. There will be no charge to you. GME will reimburse the Big Yellow Taxi. You will be required to give your name and address only. Their number is (603) 643-8294.

They will inform GME of your name and where they picked you up and where you were driven. Just notify GME by e-mail at Office.of.Graduate.Medical.Education@Hitchcock.org the next day you are at work to let GME know you have utilized this service.

Position Overview

A description of the resident and fellow physician position, including scope, expectations, supervision structure, and requirements.

Position Description

The position of resident or fellow physician entails provision of patient care matching with the individual physician's level of advancement and competence. Residency is the phase of formal medical education beginning at graduation from medical school and ending after the educational requirements for the medical specialty certifying board has been completed. A resident physician's responsibilities include patient care activities within the scope of their clinical privileges commensurate with the level of training, attendance at clinical rounds and seminars, timely completion of medical records, and other responsibilities as assigned or as required of all members of the medical staff. Under the supervision of attending physicians, general responsibilities of the resident physician may include:

Initial and ongoing assessment of patient's medical, physical, and psychosocial status.
Perform history and physical.
Develop assessment and treatment plan.
Perform rounds.
Record progress notes.
Order tests, examinations, medications, and therapies.
Arrange for discharge and after care.
Write / dictate admission notes, progress notes, procedure notes, and discharge summaries.
Provide patient education and counseling covering health status, test results, disease processes, and discharge planning.
Perform procedures.
Assist in surgery.

A: Purpose and Scope

The objective of medicine under the watchful eye of attending faculty clinicians and includes:

participation in safe, effective and compassionate patient care;
developing an understanding of ethical, socioeconomic and medical-legal issues that affect graduate medical education, and how to apply cost containment measures in the provision of patient care;
participation in the educational activities of the training program, and as appropriate, assumption of responsibility for teaching and supervising other residents and students, and participation in institutional orientation and education programs and other activities involving the clinical staff;
participation in institutional committees and councils to which the house staff physician is appointed or invited; and
performance of these duties in accordance with the established practices, procedures and policies of the institution, and those of its programs, clinical departments and other institutions to which the house staff physician is assigned; including, among others, state licensure requirements for physicians in training.

B. Graded Responsibilities

The resident physician is both a learner and a provider of medical care. The resident physician is involved in caring for patients under the supervision of more experienced physicians. As their training progresses, resident physicians are expected to gain competence and require less supervision, progressing from on-site and contemporaneous supervision to more indirect and periodic supervision.

Resident physicians are given progressive responsibility for the care of the patient. The determination of a resident physician's ability to provide care to patients without a supervisor present or act in a teaching capacity are based on formative evaluations and summative evaluations of the resident physician's clinical experience, judgment, knowledge, and technical skill. These evaluations follow institutional guidelines and align resident physician learning in relation to the general competencies of medical knowledge, patient care, practice-based learning, interpersonal and effective communication, professionalism, and systems-based practice.

Ultimately, it is the decision of the staff practitioner with direct responsibility of the resident as to which activities the resident will be allowed to perform within the context of the assigned levels of responsibility. The overriding consideration must be the safe and effective care of the patient that is the responsibility of the staff practitioner.

Both formal examinations and performance ratings by the faculty are utilized, and the resident physician is personally apprised of his or her strengths and weaknesses at appropriate intervals at least twice annually. Completion by the program director of an annual summative review is an important part of this evaluation process. The Residency Program Director has the responsibility to determine and to document in writing, that the resident physician possesses the skills necessary to practice at the level commensurate with their training.

C. Organizational Relationships and Supervision

All resident physicians are supervised by licensed independent practitioners who are faculty members practicing at DHMC or affiliated institutions.

The resident physician shall participate in patient care under the direction of physicians whose clinical privileges are appropriate to the activities in which the resident physician is engaged. Neither the resident physician's clinical privileges nor their clinical responsibilities shall exceed in scope those of the supervising physician. The supervising physician shall make clinical assignments to each assigned resident physician consistent with the resident physician's experience and demonstrated clinical competence, and strive to ensure that each resident physician performs assigned duties in an appropriate manner. Resident physicians shall be responsible in their clinical activities to the Chief of the designated Section and through the Chief to the Clinical Department Chair. Except for admitting privileges, the privileges of each resident physician are determined by the appropriate Section members and Department Chair in context of the respective professional graduate training program requirements

General Supervision

General supervision is provided by appropriately privileged teaching staff. This supervision is proximal, continual, and based on normative and summative evaluations following institutional guidelines. All resident care is supervised and the attending physician is ultimately responsible for care of the patient. The proximity and timing of supervision, as well as the specific tasks delegated to the resident physician depend on a number of factors, including:

the level of training (i.e., year in residency) of the resident
the skill and experience of the resident with the particular care situation
the familiarity of the supervising physician with the resident's abilities
the acuity of the situation and the degree of risk to the patient

Outpatient Clinics

Resident physicians in all outpatient clinics are supervised by attending faculty members on-site. Resident physician clinics are held in designated areas (or the same practice area as the faculty practice) and are supported in the areas of nursing, laboratory and other services in the same manner as the faculty practice settings.

Inpatient Settings at Night and on Weekends

Faculty members are available at DHMC 24 hours per day (or generally present in-house but always available by telephone at all times). A faculty member will customarily see any complex or seriously ill patient promptly after admission. Immediate specialty consultations by attending faculty are available on-call at all times to resident physician staff in the same manner that is available to any active member of the medical staff. All patients admitted by resident physicians are reviewed by faculty. In the case of critically ill patients, a treatment plan is usually initiated by an attending staff member and/or consultants in the Emergency Room prior to transfer to the critical care units.

Emergency Room

Resident physicians are supervised by full time emergency room faculty 24 hours per day. The faculty members are responsible for demonstrating and instructing resident physicians in proper emergency patient managements. They supervise the clinical activity of the resident physician and assume the responsibility for evaluating the resident physician??s clinical competence and delegating increasing patient care responsibilities as appropriate.

Quality Assurance

All residency programs participate in the medical center-wide quality assurance system. Performance evaluations of residents are coordinated and administered by Residency Program Directors (staff physicians within a particular specialty). Performance evaluations are reflective of both academic knowledge and patient care/clinical skills. These evaluations are considered to be confidential and privileged (by New Hampshire laws RSA 151:13a and RSA329:29a). The ultimate goal of a performance evaluation is to determine if a resident physician's skill, knowledge and experience is sufficient to provide quality care to patients in the future.

Job Requirements

A. Education and Training

Applicants must meet one of the following qualifications to be eligible for appointment to ACGME-accredited residency and fellowship programs at DHMC:

Graduates of medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME) and successful completion of any pre-requisite accredited training specified by ACGME Residency Review Committees. Some programs require successful passage of board exams (or good faith effort to pass) for promotion through subsequent years of fellowship.
Graduates of colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA) and successful completion of any pre-requisite accredited training specified by ACGME Residency Review Committees.
Graduates of medical schools outside the United States and Canada who meet one of the following qualifications:
1. Have a currently valid certificate from the Educational Commission for Foreign Medical Graduates prior to appointment, or
2. Have a full and unrestricted license to practice medicine in a US licensing jurisdiction in which they are in training, and
3. Successful completion of any pre-requisite accredited training specified by ACGME Residency Review Committees.
Graduates of medical schools outside the United States who have completed a Fifth Pathway program* provided by an LCME-accredited medical school and successful completion of any pre-requisite accredited training.

* A Fifth Pathway program is an academic year of supervised clinical education provided by an LCME-accredited medical school to students who meet the following conditions: (1) have completed, in an accredited college or university in the United States, undergraduate premedical education of the quality acceptable for matriculation in an accredited United States medical school; (2) have studied at a medical school outside the United States and Canada but listed in the World Health Organization Directory of Medical Schools; (3) have completed all of the formal requirements of the foreign medical school except internship and/or social service; (4) have attained a score satisfactory to the sponsoring medical school on a screening examination; and (5) have passed either Parts I and II of the examination of the National Board of Medical Examiners or Steps 1 and 2 of the United States Medical Licensing Examination (USMLE).

B. Technical Requirements

The resident physician must be in possession of a NH Training or unrestricted license, a valid DEA number and current BLS certificate plus other advanced competencies as deemed necessary for their level of training, (ACLS, ATLS, PALS, etc.) to become involved in direct patient care.

GME Orientation

All new Residents and Fellows are required to complete an online orientation and attend the mandatory GME Institutional Orientation before beginning the training year. Orientation is routinely scheduled on June 24th and 25th as well as July 1st and 2nd.

The June 24th and 25th Orientation is generally for first year residents.

The July 1st and 2nd Orientation is generally for second year residents through Fellow level appointments.

Completion of all assigned online modules in addition to attendance during both days of the assigned orientation session is mandatory. Programs will conduct individual orientations on separate dates.

**House staff beginning their training year off-cycle as well as visiting house staff from other institutions, must complete a GME orientation before they are allowed to begin training and provide patient care. Off-cycle and visiting house staff must begin training on a Monday, so they may attend the institutional general orientation, MD eD-H class, a patient safety orientation and an occupational medicine pre-employment screening, in addition to other appointments that may be required by the program.

Supervision

The objective for supervised graduate medical education is to prepare the resident physician for the independent practice of medicine and includes:

Participation in safe, effective and compassionate patient care;
Developing an understanding of ethical, socioeconomic and medical-legal issues that affect graduate medical education, and how to apply cost containment measures in the provision of patient care;
Participation in the educational activities of the training program, and as appropriate, assumption of responsibility for teaching and supervising other residents and students, and participation in institutional orientation and education programs and other activities involving the clinical staff;
Participation in institutional committees and councils to which the house staff physician is appointed or invited; and
Performance of these duties in accordance with the established practices, procedures and policies of the institution, and those of its programs, clinical departments and other institutions to which the house staff physician is assigned; including, among others, state licensure requirements for physicians in training.

The resident physician is both a learner and a provider of medical care. The resident physician is involved in caring for patients under the supervision of more experienced physicians. As their training progresses, resident physicians are expected to gain competence and require less supervision, progressing from on-site and contemporaneous supervision to more indirect and periodic supervision.

Resident physicians are given progressive responsibility for the care of the patient. The determination of a resident physician's ability to provide care to patients without a supervisor present or act in a teaching capacity includes formative and summative evaluations of the resident physician's clinical experience, judgment, knowledge, and technical skill. These evaluations follow institutional guidelines and align resident physician learning in relation to the general competencies of medical knowledge, patient care, practice-based learning, interpersonal and effective communication, professionalism, and systems-based practice.

Ultimately, it is the decision of the Program Director and attending physician with direct responsibility of the resident as to which activities the resident will be allowed to perform within the context of the assigned levels of responsibility. The overriding consideration must be the safe and effective care of the patient.

Both formal examinations and performance evaluations by the faculty are utilized, and the resident physician is personally apprised of his or her strengths and weaknesses at appropriate intervals at least twice annually. Completion by the program director of resident yearly report forms is an important part of this evaluation process.

The Residency Program Director has the responsibility to determine that the resident physician possesses the skills necessary to practice at the level commensurate with their training. Annually, at the time of promotion, or more frequently, appropriate documentation will be provided to the Department Chair, the GME Director (Designated Institutional Official), Residency Program Coordinator or Administrator, and into the residency program's records.

Licensed independent practitioners who are faculty members practicing at DHMC or affiliated institution are among those who supervise all resident physicians.

The resident physician shall participate in patient care under the direction of physicians whose clinical privileges are appropriate to the activities in which the resident physician is engaged. Neither the resident physician's clinical privileges nor their clinical responsibilities shall exceed in scope those of their supervising physician. The supervising physician shall make clinical assignments to each assigned resident physician consistent with the resident physician's experience and demonstrated clinical competence, and strive to ensure that each resident physician performs assigned duties in an appropriate manner. Resident physicians shall be responsible in their clinical activities to the Chief of the designated Section and through the Chief to the Clinical Department Chair. Except for admitting privileges, the responsibilities of each resident physician are determined by the appropriate Section members and Department Chair in context of the respective professional graduate training program requirements.

General Supervision

General Supervision is provided by appropriately privileged teaching staff. This supervision is proximal, continual, and based on normative and summative evaluations following ACGME and institutional guidelines. All resident care is supervised and the attending physician is ultimately responsible for care of the patient. The proximity and timing of supervision, as well as the specific tasks delegated to the resident physician depend on a number of factors, including:

the level of training (i.e., year in residency) of the resident
the skill and experience of the resident with the particular care situation
the familiarity of the supervising physician with the resident's abilities
the acuity of the situation and the degree of risk to the patient

Outpatient Clinics

Resident physicians in all outpatient clinics are supervised by attending faculty members on-site. Resident physician clinics are held in designated areas (or the same practice area as the faculty practice) and are supported in the areas of nursing, laboratory and other services in the same manner as the faculty practice settings.

Inpatient Settings at Night and on Weekends

Faculty members are available at DHMC 24 hours per day (or generally present in-house but available by telephone at all times). A faculty member will customarily see any complex or seriously ill patient promptly after admission. Immediate specialty consultations by attending faculty are available on-call at all times to resident physician staff in the same manner that is available to any active member of the medical staff. Faculty review all patients admitted by resident physicians. In the case of critically ill patients, an attending staff member usually initiates a treatment plan and/or consultants in the Emergency Room prior to transfer to the critical care units.

Emergency Room

Full-time emergency room faculty supervise resident physicians 24 hours per day. The faculty members are responsible for demonstrating and instructing resident physicians in proper emergency patient management. They supervise the clinical activity of the resident physician and assume the responsibility for evaluating the resident physician's clinical competence and delegating increasing patient care responsibilities as appropriate.

Evaluation

Assessment of Learning

DHMC recognizes learning on a continuum from novice to advanced beginner to competent at a level expected of a new practitioner. Each MHMH training program provides assessment of trainee learning in consideration of this continuum, aligned with basic RRC requirements as to the scope and number of both formative and summative evaluations.

Each MHMH residency program utilizes measures to assess residents' competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Mechanisms are developed and updated to provide regular and timely performance feedback to residents. This process involves the use of assessment results to achieve progressive improvements in residents' competence and performance consistent with graduated roles and responsibilities as assigned.

Evaluation of Residents/Fellows

Written assessments of learning focus on a trainee's ability to perform up to defined expectations. These expectations are outlined in a program curriculum. Behavioral expectations are outlined in the DHMC Code of Ethical Conduct and include the recording of procedures in case logs if required by the ACGME Residency Review Committee (RRC), and the timely and accurate reporting of duty hours. At scheduled intervals during the training year, written formative evaluations are provided to the trainee. At the conclusion of a training year, and at the end of the training program, written summative evaluations are provided to the trainee.

Quality Assurance for Residents/Fellows

All residency programs participate in the medical center-wide quality assurance system. Performance evaluations of residents are coordinated and administered by Residency Program Directors (staff physicians within a particular specialty). Performance evaluations are reflective of both academic knowledge and patient care/clinical skills. These evaluations are considered to be confidential and privileged (by New Hampshire laws RSA 151:13a and RSA 329:29a).

Quality Assurance Algorithm

Observation
1. Recognize problem
2. Develop plan
3. Method of assessment
4. Verbal notice to resident
5. Written notice in program file, noting verbal interaction only
Concern
1. Culpable or recurring adverse behavior or failure to respond to observed concerns
2. Written notification
3. Fair hearing policy
4. Remedial plan including problems, remediation, time frame, method to assess, and warning about possible need to report to the NH Board of Medicine.
5. Notice to GME and resident's file
Probation
1. Failure to meet remedial plan
2. Analysis of need for suspension
3. Written evaluation considering dismissal, non-renewal
4. Formal notice to GME and resident's file
5. GME report to NH Board of Medicine as needed

Evaluation of Faculty

Each MHMH residency program monitors educational effectiveness of faculty and attending physicians. At prescribed intervals, residents are asked to provide written or electronic evaluations of individual faculty member. These evaluations are confidential.

Evaluation of Program

At prescribed intervals, residents are asked to provide written or electronic feedback about the program including curriculum, working environment, scholarly milieu, evaluation systems, and other features. These evaluations are confidential. Each MHMH residency program uses these resident assessments, combined with faculty input, to evaluate the educational effectiveness of the training program.

Emergency Course Requirements

Basic Life Support (BLS) Training Policy

The following excerpt from the 2004 "Cardiopulmonary Resuscitation (CPR) Policies", developed by the CPR Committee and approved by the Board of Governors, relates to the institutional policy for BLS.

It is well documented that training and competency in Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Neonatal Resuscitation Program (NRP) substantially improve performance of life support skills involved in a resuscitation. Additionally, CPR and early defibrillation have been shown to improve patient survival. In order to insure that BLS is administered as quickly as possible to a victim of cardiopulmonary arrest, it is required that all health care providers who deliver direct patient care or support personnel who come in direct contact with patients demonstrate competency in BLS every two years as evidenced by completing the American Heart Association Health Care Provider Course or the Heartsaver with Automated External Defibrillator Course - or its equivalent as judged by the Life Support Program Coordinator. These providers include, but are not limited to all members of MHMH Professional Staff as defined by the Office of Clinical Affairs:

Doctor of Osteopathy (DO)
Foreign equivalent of MD (MBBS)
Doctor of Medicine (MD)

Implementation Policy

Each department will determine the categories of staff who are direct care providers or support personnel who come in direct contact with patients and must be trained in BLS. All designated persons will be trained in BLS within eight weeks of employment and/or appointment and will continue to demonstrate competence every two years.

A grace period of one month is extended for those who must recertify in BLS. A penalty may be imposed if BLS status is not current for an individual.

Attending staff are not granted admitting privileges unless BLS is current.
If a nurse, technologist, or technician is not retrained by the end of the following month after her/his BLS expiration date, she/he will be suspended without pay until competency is demonstrated. A contract for BLS retraining will then be established with the appropriate leadership person.
If a resident is not retrained by the end of the following month after their BLS expiration date, he/she may lose medical staff privileges.

If a person is unable to perform the BLS skills due to a physical disability or medical condition, the BLS written test must be completed and a written physician verification must be given to one's supervisor and reviewed annually.

For more information about life support courses and sign-up, call the Patient Safety Training Center, ext. 3-3399.

Available Courses:

Basic Life Support Healthcare Provider (BLS)

Course content

One and two person adult resuscitation
One person child & infant resuscitation
Obstructed airway management in the adult, child, & infant
Mouth-to-mask & bag-valve-mask ventilation
Automated external defibrillation using Philips AED

Requirement

Required for every physician
*BLS Healthcare Provider may be achieved at either Provider or Instructor level.

Certification

Two years

Course schedule

Provider training for all incoming residents during orientation to DHMC;
Recertification available every March and June thereafter.
Provider training held second Wednesday of every month from 9:00 a.m. to 3:00 p.m.

Cost of course

$10

Advanced Cardiac Life Support (ACLS)

Course content

Advanced airway management
Pharmacological intervention
Defibrillation/external pacing
Acute coronary syndrome
Acute ischemic stroke
Cardiac rhythm disturbances
Post resuscitation care

Requirement

Required for all Internal Medicine residents GL 2 & 3 and Anesthesia residents GL 2 ,3 & 4 and Pain Management fellows.
Desirable for Pediatric house staff, GL 2 & 3.
*ACLS may be achieved at either Provider or Instructor level.

Certification

Two years

Course schedule

Provider & Provider Recertification Courses are held during year; see Life Support Program web page.

Cost of course

$175 for Provider Course (texts included) & $50 for Provider Recertification Course ($38 additional for texts)

Advanced Trauma Life Support (ATLS)

Course content

Initial assessment
Airway management
Shock Burn and cold injuries
Thoracic trauma
Abdominal trauma
Head trauma
Spine trauma
Musculoskeletal trauma
Extremes of age (Peds & Geriatrics)
Trauma in women

Requirements

Required for General Surgery residents prior to GL-2 year; Anesthesia residents prior to GL-4 year.
*ATLS may be achieved at the provider level

Certification

Four years

Course schedule

Provider courses are generally scheduled twice per year

Cost of course

No charge for General Surgery and Anesthesia residents. Others: $425 for provider course

Pediatric Advanced Life Support (PALS)

Course content

Airway management
Pharmacological intervention
Cardiac rhythm disturbances
Defibrillation
Arrest prevention
Fluid resuscitation
Neonatal resuscitation

Requirement

Required for all Pediatric residents, GL 1, 2 & 3
*PALS may be achieved at Provider or Instructor level

Certification

Two years

Course schedule

Provider & Provider Recertification Courses are held during year; see Life Support Program poster and web page

Cost of course

No charge to CPR Team members. Others: $225 for Provider Course (texts included), and $75 for Provider Recertification Course ($40 additional for texts).

Neonatal Resuscitation Program (NRP)

Course content

Delivery room management
Initial steps of resuscitation
Use of bag/valve device
Chest compressions
Endotracheal intubation
Pharmacological intervention

Requirement

Required for all Pediatric residents GL 1, 2 & 3
*NRP may be achieved at Provider or Instructor level

Certification

Two years

Course schedule

Several courses are held during year; watch for poster

Cost of course

No charge

Confidential Reporting

MHMH provides several ways in which residents and fellows may raise and resolve issues in a confidential and protected manner without fear of intimidation or retaliation.

GME Confidential Page 9401. This is an internal DHMC Education Department pager available to all residents during the hours of 8 a.m. - 5 p.m. Monday through Friday to address concerns in a confidential and protected manner. An Organizational Development Specialist (ODS) will be available to listen to concerns, discuss potential solutions, and make suggestions about what to do next. The ODS will also answer questions about DHMC policies and help the resident find appropriate resources when needed. Also, during the hours of 8 a.m. - 5 p.m. Monday through Friday, residents with concerns may call the Education Department at 653-1570 and ask to speak with an ODS.
Compliance Helpline (888) 422-2084. Dartmouth-Hitchcock has contracted with a third party for this confidential phone helpline which is available 24 hours a day, seven days a week. Your call can be made anonymously and without fear of retribution or retaliation. All reports are treated in a completely confidential manner and are routed to GME via the DHMC Compliance Officer. There will be no retribution for asking questions or making a good-faith report of improper or questionable conduct.
GME Resident Assistance The Associate Dean of GME and the Administrative Director are available to discuss any issue of concern to residents. We maintain an open door policy and are happy to address questions or concerns in a confidential manner. GME acts as an advocate for residents and acts to promote and maintain their well-being and, when necessary, rehabilitation. As noted above, confidentiality of residents will be paramount.

Documents Submitted to the ACGME

Scope

The policy applies to all ACGME-accredited residency and fellowship programs at DHMC.

Purpose

1. To define the requirements for the review, approval and co-signature of documents being submitted to the Accreditation Council for Graduate Medical Education (ACGME).
2. To ensure institutional oversight as required by the ACGME Institutional Requirements.

Policy Guidelines

Review of Documents

As set forth in the ACGME Institutional Program Requirements, documents and correspondence sent to the ACGME by Program Directors must be reviewed and approved by the DHMC Graduate Medical Education Advisory Committee (GMEAC) and/or the Designated Institutional Official (DIO) as outlined in this document.
Documents requiring GMEAC review and approval per the Institutional Program Requirements include:
- All applications for ACGME accreditation of new programs;
- Changes in resident/fellow complement;
- Major changes in program structure or length of training;
- Additions and deletions of participating sites;
- Appointments of new program directors;
- Progress reports requested by any Review Committee;
- Responses to all proposed adverse actions;
- Requests for exceptions of resident duty hours;
- Voluntary withdrawal of program accreditation;
- Requests for an appeal of an adverse action;
- Appeal presentation to a Board of Appeal of the ACGME.
In addition to the above listed documents, the DIO is also required to review and sign-off on:
- Program Information Forms (PIF’s);
- Any other documents or correspondence sent to the ACGME by the Program Director.

GMEAC Approval and Co-Signature of Documents

GMEAC approval and a co-signature by the DIO attest to the accuracy, completeness and support of the content of the document. Therefore, it is essential that adequate time be allowed for review, including opportunity for recommending edits and/or corrections, prior to final approval or co-signature of a document. To facilitate this process:
- Documents that require GMEAC approval must be received in the GME Office no later than one week (seven days) in advance of the GMEAC meeting at which they will be reviewed and voted on. Upon approval by the GMEAC, the DIO will subsequently co-sign the document and return to the Program Director.
- For PIF’s and other documents that do not require GMEAC review and approval, the DIO must receive the documents no later than four weeks (twenty-eight days) in advance of the “send deadline.” As noted above, advance receipt of these documents will provide adequate time to read and offer suggestions for edits and/or corrections. Upon review of the final document, the DIO will cosign and return to the Program Director.
The DIO is required to co-sign all documents submitted to the ACGME by Program Directors. In the DIO’s absence:
- The Associate Director of Graduate Medical Education is granted primary authority to co-sign documents submitted to the ACGME.
- If the DIO and Associate Director of Gradate Medical Education are both absent, the Department Chair is granted authority to co-sign documents submitted to the ACGME.
- All documents co-signed by the Associate Director or Department Chair will be reviewed by the DIO upon return to duty.

Responsibilities

The Program Director is responsible for:
- Informing the DIO of upcoming pending documents that require GMEAC approval and/or DIO signature.
- Planning and implementing a timeline to ensure that documents requiring approval by the GMEAC and/or co-signature by the DIO are forwarded by the deadlines noted above.
The GMEAC is responsible for:
- Reviewing documents from Program Directors for the ACGME, offering recommendations for edits and/or corrections, and approving documents prior to their final submission to the ACGME.
The DIO is responsible for:
- Ensuring that documents forwarded by Program Directors for GMEAC review and approval are added to the agenda of the next available GMEAC meeting.
- Reviewing, recommending edits/corrections, and co-signing PIF’s and other documents submitted to the ACGME as outlined in this policy.
- Establishing and implementing a plan for co-signing documents to be sent to the ACGME in the absence of the DIO.

Related Policies and Reference Material

ACGGME Institutional Requirements at: http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf

Specific sections applicable to this policy include I.B.4.a (requirement to implement co-signature procedures) and
III.B.10.a- k (requirement for GMEAC review and approval)

GME Policies

A listing of policies that specifically pertain to the residents, fellows, and Graduate Medical Education programs at Dartmouth-Hitchcock Medical Center.

Accommodations for Disabilities Policy

Dartmouth-Hitchcock is committed to the fair and equal employment of people with disabilities. Reasonable accommodation is the key to this non-discrimination policy. While many individuals with disabilities can work without accommodation, other qualified applicants and residents face barriers to employment without the accommodation process. It is the policy of the Dartmouth-Hitchcock to reasonably accommodate qualified individuals with disabilities unless the accommodation would impose an undue hardship. In accordance with the Americans with Disabilities Act, accommodations will be provided to qualified individuals with disabilities when such accommodations are directly related to performing the essential functions of a job, competing for a job, or to enjoy equal benefits and privileges of employment. This policy applies to all applicants, residents, and residents seeking promotional opportunities.

Definition

Disability: For purposes of determining eligibility for a reasonable accommodation, a person with a disability is one who has a physical or mental impairment that materially or substantially limits one or more major life activities.

Reasonable accommodation

A reasonable accommodation is a modification or adjustment to a job, an employment practice, or the work environment that makes it possible for a qualified individual with a disability to enjoy an equal employment opportunity.

Examples of accommodations may include acquiring or modifying equipment or devices; modifying training materials; making facilities readily accessible; modifying work schedules; and reassignment to a vacant position.

Reasonable accommodation applies to three aspects of employment:

To assure equal opportunity in the employment process;
To enable a qualified individual with a disability to perform the essential functions of a job; and
To enable a resident with a disability to enjoy equal benefits and privileges of employment.

Procedure – Current residents

The resident should notify the Benefits Administration office (3-1400) of a need for an accommodation.

Both the resident and their physician will need to complete the ADA application and return it to the Benefits Administration Office.
When a qualified individual with a disability has requested an accommodation, Dartmouth-Hitchcock shall, in consultation with the individual and the department:
- Discuss the purpose and the essential functions of the particular job involved. Completion of a step-by-step analysis may be necessary.
- Determining the precise job-related limitation,
- Identify the potential accommodations and assess the effectiveness each would have in allowing the individual to perform the essential functions of the job.
- Select and implement the accommodation that is the most appropriate for both the individual and the employer. While an individual's preference will be given consideration, Dartmouth-Hitchcock is free to choose among equally effective accommodations and may choose the one that is less expensive or easier to provide.
- The ADA Team designee will work with the resident to obtain technical assistance, as needed.
- The ADA Team will provide a decision to the resident within a reasonable amount of time.

Affiliation Agreement & Program Letters of Agreement Policy

Scope

The policy applies to domestic, non-DH rotations in all residency and fellowship programs.

Purpose

The Office of Graduate Medical Education and the GMEC endorse resident rotations to off-site locations to gain additional, specific educational experiences. It is the policy of the GMEC through the Office of Graduate Medical Education to ensure that residents continue to receive stipends, benefits and ACGME-compliant educational experiences when they participate in non-DH affiliated rotations.

Definitions

Master Affiliation Agreement - maintained by the GME Office to establish inter-entity agreement across programs as defined by the ACGME.
Affiliation Agreement - required for rotations thirty days or more in length; rotations required for all residents in a specific program; and/or rotations to affiliate sites that are hospitals or similar corporate entities.
Program Letters of Agreement (PLA) - required for all other domestic, non-DH rotations.
Addendum - periodic updates to established Affiliation Agreements or Master Affiliation Agreements.

Policy Guidelines

General

Written Master Affiliation Agreements, Affiliation Agreements or Program Letters of Agreement must be in place to document and define the relationship between MHMH and the other institution or organization. As required, a periodic Addendum must be made to give notice of change or to update elements of the relationship. These written agreements must follow the current templates provided by the GME Office and, per the Common Program Requirements, must:
- Identify the faculty who will assume both educational and supervisory responsibilities for residents at the off-site location;
- Specify off-site faculty responsibilities for teaching, supervision, and formal evaluation of residents;
- Specify the duration and content of the educational experience including curricular goals and objectives;
- State the policies and procedures that will govern resident education during the assignment;
- Specify work environment and duty hour requirements;
- Specify accreditation status of other facility if a hospital.
It is the responsibility of the program director to follow all established RRC-specific guidelines regarding additional expected content of these agreements.
In addition, Affiliation Agreements and Program Letters of Agreement must comply in writing with D-H institutional requirements up to and including:
- Specify professional insurance and liability;
- Research conducted by MHMH personnel at other site must be managed pursuant to relevant MHMH guidelines;
- Each party must indemnify and hold harmless the other party from and against all losses, liabilities, and damages;
- Compliance with HIPAA (Health Information Portability and Accountability Act) and its rules and regulations;
- Access for Medicare audit purposes, until four (4) years after the termination of an Affiliation Agreement or Program Letter of Agreement;
- Specify that an Affiliation Agreement or Program Letter of Agreement may be terminated without cause.
A PLA is not required for rotations to physician’s offices and ambulatory center(s) under the direct governance of DH.
At no time will a resident or fellow be allowed to commence a non-DH rotation without a completed, current Affiliation Agreement or Program Letter of Agreement on file in the GME Office.

Updates, Additions and Deletions

All Master Affiliation Agreements and Affiliation Agreements must be renewed at least every five years.
Agreements must be updated with a standard Addendum whenever there are changes in program director or participating site director, resident assignments, or revisions to the items specified in the Common Program Requirements.
The program director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all residents, of one month full time equivalent or more to the GMEC for review and approval.
Following GMEC approval, the program director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all residents, of one month full time equivalent or more through the Accreditation Council for Graduate Medical Education (ACGME) Accreditation Data System (ADS).
The program director must submit any additions or deletions of participating sites routinely providing an educational experience required by an RRC that must be documented in the Program Information Form at the time of accreditation site visit and review through the Accreditation Council for Graduate Medical Education (ACGME) Accreditation Data System (ADS).

Related Policies and Reference Material

DH Affiliation Agreement template
DH Affiliation Agreement addendum template
VAH Affiliation Agreement addendum template
DH Program Letter of Agreement template
GME Office Master Affiliation Agreements
1. Veterans Affairs Medical Center, White River Junction
2. Concord Hospital
3. New Hampshire Hospital
4. Southern New Hampshire Medical Center
ACGME Institutional Requirements (I.C 1-3) at: http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf
ACGME Common Program Requirements (I.B.1-2) at:
http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf

Agreement of Appointment Signature Policy

Scope

The policy applies to all residency and fellowship programs at DHMC.

Purpose

To ensure that all residents and fellows are provided with a written Agreement of Appointment outlining the terms and conditions of their appointment to a program.
To ensure appropriate appointment of trainees to the DHMC medical staff.
To ensure verification of appropriate credentials for residents rotating to the VAH.

Policy Guidelines: Responsibilities

The Program Director is responsible for:
- Submitting a completed appointment/reappointment form for each resident and fellow participating in the training program on an annual basis.
- Notifying the DHMC Office of Clinical Affairs of all appointments and terminations.
- Submitting a completed VAH Credentials Verification Letter for all residents rotating at the VAH.
The Office of Graduate Medical Education is responsible for:
- Completion of the Resident/Fellow Agreement of Appointment form to include the following information:
  - Resident/fellow name
  - Program/level of training
  - Duration of appointment
  - Stipend
- Co-signature of the Agreement of Appointment document by the Administrative Director of Graduate Medical Education.
The Resident/Fellow is responsible for:
- Reviewing, signing and returning their completed Agreement of Appointment to the GME office.

Policy Guidelines: General Guidelines

All training programs must ensure that each resident and fellow has a current, signed Agreement of Appointment on file in the GME office.
Failure or refusal by the resident/fellow to sign the Agreement of Appointment may result in:
- Loss of pay;
- Loss of clinical privileges and;
- Cancellation of training licensure.

Policy Guidelines: Non-renewal of Appointment or Non-promotion

In instances where a resident’s agreement will not be renewed, or when a resident will not be promoted to the next level of training, the program director must provide the resident with a written notice of intent no later than one hundred twenty (120) days prior to the end of the resident’s current agreement. If the primary reason(s) for non-renewal or non-promotion occur(s) within 120 days prior to the end of the agreement, the program director must provide the resident with as much written advance notice as circumstances will reasonably allow.

Related Policies and Reference Material

Concern Policy

A concern is defined as an issue perceived by a resident or program director as needing resolution. Generally, such a matter will not significantly threaten a resident's intended career development nor have the potential of leading to a recommendation of dismissal or non-renewal.

Process for Addressing House Staff Concerns

Resident concerns may be brought to the Chief Resident, Program Director, Department Chair or the Resident Council. If not resolved, the concern may be brought to the attention of the Director or Administrative Director of Graduate Medical Education. The resident may also come directly to the Office of Graduate Medical Education and discuss the concern confidentially. The Office of Graduate Medical Education may act as mediator and intercede for the resident, so as to try to reconcile differences and resolve the concern in a confidential manner. The resolution of the Office of Graduate Medical Education using appropriate interaction with the resident, Program Director, and any others deemed integral to the decision, will be final.

Disaster Policy

Scope

This document is intended to complement and coincide with all existing disaster plans at Dartmouth-Hitchcock Medical Center (DHMC).

Purpose

To define the basic procedures and assigned responsibilities to efficiently and effectively reconstitute and restructure resident training experiences following a disaster. It recognizes that this may necessitate transferring educational experiences to another institution. (Hereinafter in this policy, the term "resident" will include fellows.)

Policy Guidelines

Definition of a Disaster

A disaster is defined as an event or set of events causing significant alteration to the residency experience at one or more residency programs.

Declaration of a Disaster

The DHMC DIO will immediately notify the ACGME of the occurrence of a disaster at DHMC.
Upon notification from the DHMC DIO or another credible source, the ACGME Chief Executive Officer will make a declaration of a disaster. A notice of such will be posted on the ACGME website with information relating to the ACGME response to the disaster.

Defined Responsibilities Following the Declaration of a Disaster

Responsibilities of the DHMC Designated Institutional Official (DIO):

The DIO will immediately convene the Graduate Medical Education Committee (GMEC) and other institutional leadership in order to ascertain the status and operating capabilities of all DHMC training programs.
Within ten days after the declaration of a disaster, the DIO will contact the ACGME to discuss the due dates that the ACGME will establish for DHMC programs to:
1. submit program reconfigurations to the ACGME, and
2. inform each resident of the transfer decision.
The due dates for submission shall be no later than thirty days after the disaster unless otherwise approved by the ACGME.
The DHMC DIO should call or email the Institutional Review Committee Executive Director with information and/or requests for information.

Responsibilities of the Program Directors:

Immediately verify the health and safety of all residents in their training program and relay this information to the DIO.
Arrange temporary transfers to other institutions until such time as the DHMC is able to resume providing an adequate educational experience.
Assist residents in obtaining permanent transfers to other institutions, as needed, in order to continue and complete their training.
If a transfer to another institution is necessary and if more than one institution is available, the Program Director will consider the educational needs and preferences of each resident and make their best efforts to find an appropriate training site. Programs must make these transfer decisions expeditiously so as to maximize the likelihood that each resident will finish their training in a timely fashion.
At the outset of a temporary resident transfer, the program must inform each transferred resident of the minimum duration and the estimated actual duration of their temporary transfer, and continue to keep each resident informed of such durations. If and when a program decides that a temporary transfer will continue to and/or through the end of a residency year, it must so inform each such transferred resident. Transferred residents will be allowed to return to DHMC as soon as the institution is operative, or they may stay at the transferred institution for a reasonable length of time in order to maintain a continuum of their education.
Program directors will make their best efforts to ensure that each transferred resident receives a quality educational experience at their new training site. The program director will regularly confer with the residents and program director(s) at the site to make sure that educational needs are being met.
The Program Director should call or email the appropriate Review Committee Executive Director with information and/or requests

Responsibilities of the Residents:

Residents should contact their program director as soon as reasonably possible to verify their safety, current/anticipated location, and any changes to their contact information.
Residents should call or email the appropriate Review Committee Executive Director with information and/or requests for information.
All transferred residents should refer to instructions on the ACGME Web Accreditation System to change resident email information.

Other Responsibilities Related to GME Preparedness for a Disaster

In order to ensure that all residents have access to funds in the event of a disaster, all residents will be strongly encouraged to elect to receive their paycheck through direct deposit.

Duty Hours Policy

Scope

The policy applies to all Dartmouth-Hitchcock residents, fellows (hereafter referred to as residents), and their respective training programs.

Purpose

DHMC is committed to the provision of a high-quality resident training environment, balancing time for educational experiences with patient care responsibilities. We supervise and promote resident physicians' health and well-being while they learn to deliver safe, effective patient care. We have instituted and we support limits on resident work hours, while assuming responsibility for addressing the impact of compliance with the ACGME Duty Hours requirements on our delivery of care and our resident physicians' educational experience.

Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours.

Definition

Providing residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education has priority in the allotment of residents' time and energies. Duty hour assignments shall recognize that faculty and residents have collective responsibility for the safety and welfare of patients. The institution shall adhere to the resident duty hour rules as defined by the ACGME.

Duty Hours

Duty hours must be limited to 80 hours per week averaged over 28 days or the length of the block, whichever is shorter. Duty hours are defined as all clinical and academic activities related to the residency program.
1. The following must be included when reporting resident duty hours:
  - Patient care (both inpatient and outpatient);
  - Administrative duties related to patient care;
  - The provision for transfer of patient care / signouts;
  - Time spent in-house during call activities;
  - Scheduled academic activities such as conferences;
  - Research;
  - Hours spent on activities that are required by the accreditation standards, such as membership on a hospital committee, or that are accepted practice in residency programs, such as residents’ participation in interviewing residency candidates;
  - Any of the above duties, when performed at home or outside the clinical workplace, including EMR note writing and preparation of discharge summaries;
  - Time spent at regional / national conferences / meetings when attendance at the meeting is required by the program, or when the resident is acting as a representative of the program (i.e. presenting a paper or poster). Only actual meeting time counts towards duty hours, travel and non-conference time is excluded;
2. The following should not be included when reporting duty hours:
  - Reading and study time spent away from the duty site;
  - Academic preparation time, such as time spent preparing for presentations or journal club.
Residents must be scheduled for a minimum of one day free of duty every week, when averaged over four weeks.
1. At-home call cannot be assigned on these free days.
2. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
3. It is not permissible to have the day off regularly or frequently scheduled on a resident’s post-call day, but in smaller programs it may occasionally be necessary to have the day off fall on the post-call day.
PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods. Intermediate level residents [as defined by the Review Committee] should have 10 hours free of duty, and must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty. While it is desirable that residents in their final year of training [as defined by the Review Committee] have eight hours free of duty between scheduled duty periods, there may be circumstances [as defined by the Review Committee] when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty. Circumstances of return-to-hospital activities with fewer than eight hours away from the hospital by residents in their final years of education must be monitored by the program director.
Rotations shorter than 28 days must be fully compliant with the 80 hour and 1 day off in 7 rules. Averaging shorter blocks of high intensity and low intensity rotations is not allowed.
When vacation is taken during a block, the remainder of the block must be compliant with all duty hour rules.

Call / Extended Duty Periods

The objective of on-call activities is to provide residents with continuity of patient care experiences throughout an extended period. In-house call is defined as those duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution.

In-House Call:
1. Duty periods of PGY-1 residents must not exceed 16 hours in duration.
2. Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital.
  - Extended duty hour shifts / call may not be more frequent than every third night, averaged over 28 days with the following qualifications:
    - Scheduled duty shifts (usually 8, 10, or 12 hours long) such as those worked in the ICU, on Emergency Medicine rotations, or on Night Float are exempt from this requirement;
    - Residents can be assigned to a maximum of four call nights in any seven-day period. This can only be done one week per month;
    - Residents must not take night call for two consecutive nights.
  - Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty, to include:
    - The care of new patients in any clinical setting;
    - Continuity or outpatient clinics;
    - Participation in new procedures including elective scheduled surgery.
  - Residents may be allowed to remain on site for patient safety or resident education; however, this period of time must be no longer than an additional four hours.
3. In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. Under those circumstances, the resident must:
  1. appropriately hand over the care of all other patients to the team responsible for their continuing care;
  2. document the reasons for remaining to care for the patient in question, and;
  3. submit that documentation in every circumstance to the program director.
  The program director must review each submission of additional service, and track both individual resident and program-wide episodes of additional duty.
4. Residents must not be scheduled for more than six consecutive nights of night float.
At Home Call:
1. At-home call (pager call) is defined as call taken from outside the assigned institution.
2. 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.
3. Home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.
4. Home call is only appropriate if the service intensity and frequency of being called is low.
5. Residents are permitted to return to the hospital while on at-home call to care for new or established patients. Each episode of this type of care must be included in the 80-hour weekly maximum but will not initiate a new "off-duty period." The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands or fatigue.
6. PGY-1 residents are limited to a 16-hour shift and are not allowed to take at-home call.

Moonlighting

Because residency education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the ability of the resident to achieve the goals and objectives of the educational program.
The program director must comply with the DHMC’s written policies and procedures regarding moonlighting.
All moonlighting must be counted toward the 80-hour weekly limit on duty hours.
PGY-1 residents may not moonlight.

Program-Level Policy

DHMC will not accept for review, nor endorse any applications from individual GME training programs seeking exceptions to ACGME duty hour rules and regulations.
Each DHMC training program, regardless of ACGME-accreditation status, must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours.
Each program must distribute these written policies to residents and faculty.

Education & Orientation

Institutional and program leadership must project a clear message to all DHMC faculty and residents regarding the critical importance of adhering to the Institutional and Program Requirements for resident duty hours. The importance of honesty in reporting must be emphasized at every opportunity.
The GME staff will incorporate an educational module into the general GME orientation emphasizing the institutional expectations of compliance with duty hour regulations as well as duty hours reporting compliance, and will include didactic material about the effects of sleeplessness and fatigue on physical health, cognitive development, and mental well-being.
A review of the rationale for duty hour limitations, expectations regarding reporting compliance, and the importance of honesty in reporting must be provided by a figure of authority (Chair, Section Head or Program Director) to residents in every training program at the beginning of each academic year.

Reporting Procedures

DHMC has a standard system for use by all residents to document duty hours. Currently this standard system is a part of the E*Value resident management system. GME Office staff assists with the adaptation of E*Value software for specific program use, as well as the training of program staff in the use of E*Value, as needed. To ensure accuracy and timeliness of the data:
- Each resident is responsible for direct entry of their own duty hour information into the E-Value system.
- iThe E-Value system will allow programs the option to establish an automated email announcement to be sent to all residents who have not completed their duty hour calendar for the specified period of time.
- A global set of duty hour labels are available to all programs to ensure reported data is consistent across programs.
The standard definition of "reporting compliance" is that within seven days of a month’s end, each resident completes 80% of that month’s calendar.
Programs will have a seven day window, immediately following the seven days provided to residents, for completion of their monthly calendar, to internally audit and confirm duty hours as reported by their residents before the reports are finalized. No changes to the monthly duty hour report should be entered beyond the specified audit window.
The GME Office utilizes a standard reporting form across all programs to track data relating to both reporting compliance and duty hour violations. All required data is derived from the E*Value system and may be acquired by GME staff independent of the training program.
In order to increase transparency, as well as foster improved compliance, the standard GME-generated data set will be made widely available to all residents, faculty, and administrative members of the DHMC community on a quarterly basis.

Reporting Non-Compliance & Administrative Action

A standard threshold for "administrative action" in response to reporting noncompliance exists across all DHMC programs with the following thresholds and administrative actions:
- Three months of zero compliance in any given academic year will generate a Letter of Concern from the Director of GME to be placed in the resident’s QA file citing a pattern of reporting non-compliance that reflects negatively on the resident physician’s professionalism.
- Continued reporting non-compliance following receipt of a Letter of Concern will trigger a review by the GME Duty Hours Subcommittee and may result in disciplinary action up to and including dismissal.
There are two systems available for confidential reporting: GME Confidential is available for confidential reporting or guidance regarding duty hours, and a confidential telephone hotline is also available. Both systems forward all reports to the Duty Hours Subcommittee. Residents should be educated about confidential reporting by both GME and their own programs.

Duty Hours Subcommittee

The GMEC will have a standing Duty Hours Subcommittee. This subcommittee is composed of the GME Office leadership team, one program director, one residency coordinator and six resident representatives, to include one surgery chief resident and one medicine chief resident. The Duty Hours Subcommittee is charged to:
- review data from the E*Value system at each Subcommittee meeting;
- annually, in May or June, review/update the DHMC Duty Hours Policy;
- review all confidential suggestions/concerns submitted through confidential systems at the first available meeting after receiving the concern;
- report to the GMEC every 6 months (June and December) or more frequently as the need arises;
- review cases and make decisions regarding disciplinary action for egregious reporting non-compliance, and;
- arbitrate significant resident/program issues related to duty hours.

Evaluation Policy

Scope

The policy applies to all ACGME-accredited residency and fellowship programs at DHMC.

Purpose

The ACGME Institutional Requirements, Program Requirements, and Common Program Requirements require a policy on resident, faculty and program evaluation.
Each GME program must develop and maintain academic requirements for the educational development of the residents in that program. In order to progress academically in the program, the resident must meet those academic requirements.

Policy Guidelines

Assessment of Learning

DHMC recognizes learning on a continuum from novice to advanced beginner to competent at a level expected of a new practitioner. Each training program provides assessment of trainee learning in consideration of this continuum, aligned with basic RRC requirements as to the scope and number of both formative and summative evaluations.

Each residency program must utilize measures to assess residents' competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Mechanisms are developed and updated to provide regular and timely performance feedback to residents. This process involves the use of assessment results to achieve progressive improvements in residents' competence and performance consistent with graduated roles and responsibilities as assigned.

Evaluation of Residents

Written assessments of learning focus on a trainee's ability to perform up to defined expectations as outlined in the program curriculum. Behavioral expectations are outlined in the DHMC Code of Ethical Conduct and include the recording of procedures in case logs if required by the ACGME Residency Review Committee (RRC), and the timely and accurate reporting of duty hours. Programs must use multiple evaluators (e.g. faculty, peers, patients, self, and other professional staff). At scheduled intervals during the training year, written formative evaluations are provided to the trainee. At the conclusion of a training year, and at the end of the training program, written summative evaluations are provided to the trainee via a documented face-to-face meeting with the program director or their designee. Evaluations of resident performance must be readily accessible for review by the resident. The standards of evaluation must be applied equitably to all residents and assure due process.

Summative Evaluation

The program director must provide a summative evaluation for each resident upon completion of the program. This evaluation must become part of the resident's permanent record maintained by the institution, and must be accessible for review by the resident in accordance with institutional policy. The final summative evaluation must document the resident's performance during the final period of education, and verify that the resident has demonstrated sufficient competence to enter practice without direct supervision.

Evaluation of Faculty

Each residency program must monitor the educational effectiveness of faculty and attending physicians. At least annually, residents are asked to provide written or electronic evaluations of individual faculty members. These evaluations should include a review of the faculty's clinical teaching abilities, clinical knowledge, professionalism, and interpersonal and communication skills. These evaluations are confidential.

Evaluation of Program

At prescribed intervals, residents are asked to provide written or electronic feedback about the program including curriculum, working environment, scholarly milieu, evaluation systems, and other features. These evaluations are confidential. Each residency program uses these resident assessments, combined with faculty input, to evaluate the educational effectiveness of the training program. Programs are expected to utilize the GME office template for the Annual Program Evaluation and Improvement Plan to guide and document this annual improvement process. All programs must submit a completed Program Evaluation and Improvement Plan to the GME office on an annual basis.

Resident Quality Assurance Files

All residency programs participate in the medical center-wide quality assurance system. Performance evaluations of residents are coordinated and administered by Residency Program Directors. Performance evaluations are reflective of academic knowledge and patient care/clinical skills and are to be used in making decisions about promotion, program completion, remediation, and any disciplinary action. These evaluations are considered to be confidential and privileged (by New Hampshire laws RSA 151:13a and RSA 329:29a).

Related Policies and Reference Material

ACGME Common Program Requirements at: http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf

Specific section applicable to this policy:
V. A-C
Institutional Annual Program Evaluation and Improvement template.

Extreme Emergent Situation Policy

Scope

This document is intended to complement and coincide with all existing disaster plans at Dartmouth-Hitchcock Medical Center (DHMC).

Purpose

To state the principles to be applied when considering residents for clinical duties during a Local Extreme Emergent Situation, and, to state the process that should be followed to alert the ACGME that a Local Extreme Emergent Situation has occurred.

Policy Guidelines

Definition of a Local Extreme Situation

A local extreme emergent situation is an event that affects resident education or the work environment but does not rise to the level of an ACGME-declared disaster which could impact an entire community or region for an extended period of time. Example: a hospital-declared disaster for an epidemic. An extreme emergent situation is localized to one sponsoring institution, a participating institution, or another clinical setting.

Duties of Residents during Local Extreme Emergent Situations

Residents are first and foremost, physicians, whether they are acting under normal circumstances or in extreme emergent situations. Residents must be expected to perform according to society’s expectations of physicians 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 in the state and therefore they may be able to provide care independent of supervision.
Residents are students. 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 license 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 in any situations outside of the scope of their individual license. Expectations for performance under extreme circumstances must be qualified by the scope of licensure.
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 employee:
- The nature of the health care and clinical work that a resident will be expected to deliver;
- The resident’s level of post-graduate education specifically regarding specialty preparedness;
- Resident safety, considering their level of post-graduate training, associated professional judgment capacity, and the nature of the disaster at hand;
- Board certification eligibility during or after a prolonged extreme emergent situation;
- Reasonable expectations for duration of engagement in the extreme emergent situation; and,
- Self-limitations according to the resident’s maturity to act under significant stress or even duress.

Defined Responsibilities Concerning a Local Extreme Emergent Situation

Responsibilities of the DHMC Designated Institutional Official (DIO)

Serve as the point of contact for Program Directors for answers to questions.
The DIO should contact the Executive Director, Institutional Review Committee (ED-IRC) via telephone only if an extreme emergent situation causes serious, extended disruption to resident assignments, educational infrastructure or clinical operations that might affect Dartmouth-Hitchcock or any of its programs' ability to conduct resident education in substantial compliance with ACGME Institutional, Common, and individual Program Requirements. On behalf of D-H, the DIO will provide information to the ED-IRC regarding the extreme emergent situation and status of the educational environment for its accredited programs resulting from the emergency.
At the ED-IRC’s request, the DIO will submit a written description of the disruption at the institution and provide details regarding activities undertaken in response. The DIO will provide updates as requested.
The DIO will receive electronic confirmation of this communication with the ED-IRC which will include copies to all EDs of Residency Review Committees (RRCs). The DIO will distribute this confirmation to D-H Program Directors.
The DIO will notify the ACGME when the extreme emergent situation has been resolved.

Responsibilities of the Program Directors:

Upon receipt of the electronic confirmation of the correspondence between the DIO and ED-IRC, PDs may contact their respective EDs-RRCs if necessary to discuss any specialty-specific concerns regarding interruptions to resident education or effect on the educational environment.
PDs are expected to follow their institutional disaster policies regarding communication processes to update the DIO on the results of conversations with EDs-RRCs regarding any program specific issues.

Other Responsibilities Related to Local Extreme Emergent Situation

The ED-IRC will alert EDs-RRCs when DHMC reports an extreme emergent situation. These communications will be included as interim correspondence in institutional and program files.
PDs from affected institutions may communicate directly regarding specialty-specific concerns once local extreme situations have been confirmed through the ED-IRC.
After communication between a PD and an ED-RRC, the ED-RRC will notify the ED-IRC if there is a perception of substantive institutional accreditation issues occurring within DHMC during the event.
The ED-IRC will notify all EDs-RRCs when institutional extreme emergent situations have been resolved.

Grievance Policy

The purpose of this policy is to delineate Fair Hearing procedures which assure due process to Residents who have concerns or are recommended for non-renewal or dismissal from a program due to academic deficiency, non-academic deficiency or behavior incompatible with the role of the physician, or for other reasons that, if not resolved, could significantly threaten a Resident's intended career development.

Related pages

Grievance Process

At any time during this process, the Resident may resign. Once a written resignation has been delivered to the Program Director, however, the Resident shall be deemed to have waived all rights to a hearing or to a continuance of their appointment.

Hearing Procedure

Upon notification by the Resident that a review is requested, the Director of Graduate Medical Education or his designee shall form a committee consisting of the Director of Graduate Medical Education or his designee, a Hospital administrator, a house officer and two program directors or one program director and one physician faculty member selected by the Director of Graduate Medical Education or his designee (hereafter called the Committee.) The Director shall not select any person having a direct working relationship with the Resident. The Director of Graduate Medical Education or his designee shall chair the Committee.
The Committee shall schedule a hearing to occur within 14 days, or within a reasonable period of time based upon availability of the Resident, Program Director and Committee, but not less than seven days from the date of the Resident's request for review. In the interim, the GME Office shall obtain all relevant evaluation and academic records.
All evidence available to the Committee shall be provided to the Resident and Program Director at least three working days prior to the hearing. The specification of reasons for non-renewal or dismissal or other factors in the original written notice shall not prevent the Committee from relying on other reasons which are presented at the hearing; provided that the Committee may, at the request of the Resident and without special notice, recess the hearing and reconvene later in order to allow the Resident adequate opportunity to address reasons not included in the notice. The Committee may also, at its sole discretion and without special notice, recess the hearing and reconvene later in order to study new evidence presented by the Resident at the hearing.
The Resident shall be present and prepared to proceed at the scheduled hearing or shall be deemed to have waived all rights to a hearing and to have accepted any adverse recommendation or decision made by the Committee. Another hearing may be scheduled at the Committee's sole discretion if the Resident presents good cause for failing to appear or proceed. Hearings scheduled under these Guidelines shall be postponed only for good cause and at the sole discretion of the Committee.
The Resident and the Program Director may invite up to five witnesses each to present before the Committee. The Resident and Program Director may also ask others not invited to speak to submit written statements which will be collected for the GME Office at least five days prior to the hearing date.
The GME Director may appoint a separate hearing officer or designate a member of the Committee to preside over the hearing, to determine the order of procedure, to assure that all participants have a reasonable opportunity to present relevant oral and documentary evidence, to maintain decorum and to make any necessary procedural rulings.
The hearing need not be conducted strictly according to the rules of law relating to the examination of witnesses or the presentation of evidence. Any relevant matter upon which responsible persons customarily rely in the conduct of serious affairs shall be considered.
The Resident shall be entitled to submit, either prior to or during the hearing, memoranda concerning any issue of procedure or fact and such memoranda shall become part of the hearing record.
The order of presentation shall be determined by the Chair of the Committee. The Program Director shall be responsible for presenting appropriate evidence in support of the decision being questioned by the Resident. The Resident shall be responsible for presenting evidence which contradicts the Program Director's evidence or indicates that the Program Director's decision was arbitrary, unreasonable or capricious.
The Resident, the Program Director and the Committee may be entitled to consult with legal counsel in preparation for the hearing or with regard to other related matters.
Neither the Resident nor the Program Director shall be represented at the hearing by an attorney.
The Resident or Program Director may utilize a DHMC physician or staff member as an advisor during the Fair Hearing Process. This advisor may be present throughout the hearing.
The Committee may, without special notice, recess the hearing and reconvene the same for the convenience of the participants or for the purpose of obtaining new or additional evidence or consultation. Upon conclusion of the presentation of oral and written evidence, the hearing shall be closed.
The hearing may not be tape-recorded.

Post-Hearing Procedure

The Committee shall conduct its deliberations in closed sessions. Only Committee members will be permitted to observe or participate in the deliberations.
Within 14 days, or a reasonable period of time after the conclusion of the hearing, the Committee shall make its final decision and shall deliver written notice thereof to the Program Director and the Resident. The notice shall indicate the reasons relied upon by the Committee in reaching its decision.
In the event the Committee should not concur with the Program Director's recommendation for non-renewal or dismissal or other issues regarding the Resident, the Program Director may be asked to accept the Resident in the departmental program for an additional period of specified duration during which remedial efforts may be continued on the Resident's behalf. The Resident's appointment shall be continued under such conditions as shall be defined in writing by the Program Director to the Resident and to the Director of Graduate Medical Education.
There shall be no appeal from the decision of the Committee.

Procedures

Academic Deficiency

Definition: Academic deficiency shall include, but not be limited to: a) insufficient fund of medical knowledge, (b) inability to use knowledge effectively, and/or (c) behavior detrimental to the educational process or the care of patients.

Length and Goals of Remediation: A Resident whose academic performance does not meet departmental standards may be entitled to a defined period of remedial training in order to allow the Resident to improve academically and remain in the program.
Non-academic Deficiency

Definition: Medical and surgical disciplines require unique abilities and talents which are unrelated to intellect, motivation or other academic qualities common to the physician. When a Resident's non-academic abilities and talents are judged insufficient by the Program Director, notification should be offered at an early stage, when a change in career direction will be least disruptive to the Resident.

Length and Goal of Remediation: A Resident whose non-academic performance does not meet department standards may be offered a defined period of remedial training in order to allow the Resident to improve and remain in the program. If correction is not deemed feasible by the Program Director, the Resident's exploration of career alternatives and Program Director's assistance in finding a position more in keeping with the Resident's abilities and talents will take place.
Behavior Incompatible with the Role of the Physician

Definition: Some behavior may be judged by the Program Director to be illegal, immoral, unethical or so objectionable as to be incompatible with the role of the physician. When such behavior on the part of a Resident has been alleged and not refuted to the Program Director's satisfaction, the Program Director, after discussion with the Director of GME, may recommend the Resident's dismissal without an intervening probationary period.

Length and Goal of Remediation: There is no right to remediation under these circumstances.
Procedure for Notification of Non-renewal, Dismissal or Other Concerns
1. The Resident shall be informed in writing of the documented deficiencies or allegations and of the recommendation for non-renewal, dismissal or remedial training in a private meeting with the Program Director or a duly appointed representative. At this meeting or as soon thereafter as possible, the Resident shall be provided with a copy of this policy.
2. The Program Director shall submit written notification of the deficiencies, allegations and recommendation for non-renewal or dismissal to the Resident, the Director of Graduate Medical Education, the Chief of Staff of the Veterans Affairs Medical Center (White River Junction, Vermont) and the GMEC where appropriate.
3. The Resident shall have five days, or within a mutually agreed upon time, from the date of this written notification to either (a) agree to the remedial plan (b) submit a resignation effective at a mutually acceptable date within the context of these guidelines, or (c) request a review of the case from the Director of Graduate Medical Education.
4. If the Resident does not reach resolution after meeting with the Director of GME and attempted mediation, the Resident may request a review in a written request for the Fair Hearing Process, as described below, to be followed.

Internal Review Policy

Purpose

The Graduate Medical Education Committee (GMEC) is responsible for the development, implementation, and oversight of an internal review process for accredited Mary Hitchcock Memorial Hospital (MHMH) graduate medical education programs.

Subcommittee Charge

In fulfillment of the ACGME institutional accreditation requirement mandating oversight of the internal review process, the GMEC establishes an Internal Review Subcommittee to develop and implement an internal review policy; evaluate and approve program internal reviews; and monitor internal review action item improvement work plans. The chair will make periodic and timely reports of subcommittee deliberations and actions to the full body of the GMEC. The subcommittee will be comprised of a balanced mix of residency program directors, and residents, and may also include non-physician administrators. Members of the subcommittee are exempt from service on internal review committees during subcommittee tenure.

Process

A standard internal review is conducted by a committee designated by the GMEC to review each ACGME-accredited program in order to judge whether the program is in substantial compliance with the RRC Common Program Requirements; specialty-specific RRC Program Requirements; andthe ACGME Institutional Requirements

Each standard internal review committeemust include faculty and residents, and may include non-physicians. The review must follow the written protocol approved by the GMEC. The internal review closure date is the GMEC-identified mid-point. Closure of the internal review should occur within 60 days of the actual ACGME-identified mid-point date. The start and closure dates of program internal reviews must be documented in GMEC minutes.

When a program has no residents enrolled at the mid-point of the review cycle the GMEC will continue oversight through a modified internal review to ensure the program maintains adequate faculty and staff resources, clinical volume, and other necessary curricular elements required to remain in substantial compliance with the institutional, common and specialty-specific program requirements prior to the program enrolling a resident. After enrolling a resident, a standard internal review must be completed within the second six-month period of the resident's first year in the program.

While assessing the residency program's compliance with each of the ACGME RRC's program standards, both standard and modified reviews must appraise:

Educational objectives of the program
Effectiveness of the program in meeting its objectives
Adequacy of available educational and financial resources to support the program
Effectiveness of the program in addressing areas of noncompliance and concerns in previous ACGME accreditation letters and previous internal reviews
Effectiveness of the program in defining the specific knowledge, skills, attitudes, and educational experiences required for the residents to achieve competence in the following: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice
Effectiveness of the program in using evaluation tools developed to assess a resident's level of competence in each of the six general areas listed above
Effectiveness of the program in using dependable outcome measures developed for each of the six general competencies listed above
Effectiveness of the program in implementing a process that links educational outcomes with program improvement. This will include a review of the program's own annual review of aggregate resident performance, faculty development, graduate performance, and program quality.
Effectiveness of the program's duty hour monitoring system.
Written guidelines for and effectiveness of supervision of residents according to specialty requirements.
Effectiveness of administrative systems in support of the educational program.

Materials and data to be used in the review process must include program documents as specified in the internal review protocol. In addition to reviewing program documentation the internal review committee is expected to review GME Office surveys of all current residents, faculty, and recent graduates. The committee is expected to interview the program director, a representative sample of faculty and peer-selected residents from each level of training in the program. Other staff within the clinical setting and other individuals from outside the program may also be deemed appropriate for interview by the committee.

Protocol

Staffing

The GMEC designates the Office of Graduate Medical Education (GME) to coordinate the conduct of regular internal reviews of MHMH residency programs to assess compliance with ACGME institutional requirements and RRC program requirements, to evaluate how effectively the programs are fulfilling their educational missions, and to report to the GMEC findings of the internal review.

Internal reviews will be conducted under the supervision of the Associate Dean for Graduate Medical Education (DIO). Whenever possible the DIO will chair internal review committees for short-cycled programs; other review committees will be chaired by program directors or faculty members from outside the department wherein the program under review resides. The DIO will appoint GME Office staff to support the work of each review committee.

Review Committee Membership

Committee members must be drawn from outside the program under review, and from outside the department wherein the program under review resides. Minimum committee membership is three people, including at least one program director or former program director and one resident. The committee may include non-physician administrators as deemed appropriate. External reviewers from outside MHMH and Dartmouth-Hitchcock Medical Center (DHMC) may also be included on the review committeeas determined by the DIO and GMEC.

Review Committee Size

Recognizing that a primary activity for committee members is to interview a program's faculty and current residents, the GMEC recommends an internal review committee be sized to adequately engage the program. An appropriate balance of faculty, residents, and any administrators must be maintained.

Review Committee Responsibilities

Specific duties for committee members include participating in a meeting to kick-off the process; reviewing program materials and data; interviewing faculty and residents; preparation of a written summary of the interviews for inclusion in the final internal review report; and providing feedback on the draft report.

Additional responsibilities for review committee chairsincludes providing leadership; approval of final wording in the draft report; and participation in the closure meeting. Review committee chairs are also invited to participate in the presentation of the review report to the GMEC subcommittee.

Program Information

As part of the internal review process the program and GME Office will collaboratively prepare a set of materials to document various aspects and elements of the training program. Materials will be electronically archived by the GME Office and made available to committee members for their review. Documentation will include:

Internal Review Committee Roster
Past Internal Review Reports and Work Plans
Internal Review Surveys - Residents, Recent Graduates, and Faculty
Interview Guidelines
ACGME Resident Survey Results
Resident, Recent Graduates, Faculty Rosters
Program Description
ACGME – RRC Accreditation Requirements
RRC Accreditation Correspondence
Program Policies
Program Curriculum
Program Schedules
Evaluation Tools, Schedules, Outcomes
Resident Logs
In-Service Training Examination Results
Board Completion and Pass Rates
Annual Program Evaluation Minutes
Resident Duty Hours
Key Faculty CVs
Affiliation Agreements
GME Policies and Procedures

From time to time the review committee may require other program documents to aid in the evaluation process.

File Audit

As part of the review process the GME Office will conduct an audit of program files to ensure they meet standards. Findings will be included in the final internal review report.

Internal Review Report

For both standard and modified internal reviews there must be a written report that contains, at a minimum, the following:

Name of the program reviewed, the date of the ACGME-assigned midpoint; the date of the GMEC-assigned midpoint; the dates of the review; closure date; and date of review and approval of the report by the GMEC Internal Review Subcommittee
Names and titles of the internal review committee members including identification of residents and indication of PGY level
Brief description of the internal review process used including who was interviewed (specific names will not be included in the final report to protect confidentiality, but will be maintained in the GME office for verification purposes) and the documents reviewed
List of the areas of noncompliance or any concerns or comments from the previous ACGME accreditation letter and last internal review with a summary of how the program and/or institution addressed each one
Sufficient documentation or discussion to demonstrate that a comprehensive review was conducted and was based on the GMEC's internal review protocol
Identification of any areas of non-compliance or concerns identified as action items for internal follow-up and review by the GMEC

Closure

GME Office staff and the chair of the internal review committee will meet with the program director to share findings of the draft report and discuss next steps including presentation to the entire GMEC and any action item follow-up that may be indicated. The final report will be sent to the program director by the GME Office within 48 hours of the closure meeting.

Continuous Quality Improvement

A work plan addressing corrective measures to any action items identified in the internal review report must be submitted by the program director to the GME Office within 30 days of closure. Interim progress reports may be identified by the program or required by the GMEC. A final progress report will be made to the DIO approximately 6 months prior to the next anticipated RRC site visit. The Internal Review Subcommittee chair or their designee will provide work plan completion status reports to the GMEC.

Presentation to the GMEC

The GMEC's Internal Review Subcommittee will meet bi-monthly to review and approve all internal review reports. Program directors and the chair of their internal reviews are invited to participate in subcommittee discussions when reports are presented.

The subcommittee will report regularly to the entire GMEC on the approved reports; areas of significant concern and recommendations requiring immediate action; and examples of exemplary practices. Minutes of GMEC must reflect action taken on each internal review report.

Documentation for RRC

Upon GMEC acceptance of a program's report, the GME Office will provide the program with a letter confirming completion of the internal review process for verification by site visitors. A copy of this policy will be attached. The confirmation letter will not contain information from or conclusions drawn in the report other than the names and credentials of committee members.

Confidentiality

The internal review process is a quality assurance program evaluation that is protected pursuant to NH RSA 151 13a and RSA 329:29a. The GMEC supports confidentiality and accepts responsibility to keep secure and confidential the information collected about a program during and after the internal review process. A confidential cover page must always accompany reports related to the internal review process, indicating NH RSA 151 13a and RSA 329:29a quality assurance protection.

Internal review reports are confidential and must not be shared with RRC site visitors. To confirm compliance with this protocol and institutional requirements, internal review reports are included in the institutional review document. They are reviewed by the Institutional Review Committee at the time of institutional accreditation review to verify that we are following our internal review policy and protocol.

Sharing Results of Internal Review Report with Faculty and Residents

In order to complete the review process, the director should share the results of the review with all residents and faculty in the program. Discussion of the report and the action items should take place as part of the program's quality improvement process and should be integrated with faculty and resident evaluation of the program.

Leave of Absence Policy

It is the policy of Graduate Medical Education at Mary Hitchcock Memorial Hospital to make leaves of absence (LOA) available to its residents and fellows (herein after referred to as "residents") recognizing the need of said residents to occasionally be away from training for compelling reasons; and further to comply with all applicable state and federal laws. Specific information on appropriate process and benefit continuation is available at the Graduate Medical Education (GME) office.

Satisfactory resolution of issues affecting the on-call schedule is the responsibility of the resident requesting LOA and the Program director. Consideration should be given to the needs of the resident, the welfare of others training in the program, and the needs of the program as a whole.

Each specialty board residency review committee (RRC) and/or intramural residency program has its own unique requirements related to board eligibility or program completion. Residents may be required to make up absent time should there be a limit on missed time from training as specified by any of these bodies.

Disability Leave / Medical Leave of Absence

Overview

For the purpose of this policy, disability includes any injury or illness including those arising from pregnancy, childbirth, and related medical conditions that temporarily impede a resident from being able to perform the essential functions of their position. A female resident affected by pregnancy, childbirth or related medical conditions will be treated in the same manner as any resident affected by any other temporary disability. Any resident absent from work or expected to be absent from work for more than two consecutive calendar weeks due to disability should be placed on disability leave and should apply for short-term disability benefits. The leave date begins on the initial date of the inability to work because of the disability. Disability leave may be granted with full pay and continued benefits for 90 days. Disabilities extending beyond 90 days will be covered according to Long Term Disability (LTD) policy

FMLA Leave

MHMH complies with the Family and Medical Leave Act (FMLA) and provides eligible residents with up to twelve (12) work weeks of job protected unpaid family or medical leave during any rolling twelve (12) month period for one or more of the following events:

Birth and first year care of a child.
Placement of a child for adoption or foster care in the house staff member's home and for first year care of the child.
To care for a spouse, parent, minor child, or adult child (when the adult child is not capable of self-care because of a physical or mental disability) with a serious health condition. (A serious health condition is defined as an illness, injury, impairment or physical or mental condition that involves inpatient care in a hospital, hospice or residential medical care facility, or continuing treatment by a health care provider for more than three days.)
Resident's own serious health condition, which renders him/her unable to perform the functions of the house staff member's job.
The qualifying exigency (as defined by FMLA regulations) arising out of the fact that the spouse, or a son, daughter or parent of the resident is on active duty in the United States Armed Forces (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation.

Rolling 12-month period

For purposes of calculating the amount of FMLA leave an eligible house staff member may take, the term "during any twelve (12) month period" means a rolling twelve (12) month period measured backward from the date an FMLA leave begins.

Eligibility Requirements

A resident is eligible for FMLA leave if he/she has:

Been employed with MHMH for at least twelve (12) months (which need not be consecutive).
Worked at least 1,250 hours in the twelve (12) consecutive months prior to the leave.

Status of Benefits during FMLA Leave

An eligible resident's group health plan participation will be maintained for the duration of the FMLA leave at the level and under the same conditions coverage as would have been provided if the resident had not taken leave. The resident will be responsible for continuing to pay his/her share of the premium as a condition of continuing his/her participation. Should the resident fail to return from leave, the employer may recover the premium for the dental coverage incurred during the leave.

No Other Work While on Leave

A resident may not accept or perform other employment, consulting or independent contractor work of any kind during leave. If the resident violates this provision; the resident will be considered to have resigned from his/her training program.

Reinstatement from Leave

Residents returning from FMLA medical leave will be reinstated to a position in accordance with the Family and Medical Leave Act of 1993, if applicable. For situations that extend beyond FMLA protection, reinstatement will be at the discretion of the program director and the GME Office, except in workers' compensation situations when an employee has a potential right to job reinstatement for eighteen (18) months from date of injury.

Non-FMLA Leave

All residents, regardless of benefit status or FMLA eligibility, are eligible to take a leave of absence (LOA) from training for the resident's own medical issues rendering them unable to work.

Request for Leave

A request for a leave of absence (LOA) should be initiated with your program director at least thirty (30) days in advance when at all possible. When advance notice cannot be provided, residents should contact their program director as soon as possible.

For a leave (other than medical disability) that qualifies under FMLA, the resident must complete a "Certification of Health Care Provider" form and submit to the benefits department at 603-676-4272. These forms can be obtained by calling the GME Office.

Effect of Leave on Pay

All medical leave is unpaid. However, residents may apply for Short or Long-Term Disability benefits.

Personal Leave

A leave of absence (LOA) for personal reasons may be granted to House Staff with at least one year of continuous service at DHMC for a period up to, but not exceeding, 90 days. This leave will be unpaid.

Personal leave must be approved by the Program director. It is suggested that personal leaves not qualifying under the Family and Medical Leave Act (FMLA) be submitted at least 60 days in advance. Application for personal leave is accomplished by completing and submitting the GME Leave of Absence Request Form.

Bereavement Leave

In the event of a death in the immediate family, the Program director may approve up to five (5) days bereavement leave with pay. For these purposes, immediate family includes: spouse, partner, parents, grandparents, grandchildren, mother/father-in-law, brother, sister, step-parents, step-brother, step-sister, child, step-child, brother-in-law and sister-in-law. The leave may be used over an extended period of time to accommodate the reasonable needs of the employee.

The intent of the policy is to provide time to recognize the emotional impact of the death of a member of the immediate family. The Hospital accepts that there may be other relationships which have equal meaning to an employee but cannot provide bereavement paid time off for all such extended relationships.

Military Leave

Military leave is available to all residents who voluntarily or involuntarily serve in the United States Armed Forces or National Guard. A request for a military leave of absence (LOA) should be initiated with your Program director at least thirty (30) days in advance when at all possible. When advance notice cannot be provided, residents should contact their program director as soon as possible.

Moonlighting Policy

Scope

The policy applies to all MHMH residents and fellows (hereafter referred to as residents) and training programs.

Purpose

The Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements stipulate that the sponsoring institution must have policies regarding professional activities outside the educational program.

Definition

Dartmouth-Hitchcock Medical Center neither encourages nor discourages moonlighting. Residents are specifically not required to moonlight.
All residents participating in moonlighting must first complete a Moonlighting Request form and obtain approval and signature by their Program Director and the Administrative Director of GME prior to undertaking such activity. Moonlighting Request forms are available through the GME office.
Internal moonlighting is defined as any moonlighting that occurs within DHMC (MHMH or the VAMC).
External moonlighting is defined as any moonlighting that occurs outside of DHMC (MHMH or the VAMC).
A resident must have the following to participate in either internal or external moonlighting:
- An unrestricted, permanent license to practice medicine in each state where he/she moonlights. A permanent license is different from a training license and residents are not legally allowed to moonlight under a training license.
- A federal DEA #. A federal DEA # is different from a training DEA # and residents are not legally allowed to moonlight under a training DEA #.
Residents who moonlight within DHMC (internal moonlighting) will be covered for medical malpractice under the Dartmouth-Hitchcock Professional Liability Insurance Policy so long as they are acting within the level of their training and within the scope of their employment, and are appropriately credentialed by the institution.
Residents moonlighting outside of DHMC (external moonlighting) are not covered by the Dartmouth-Hitchcock Professional Liability Insurance Policy and must make certain that the outside employer provides adequate professional liability coverage. It is the resident’s responsibility to determine what level of coverage is “adequate.”
All approvals for moonlighting:
- shall remain in force for the current academic year unless terminated by the program director.
- shall automatically expire on June 30 of a given academic year.
Renewal requests the next academic year must be processed and approved before undertaking additional moonlighting activities.

Responsibilities

Program Director Responsibilities

Each program must have a written program-specific Moonlighting policy which meets RRC requirements and which is consistent with the DHMC GME policy. The program-specific policy must be readily available to residents.
Prospective written approval from the Program Director and the Administrative Director of GME is required for all moonlighting activity.
The Program must maintain a copy of the completed Moonlighting Request form as part of the resident’s personnel file.
The program director is ultimately responsible for assuring that moonlighting activities do not interfere with the ability of the resident to meet the goals, objectives, assigned duties, and responsibilities of the educational program. They are expected to monitor all moonlighting activities in their program on an ongoing basis.
The program director may withdraw permission to moonlight if, at any time, moonlighting activities are seen as producing adverse effects on the resident’s training experience.

Resident Responsibilities

All residents participating in moonlighting must first complete a Moonlighting Request form and obtain approval and signature by their program director and the Administrative Director of GME prior to undertaking such activity.
It is the sole responsibility of the resident to:
- apply for and obtain a permanent license to practice medicine to support any moonlighting activities.
- apply for and obtain their own Federal DEA # to support any moonlighting activities.
Duty Hour reporting:
- All moonlighting activities, internal and external, must be reported by the resident as duty hours within E*Value using the appropriate task identifier:
  - Moonlighting-DHMC/VA, or;
  - Moonlighting-Non DHMC/VA.
- All moonlighting must be counted toward the 80-hour weekly limit on duty hours.
PGY-1 residents may not moonlight.
Residents employed under a J-1 visa are strictly prohibited by law from participating in moonlighting activities. Residents employed under an H1-B visa may be able to moonlight under specific, very limited circumstances.
Violation of these moonlighting rules and procedures by the resident may lead to disciplinary action up to and including immediate dismissal.

Off-Site Rotation Policy

Scope

The policy applies to requests for non-DH affiliated rotations in all residency and fellowship programs.

Purpose

It is the policy of the Office of Graduate Medical Education and the GMEC to provide fair and approved procedures to programs that desire to assign residents to non-DH affiliated teaching locations, either domestic or international.

Policy Guidelines

RRC Notification Requirements

Program directors must follow all established RRC guidelines for obtaining prospective approval, if required, for off-site educational experiences.
It is the sole responsibility of the Program Director to verify that all non-DH affiliated rotations will count towards meeting the requirements for board eligibility in their respective specialty.
Presentation to, and approval by, the GMEC of any proposed additions or deletions of major participating sites or participating sites is required prior to their submission through the ACGME Accreditation Data System (ADS).
Following GMEC approval, the program director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all residents, of one month duration or more through the ACGME Accreditation Data System (ADS).

GME Office Notification Requirements - Domestic Rotations

Program directors must notify the GME office using the standard "Request for Off-Site Rotation" template when seeking to establish a new off-site experience.
Requests for off-site rotations must be received by the GME Office a minimum of 90 days in advance of the rotation start date.
The "Request for Off-Site Rotation" form must:
- Establish the educational rationale and defined clinical need for the proposed off-site rotation;
- Identify the location, hospital/clinic name (if applicable), and responsible "site director;"
- Document that appropriate approval has been obtained, from the respective RRC, if required;
- Verify that the off-site rotation will comply with all ACGME work environment regulations including supervision and duty hour guidelines;
- Identify the individual responsible for evaluating the resident's performance;
For a new standing rotation, the request must be signed by the program director.
For an elective rotation done by a single resident or fellow, the request must be signed by both the resident and program director.

GME Office Notification Requirements - International Rotations

All requirements noted above for domestic rotations must also be met for international rotations.
In addition, the following requirements must also be met prior to departure by all those approved to participate in an international rotation:
- Resident sign-off on the GME letter reviewing the status of health insurance benefits and malpractice coverage while out of the country;
- Consultation with the DH Travel Clinic to review food/water precautions, vaccination recommendations, and additional travel prescription recommendations based on the travel location(s). Appropriate vaccinations and travel prescriptions can be provided at the time of this visit.
- Resident must secure emergency evacuation insurance.
Additional recommendations that we strongly encourage those traveling internationally to consider include:
- Review the "Tips for Traveling Abroad" section of the State Department's website;
- Sign-up for the State Department's "Smart Traveler Enrollment Program (STEP)";
- Leave a copy of your itinerary, as well as a copy of your passport data page, with your program coordinator and a friend or family member so that you can be contacted in case of an emergency;
- Familiarize yourself with local conditions and laws.
The GME office will not approve requests for international rotations to countries currently on the U.S. Department of State travel warning list.
The GME office does support resident involvement in short-notice relief efforts coordinated through Dartmouth/Partners In Health. Residents involved in these efforts must submit all required documentation noted above for international experiences to the GME office prior to departure. The GME office will provide expedited review of these requests.

Related Policies and Reference Material

Program Closure and Reduction Policy

Scope

The policy applies to all ACGME-accredited residency and fellowship programs at DHMC.

Purpose

The Accreditation Council for Graduate Medical Education (ACGME) requires that Mary Hitchcock Memorial Hospital, as the Sponsoring Institution of record, have a written policy that addresses a reduction in size or closure of a residency program or closure of the Institution.
To ensure appropriate institutional oversight as required by the ACGME Institutional Requirements.

Policy Guidelines

The senior leadership of the Sponsoring Institution in conjunction with the Department Chair, Program Director, Designated Institutional Official (DIO) and Graduate Medical Education Committee (GMEC) will make appropriate efforts to avoid the closure of ACGME-accredited programs.
The Sponsoring Institution must inform the GMEC, the DIO, and the affected residents within five (5) business days following a decision to reduce the size of or close one or more programs, or when the Sponsoring Institution itself intends to close.
In the event a decision is made that a training program must decrease in size:
- The appropriate Department Chair and Program Director will inform the DIO, GMEC and the residents within five (5) business days of the decision.
- The DIO and GMEC will be responsible for monitoring the complement reduction process.
- Plans to reduce the complement of residents in the program will be made, where reasonable, by first reducing the number of positions available to incoming residents.
- If the reduction needs to include residents currently in the training program, the Department Chair, Program Director and DIO will assist affected residents in enrolling in an ACGME-accredited
In the event a decision is made that a training program must close:
- The appropriate Department Chair and Program Director will inform the DIO, GMEC and the residents within five (5) business days of the decision.
- The DIO and GMEC will be responsible for monitoring the closure process.
- The sponsoring institution will preferentially structure a closure, when reasonable, that allows enrolled residents to complete the program.
- In the event a program must be closed before one or more residents are able to complete their training, the Department Chair, Program Director and DIO will work closely with the resident(s) to assist them in enrolling in an ACGME-accredited program(s) in which they can continue their education.

Related Policies and Reference Material

ACGGME Institutional Requirements at: http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf
Specific sections applicable to this policy include II.D.5.a and II.D.5.b

Resident Promotion Policy

Scope

The policy applies to all ACGME-accredited residency and fellowship programs at DHMC.

Purpose

The ACGME Institutional Requirements stipulate that the sponsoring institution establish policy on the promotion of residents.

Policy Guidelines

General

Each program must have a policy regarding the promotion of residents to a higher level of training.
As the position of resident involves a combination of supervised, progressively more complex and increasing responsibility in the evaluation and management functions of patient care, reappointment and promotion will be dependent upon meeting the academic standards and curricular requirements of the program.

Non-renewal of appointment or non-promotion

In instances where a resident's agreement will not be renewed, or when a resident will not be promoted to the next level of training, the program must provide the resident with written notice of intent no less than one hundred twenty (120) prior to the expiration of the resident's current agreement. If the primary reason(s) for the non-renewal or non-promotion occur(s) within the four months prior to the end of the agreement, the program must provide the resident with as much written notice as circumstances will reasonably allow, prior to the end of the agreement.
Residen's are allowed to implement the grievance process if they receive a written notice either of intent not to renew their agreement, or of intent to renew their agreement but not to promote them to the next level of training. Programs must provide residents with a copy of the institutional grievance policy at the time of initial notification.

Related Policies and Reference Material

ACGME Institutional Requirements at:
http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf

Specific section(s) applicable to this policy:
II.D.4
GME Grievance policy and procedures

Resident Responsibilities Policy

Scope

The policy applies to all DH residents and fellows (hereafter referred to as residents).

Purpose

During the time of residency training, residents have many professional responsibilities including but not limited to the clinical care of patients, improving their own educational preparation, and teaching those with whom they work. In addition, graduate medical education is based on the principle progressively increasing levels of responsibility in caring for patients under the supervision of qualified faculty. Each program is responsible for developing a description specific to their particular discipline. A general description of resident activities as they progress through training is included within this policy.

Definition

Clinical Care

Residents are expected to provide competent and compassionate patient care, and to work effectively as a member of the health care team. This implies professional demeanor and conduct both in direct patient care and in communication with family members, other health care professionals, and support staff. The highest level of professionalism is expected at all times. Residents are directly responsible to the faculty attending to whom they have been assigned for all matters related to the professional care of patients. Under the supervision of attending physicians, general responsibilities of the resident physicianmay include:

Initial and ongoing assessment of patient’s medical, physical, and psychosocial status
Perform history and physical
Develop assessment and treatment plan
Perform rounds
Record progress notes
Order tests, examinations, medications, and therapies
Interpret results of tests
Arrange for discharge and after care
Write or dictate admission notes, progress notes, procedure notes, and discharge summaries
Provide patient education and counseling health status, test results, disease processes, and discharge planning
Perform procedures
Assist in surgery

Residents at all levels should have a strong commitment to patient safety and professionalism. Training programs 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. 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. In addition, the program must be committed to and responsible for promoting patient safety and the program director must ensure that residents are integrated and participate in clinical quality improvement and patient safety programs.

Programs must design clinical assignments to minimize the number of transitions in patient care. All training programs must develop and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety. Residents must be competent in communicating with team members in the hand-over process.

Learning and Education

Residents are recognized as adult learners and ultimately the acquisition of knowledge, skills, and professional attitudes is the responsibility of each individual. The institution and the residency programs will provide an ample selection of educational offerings. The expectation is that residents will make every effort to benefit from the education offered, by attending educational conferences as required for each program. The conference programs are designed to provide a didactic forum to augment the resident’s reading and clinical experience.

An essential component of learning is the development of life-long learning skills; all physicians must practice disciplined ongoing acquisition of medical knowledge. The resident is expected to develop a personal program of reading. Besides the general reading in the specialty, the resident should do directed daily reading relating to problems that they encounter in the care of patients. The resident is responsible for reading prior to performing or assisting in procedures that they have not yet had the opportunity to see.

The ACGME has defined the following six areas as General Competencies and stipulates that programs require their residents to develop them to the level of a new practitioner by the completion of training:

Patient Care
Medical knowledge
Practice-based learning and improvement
Interpersonal and communication skills
Professionalism
Systems-based practice

For a full listing of the six General Competencies and their respective sub-competencies, residents are referred to the specialty-specific curricula provided by their program and the ACGME website.

Discipline-Specific Education

A primary responsibility of graduate medical trainees is to meet the educational goals of their specific programs. In all MHMH-sponsored GME programs, the residency program director is responsible for the organization and implementation of discipline-specific educational objectives. The resident is expected to manifest active involvement in learning, and has responsibility for the following:

Familiarity with the program’s educational objectives and residency curriculum
Development of competence in the six areas listed above
Development of a personal growth program of learning to foster continued professional growth
Experience with quality assurance/performance improvement

All residents must provide data on their educational experience to their program director and GME office as requested. The provision of regular feedback on faculty, program and overall educational experiences via confidential written or electronic evaluations, is an essential part of the continuous improvement of the educational programs within our institution and is required by the ACGME.

Active participation in departmental and hospital committees provide an opportunity for residents to become familiar with administrative aspects of health care and involvement with such experiences is strongly encouraged.

Teaching Others

Residents are also expected to teach and mentor junior residents, medical students, and other learners with whom they interact. Collaborative learning is an important part of graduate medical education and residents’ involvement with the education of other members of the health care team is vitally important.

Graduated Levels of Responsibility

Graduate medical education is based on the principle of progressively increasing levels of responsibility in caring for patients under the supervision of the faculty. The overriding consideration must be the safe and effective care of the patient that is the responsibility of the faculty attending. The faculty is responsible for evaluating the progress of each resident in acquiring the skills necessary for the resident to progress to the next level of training. Factors considered in this evaluation include the resident’s clinical experience, judgment, professionalism, cognitive knowledge, and technical skills. At each level of training, there is a set of competencies that the resident is expected to master. Examples of expected competencies and responsibilities for each level of training include the following:

PGY I - Individuals in the PGY I year are supervised by senior level residents or faculty either directly or indirectly with direct supervision immediately available. If indirect supervision is provided, such supervision must be consistent with RRC policies and specific criteria which PGY I residents must meet in order to be eligible for indirect supervision must be established. Examples of tasks that are expected of PGY 1 physicians include: perform a history and physical, start intravenous lines, draw blood, order medications and diagnostic tests, collect and analyze test results and communicate those to the other members of the team and faculty, obtain informed consent, place urinary catheters and nasogastric tubes, assist in the operating room and perform other invasive procedures such as arterial line or central line insertion under the direct supervision of the faculty (or senior residents at the discretion of the responsible faculty member).

The resident is expected to exhibit a dedication to the principles of professional preparation that emphasizes primacy of the patient as the focus of care. With the assistance of an assigned mentor or the program director, the first year resident must develop and implement a plan for study, reading and research of selected topics that promotes personal and professional growth and be able to demonstrate successful use of the literature in dealing with patients. The resident should be able to communicate with patients and families about the disease process and the plan of care as outlined by the attending. At all levels, the resident is expected to demonstrate an understanding of the socioeconomic, cultural, and managerial factors inherent in providing cost effective care.
PGY II- Individuals in the second post graduate year are expected to perform independently the duties learned in the first year and may supervise the routine activities of the first year residents. The PGY II may perform some procedures with indirect supervision (such as insertion of central lines, arterial lines) once competency has been documented according to established criteria. Specific procedures allowed with indirect supervision at the PGY II level will vary with training program and must be guided according to published criteria established by the faculty and program director. The PGY II should be able to demonstrate continued sophistication in the acquisition of knowledge and skills in his/her selected specialty and further ability to function independently in evaluating patient problems and developing a plan for patient care. The resident at the second year level may respond to consults and learn the elements of an appropriate response to consultation in conjunction with the faculty member. The resident should take a leadership role in teaching PGY I residents and medical students the practical aspects of patient care and be able to explain more complex diagnostic and therapeutic procedures to the patient and family. The resident should be adept at the interpersonal skills needed to handle difficult situations. The PGY II should be able to incorporate ethical concepts into patient care and discuss these with the patient, family, and other members of the health care team.
PGY III- In the third year, the resident should be capable of managing patients with virtually any routine or complicated condition and of supervising the PGY I and PGY II in their daily activities. The resident is responsible for coordinating the care of multiple patients on the team assigned. Individuals in the third post graduate year may perform additional diagnostic and therapeutic procedures with indirect supervision once competency has been documented according to established criteria. Specific procedures allowed with indirect supervision at the PGY III level will vary with training program and must be guided according to published criteria established by the faculty and program director. The PGY III can perform progressively more complex procedures under the direct supervision of the faculty. It is expected that the third year resident be adept in the use of the literature and routinely demonstrate the ability to research selected topics and present these to the team. At the completion of the third year, the resident should be ready to assume independent practice responsibilities in those specialties requiring three years of training. In those specialties requiring longer training, the resident should demonstrate skills needed to manage a clinical service or be a chief level resident.
PGY IV- Individuals in the forth post graduate year assume an increased level of responsibility as the chief or senior resident on selected services and can perform the full range of complex procedures expected of their specialty under the direct or indirect supervision of the faculty. The fourth year is one of senior leadership and the resident should be able to assume responsibility organizing the service and supervising junior residents and students. The resident should have mastery of the information contained in standard tests and be facile in using the literature to solve specific problems. The resident will be responsible for presentations at conferences and for teaching junior residents and students on a routine basis. The PYG IV should begin to have an understanding of the role of practitioner in an integrated health care delivery system and to be aware of the issues in health care management facing patients and physicians.
PGY V or Higher - The fifth year resident (generally surgical residents) takes responsibility for the management of the major surgical teaching services, under the supervision of the faculty. The PGY V can perform most complex and high risk procedures expected of a physician with the supervision of the attending physician. The attending physician should be comfortable allowing the PGY V resident to manage all common problems expected to be encountered during independent practice. During the final year of training the resident should have the opportunity to demonstrate the mature ethical, judgmental and clinical skills needed for independent practice. The PGY V gives formal presentations at scientific assemblies and assumes a leadership role in teaching on the service. The mores and values of the profession should be highly developed, including the expected selfless dedication to patent care, a habit of lifelong study and commitment to continuous improvement of self and the practice of medicine.
Fellowship Training - Subspecialty fellowship programs range from one to three years in duration. Fellow responsibilities include considerable autonomy, especially in the tasks already mastered in the core program. They should be focused on becoming proficient in the skills defined by the subspecialty they are pursuing. As they progress through the training program, they are given progressive responsibility in the skills that make up the information content of the specialty at the discretion of the faculty.

Resident Work Environment Policy

Scope

The policy applies to all MHMH residency and fellowship programs.

Purpose

The Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements requires policies regarding the resident work environment. Specific to this policy, MHMH must provide appropriate support services to minimize the work of residents extraneous to the educational programs.

Definition

Residents on duty in the hospital must be provided adequate and appropriate food services and sleeping quarters.
Patient support services including an intravenous team, phlebotomy services, laboratory services, and transportation services must be provided in a manner appropriate to, and consistent with, educational objectives and patient care.
An effective laboratory and radiologic information retrieval system must be in place to provide for appropriate conduct of the educational programs as well as timely, high quality patient care.
A medical records system that documents the course of each patent's illness and care must be available at all times and must be adequate to support patient care, the educational needs of residents, quality assurance activities, and provide a resource for scholarly activity.
Appropriate security and personal safety measures must 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.
Educational materials to support patient care in the working environment (e.g. computer with internet access, biomedical library materials, etc.) must be available at all times.

Restrictive Covenant Policy

Scope

The policy applies to all ACGME-accredited residency and fellowship programs at DHMC.

Purpose

The ACGME specifically prohibits the use of restrictive covenants in trainee agreements.
To ensure appropriate institutional oversight as required by the ACGME Institutional Requirements.

Policy Guidelines

Neither the Sponsoring Institution nor any of its ACGME-accredited training programs may require residents to sign a non-competition guarantee (restrictive covenant).

Related Policies and Reference Material

ACGGME Institutional Requirements at: http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf
Specific section applicable to this policy: II.D.6

Review, Approval and Signature Policy

Scope

The policy applies to all ACGME-accredited residency and fellowship programs at DHMC.

Purpose

To define the requirements for the review, approval and co-signature of documents being submitted to the Accreditation Council for Graduate Medical Education (ACGME).
To ensure institutional oversight as required by the ACGME Institutional Requirements.

Policy Guidelines

Review of Documents

As set forth in the ACGME Institutional Program Requirements, documents and correspondence sent to the ACGME by Program Directors must be reviewed and approved by the DHMC Graduate Medical Education Advisory Committee (GMEC) and/or the Designated Institutional Official (DIO) as outlined in this document.
Documents requiring GMEC review and approval per the Institutional Program Requirements include:
- All applications for ACGME accreditation of new programs;
- Changes in resident/fellow complement;
- Major changes in program structure or length of training;
- Additions and deletions of participating sites;
- Appointments of new program directors;
- Progress reports requested by any Review Committee;
- Responses to all proposed adverse actions;
- Requests for exceptions of resident duty hours;
- Voluntary withdrawal of program accreditation;
- Requests for an appeal of an adverse action;
- Appeal presentation to a Board of Appeal of the ACGME.
In addition to the above listed documents, the DIO is also required to review and sign-off on:
- Program Information Forms (PIF's);
- Any other documents or correspondence sent to the ACGME by the Program Director.

GMEC Approval and Co-Signature of Documents

GMEC approval and a co-signature by the DIO attest to the accuracy, completeness and support of the content of the document. Therefore, it is essential that adequate time be allowed for review, including opportunity for recommending edits and/or corrections, prior to final approval or co-signature of a document. To facilitate this process:
- Documents that require GMEC approval must be received in the GME Office no later than one week (seven days) in advance of the GMEC meeting at which they will be reviewed and voted on. Upon approval by the GMEC, the DIO will subsequently co-sign the document and return to the Program Director.
- For PIF's and other documents that do not require GMEC review and approval, the DIO must receive the documents no later than four weeks (twenty-eight days) in advance of the "send deadline." As noted above, advance receipt of these documents will provide adequate time to read and offer suggestions for edits and/or corrections. Upon review of the final document, the DIO will cosign and return to the Program Director.
The DIO is required to co-sign all documents submitted to the ACGME by Program Directors. In the DIO's absence:
- The Associate Director of Graduate Medical Education is granted primary authority to co-sign documents submitted to the ACGME.
- If the DIO and Associate Director of Gradate Medical Education are both absent, the Department Chair is granted authority to co-sign documents submitted to the ACGME.
- All documents co-signed by the Associate Director or Department Chair will be reviewed by the DIO upon return to duty.

Responsibilities

The Program Director is responsible for:
- Informing the DIO of upcoming pending documents that require GMEC approval and/or DIO signature.
- Planning and implementing a timeline to ensure that documents requiring approval by the GMEC and/or co-signature by the DIO are forwarded by the deadlines noted above.
The GMEC is responsible for:
- Reviewing documents from Program Directors for the ACGME, offering recommendations for edits and/or corrections, and approving documents prior to their final submission to the ACGME.
The DIO is responsible for:
- Ensuring that documents forwarded by Program Directors for GMEC review and approval are added to the agenda of the next available GMEC meeting.
- Reviewing, recommending edits/corrections, and co-signing PIF's and other documents submitted to the ACGME as outlined in this policy.
- Establishing and implementing a plan for co-signing documents to be sent to the ACGME in the absence of the DIO.

Related Policies and Reference Material

ACGME Institutional Requirements at: http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf
Specific sections applicable to this policy include:
- I.B.4.a (requirement to implement co-signature procedures)
- III.B.10.a- k (requirement for GMEC review and approval)

Shared Educational Resources Policies

Scope

The policy applies to all Dartmouth-Hitchcock residency and fellowship programs.

Purpose

It is the policy of the DHMC Office of Graduate Medical Education and the GMEC to assure that appropriate and fair processes govern the allocation of resources to GME programs in which there are similarities or overlaps of educational missions.

Policy Guidelines

The DIO and GMEC will assure compliance with the appropriate allocation of resources by gaining information during mid-cycle internal reviews, communicating with each program regarding ACGME requirements and mentoring Program Directors. In addition, the GMEC will give special consideration to existing programs when a department requests a new program that potentially could compete for limited clinical or other educational resources.

If programs report difficulties in the distribution of resources committed to similar or competing training, the DIO will meet with program leaders to assess the distribution and to report these findings to the GMEC, which will recommend corrective action.

Additional Information

Shared Educational Resources - Critical Care Fellowship Programs

Leadership / Administrative Structure

Administration of the Critical Care (CC) fellowships is a shared responsibility between the Fellowship Program Directors (FPD) and the Section Chief of Critical Care.
There is a CC Fellowship Program Director from each discipline who has the direct responsibility for all aspects of a fellow's clinical and educational program; including meeting discipline specific RRC requirements
1. The specific CC FPD's are:
  - Pulmonary/CCM;
  - Internal Medicine/CC;
  - Anesthesiology/CC; and
  - [Surgery/CC; planning underway].
2. The Pulmonary/CCM Program Director is responsible for fellows with a medicine background in the combined Pulmonary/CCM program while the Internal Medicine/CC FPD is responsible for fellows with a medicine background who are not combining CC with Pulmonary. The Anesthesiology CC FPD is currently responsible for fellows with a background in surgery or anesthesiology, as well as fellows with an emergency medicine background. If a Surgery Fellowship is approved, the Surgery CC Program Director will become responsible for fellows with a background in surgery.
3. Each CC Program Director is responsible for:
  1. discipline specific aspects of the educational curriculum;
  2. collectively developing and maintaining the common elements of the curriculum;
  3. coordinating the relationship between CC and other residency training programs with their respective Core (parent) Program Director (Internal Medicine for Pulmonary/CCM and IM/CC; Surgery; and Anesthesiology);
  4. oversight of RRC requirements in coordination with their respective Core Program Director and the Associate Dean for Graduate Medical Education (on behalf of the Graduate Medical Education Committee);
  5. the supervision, evaluation, and certification of competency and professional behavior for their respective fellows (as per GME and ACGME policies).
4. All program directors are Associate Directors of the Adult Intensive Care Unit
The Section Chief of Critical Care responsibilities include:
1. the coordination and collaboration of the individual Critical Care Fellowship Programs;
2. the oversight of clinical practice and professional issues related to Critical Care (as per MHMH Bylaws, Article VII Section 1; Review of Professional Staff Performance and Conduct).
3. supervision and oversight of the Critical Care Faculty in their adherence to the highest standards of trainee education. The Section Chief of Critical Care will provide an important primary conduit for implementation of the fellowship program directors' fundamental prerogatives concerning the quality of the educational environment, addressing concerns over the intellectual rigor of work/teaching rounds, and the selection of faculty best suited to provide the highest level of fellow training in the ICU environment. The roles of the Section Chief in the implementation of the program directors' prerogatives are further detailed in Section 1.d. (below).
Reporting Structure and Oversight for Educational/Training Issues:
1. In the event that a Fellowship Program Director is dissatisfied with any aspect of the implementation of their recommendations and prerogatives concerning the quality and rigor of fellowship training, or the commitment of individual faculty to upholding the educational expectations of that Program, Program Directors have the option (and obligation) to report those concerns to their core (parent) Program Director (IM, Anesthesiology or Surgery). The Core Program Directors may address the situation directly with the Section Chief of Critical Care, or may involve Section Chiefs, and/or Department Chairs, as needed, depending upon the nature of the concerns and at the sole discretion of the Core Program Director.
2. Importantly, any of these individuals may bring their concerns to the Associate Dean for Graduate Medical Education (on behalf of the Graduate Medical Education Committee) or the ICU Oversight Committee (consisting of the Chairs of Medicine, Surgery, and Anesthesia, as well as the Chief Medical Officer of DHMC). This governance body, to be convened by the Chair of Anesthesiology on a quarterly basis, is charged with responsibility for advice and consent on any issues which have potential impact across traditional Departmental lines as well as review of the implementation of important policies pertaining to maintenance of superior quality of care and education. This is a critical structural element of the governance of this multidisciplinary ICU, which provides absolute assurance that the interests of three independent, yet interdependent, Departments are represented, but that the larger interests of the provision of superior care and education in the Intensive Care Unit supersedes the interests of any individual Department.

Selection of Fellows

Fellows can be accepted into a Critical Care (CC) Program after completing an accredited residency in Medicine, Surgery, Anesthesiology, or Emergency Medicine. Fellows who have completed a residency in Medicine can either combine their CC with Pulmonary Medicine or focus solely on CC. Fellows from the other disciplines are committed to CC only.
There will not be any pre-specified quota of fellows from each of the various pathways. Rather, fellows will be selected based upon their competitiveness and clinical / academic potential.
Each CC Fellowship PD will evaluate the candidates from their pathway and select those candidates warranting further review.
All of the CC FPD's will meet to review the available candidate applications, grant interviews, and review candidate files at the end of the interview process.
Selection of candidates is a shared responsibility between the FPD's. Should CC pursue a match in the future, determination of the match rank list will similarly be a shared responsibility.
All involved parties agree that this section (Selection of Fellows) is open to revision in the future to maintain alignment with changing RRC-specific requirements and/or coverage requirements for the individual ICU teams.

Educational Structure

All fellowship program directors are responsible for collectively coordinating the clinical aspects of the training program.
Each FPD is responsible for reviewing the curriculum of their pathway(s) annually. The review will include:
1. the type, number, and timing of required clinical rotations and elective experiences;
2. the research environment, including fellow research publications and presentations; and
3. a written curriculum for the program based upon the six core competencies and designated by PGY level.
Each FPD will review the curriculum of their pathway with the Section Chief of CC annually.

Evaluation and Feedback

Evaluation system
1. The ICU will use a web-based, anonymous evaluation system to track performance of fellows, faculty, and rotations.
2. The ICU will utilize the web-based evaluation system supported by the GME office.
Fellow Evaluation
1. Faculty will evaluate each fellow at the end of each overlap period / block of 1 week or greater.
2. Each FPD will be responsible for evaluating the fellows in their pathway(s) on an ongoing basis, including six month reviews and promotion / graduation decisions.
3. FPD's are responsible for all reporting of fellow performance to their respective Boards.
Faculty Evaluation
1. Faculty will be reviewed by fellows at the end of each teaching block / overlap of 1 week or greater.
2. Fellow evaluations of faculty must be anonymous, and all data gathered will be presented as grouped data only.
3. Grouped fellow evaluations of faculty data will be reviewed with individual faculty members on an annual basis.
Program Evaluation
1. Each individual rotation will be evaluated at the conclusion of each block by fellows in an anonymous fashion.
2. Each of the CC pathways will be evaluated annually by the fellows in an anonymous fashion.
3. Data from both rotation and programs will be available to and reviewed by all of the FPD's and the Section Chief of CC. The FPD's, the Section Chief of CC, faculty representatives, and fellow representatives will meet to review these evaluations and help plan for changes and improvements in the program on an annual basis.

Educational Quality Assurance

The Section Chief of Critical Care will be responsible for the leadership and implementation of all QA processes in the ICU.
Clinical guidelines / Evidence Based Medicine / Quality Outcomes
1. The ICU will maintain an ongoing QA committee to review clinical outcomes in the ICU which will meet at least monthly.
2. The committee must include representatives from all clinical disciplines and fellowship pathways in the ICU, and will be open to all ICU faculty, staff, and fellows who wish to participate.
3. The committee will examine, in an ongoing process, areas of ICU care that are controversial or where differences of opinion between faculty members exist. The review will consist of:
  1. A literature review and discussion of best practices and practice guidelines.
  2. Follow-up to ensure continued improvement in quality metrics.
4. Fellows should be active participants in the QA process with appropriate faculty oversight.
Anonymous reporting
1. There will be an anonymous reporting mechanism whereby anyone working in the ICU can report concerns about the quality of care delivered in the ICU. Faculty, fellows, and staff will all be made aware of this system on a regular basis and encouraged to report “near misses” and any concerns about the quality of care in the ICU.
2. A committee including faculty and fellow representatives will review each reported incident and suggest further follow-up or actions.
Faculty Teaching Quality Assurance
1. The Fellowship program directors and the Section Chief of CC will meet at least twice annually to review faculty evaluations.
2. The Section Chief of CC will meet with any faculty member demonstrating less than satisfactory teaching performance, and develop a plan for improvement.
3. Faculty failing to improve their teaching performance will be removed from direct fellow and/or resident oversight, and mechanisms for resolving any disagreements over such matters are detailed in Section 1.d.

Critical Care Fellowship Oversight Diagram

Critical Care Fellowship Oversight

Shared Educational Resources - Pain Medicine Program

Scope

The policy specifically applies to the DHMC multidisciplinary Pain Medicine Fellowship program.

Purpose

The Accreditation Council for Graduate Medical Education (ACGME) has enacted policies requiring that there be only one ACGME-accredited pain medicine program within a sponsoring institution. Because pain medicine is a multidisciplinary approach to a common problem, the ACGME also requires an institutional policy governing the educational resources committed to pain medicine. This policy is intended to ensure cooperation among all involved disciplines.

Policy Guidelines

The DH multidisciplinary Pain Medicine Fellowship training program can be accessed after primary training in several medical disciplines including: anesthesiology, neurology, physical medicine and rehabilitation, and psychiatry. The pain medicine training and educational experience are modified to meet the needs of each trainee based on their background, experience, and career goals; in full compliance with institutional and program-specific RRC requirements. The pain medicine program director is assigned primary responsibility for organizing the educational program for each pain medicine trainee. The program director also assures cooperation among all involved disciplines via a Program Multidisciplinary Committee with representation from all involved disciplines. This Multi-disciplinary Committee shall provide program-level oversight of collaborative training effort.

In satisfaction of ACGME requirements, the DH Graduate Medical Education Committee (GMEC) possesses final authority in assuring cooperation among the disciplines involved in the training program as identified in the program’s RRC accreditation record, up to and including oversight of the Program Multidisciplinary Committee. If difficulties in the distribution of resources committed to pain medicine training are identified, the DIO will meet with the members of the program(s) involved to assess the issues and recommend corrective action. The DIO will report findings to the GMEC which possesses final authority in assuring cooperation among the disciplines if the conflict is not resolved through the previously described mechanism.

Supervision Policy

Scope

The policy applies to all DH residency programs, fellowship programs and supervising faculty.

Purpose

The Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements stipulate that the Graduate Medical Education Committee (GMEC) must establish guidelines regarding the levels of supervision required for all graduate medical trainees. These supervisory guidelines shall provide all residents and fellows with an educational program that is clinically and academically progressive and that complies with the requirements of the ACGME and the individual specialty boards. All accredited programs must assure that residents in their programs, as well as all supervising or attending physicians, adhere to the following standards to optimize patient care and the educational experience of our trainees.

Definition

Levels of Supervision

To ensure appropriate oversight of resident supervision, each program must use the following classification of supervision:

Direct Supervision – The supervising physician is physically present with the resident and patient.
Indirect Supervision:
- with direct supervision immediately available – The supervising physician is physically within the confines of the site of patient care, and is immediately available to provide Direct Supervision
- with direct supervision available – The supervising physician is not physically present within the confines of the site of patient care, but is immediately available via phone, and is available to provide Direct Supervision.
Oversight – The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

Progressive Authority and Responsibility

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. Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each resident and delegate to them the appropriate level of patient care authority and responsibility. Each program is responsible for developing descriptions of the level of responsibility accorded to each resident by rotation and PGY level. These descriptions must include identification of the mechanisms by which the participant’s supervisor(s) and program director make decisions about each resident’s progressive involvement and independence in specific patient care activities. In particular:

The program director must evaluate each resident’s abilities based on specific criteria established by the faculty of the training program. These criteria should be guided by national standards-based criteria when such are available;
Supervising faculty members will delegate patient care activities to residents based on the needs of the patient and the demonstrated abilities of the resident;
Senior residents or fellows should serve in a supervisory role of junior residents with appropriate patients, provided their demonstrated progress in the training program justifies this role;
In each training program, there will be circumstances in which all residents, regardless of level of training and experience, must verbally communicate with appropriate supervising faculty. Programs must identify and set guidelines for these circumstances and these guidelines must be available in writing for all residents. At a minimum, these circumstances will include:
- Emergency admission;
- Consultation for urgent condition;
- Transfer of patient to a higher level of care;
- Code Blue Team activation;
- Change in DNR status;
- Patient or family dissatisfaction;
- Patient requesting discharge AMA, or;
- Patient death.

Responsibilities

General

All patient care must be supervised by qualified faculty.
On-call and clinical assignment schedules must be available at all clinical service locations so that residents, nursing staff and ancillary personnel can easily identify the assigned resident and their faculty supervisor.
PGY-1 level residents must be supervised either directly or indirectly, with direct supervision immediately available. If indirect supervision is provided, such supervision must be consistent with RRC policies, and PGY-1 residents must meet established criteria in order to be eligible for indirect supervision.

Faculty Responsibilities

Routinely review resident physician documentation in the medical record.
Be attentive to compliance with institutional requirements such as problem lists, medication reconciliation, and additional field defined document priorities.
Provide resident physicians with constructive feedback as appropriate.
Serve as a role model to resident physicians in the provision of patient care that demonstrates professionalism and exemplary communication skills.

Resident Responsibilities

Each resident is responsible for knowing the limits of their scope of authority and the circumstances under which they are permitted to act with conditional independence.
In recognition of their responsibility to the institution and commitment to adhere to the highest standards of patient care, resident physicians shall routinely notify the responsible attending physician based on the guidelines noted above, as well as any additional circumstances identified in their program-specific supervisory policy.

Time Lost from Residency

Time lost from residency training must be made up according to the specifications of the Accreditation Council for Graduate Medical Education, Residency Review Committee for that particular specialty, and at the discretion of the Program Director.

Remuneration for time off, other than the specified three weeks paid vacation per year, and the particular benefits of health coverage, will be at the discretion of the Program Director and Director of Graduate Medical Education. House staff personal time and conference time is allowed at discretion of Program Director.

Program Resources

Specialty Board Eligibility Requirements

Residency Program

Anesthesiology http://www.theaba.org/Home/anesthesiology_initial_certification
Dermatology http://www.abderm.org/certification/registration.html
Internal Medicine http://www.abim.org/certification/
Neurology http://www.abpn.com/Initial_Neuro.htm
Neurosurgery http://www.abns.org/content/primary_certification_process.asp
Obstetrics & Gynecology http://www.abog.org/support.asp
Orthopedic Surgery https://www.abos.org/ModDefault.aspx?module=Candidates&section=BoardCertOver
Otolaryngology http://www.aboto.org/written%20&%20oral%20exam.htm
Pathology http://www.abpath.org/CandBkltIndex.htm
Pediatrics ABP
Preventive Medicine http://www.theabpm.org/requirements.cfm
Psychiatry http://www.abpn.com/Initial_Psych.htm
Psychiatry (Child & Adolescent) http://www.abpn.com/cap.htm
Radiology (Diagnostic) http://www.theabr.org/ic/ic_landing.html
Surgery (General) http://home.absurgery.org/default.jsp?certexamoffered
Surgery (Plastic) https://www.abplsurg.org/ModDefault.aspx?section=ExamInfoGeneral
Urology http://www.abu.org/certification_QEOverview.aspx
Vascular Surgery http://home.absurgery.org/default.jsp?certvsqe

Fellowship Program

Cardiology (Cardiovascular Disease) http://www.abim.org/specialty/card.aspx
Cardiology (Interventional) http://www.abim.org/specialty/icard.aspx
Cardiology (Electrophysiology) http://www.abim.org/specialty/ccep.aspx
Clinical Neurophysiology http://www.abpn.com/cnp.htm
Critical Care (Anesthesiology) http://www.theaba.org/Home/critical_care_initial_certification
Critical Care (Internal Medicine) http://www.abim.org/certification
Cytopathology http://www.abpath.org/CandBkltIndex.htm
Dermatopathology http://www.abpath.org/CandBkltIndex.htm
Endocrinology, Diabetes & Metabolism http://www.abim.org/specialty/endo.aspx
Gastroenterology http://www.abim.org/specialty/gastro.aspx
Hematology/Oncology
Hematology Certification http://www.abim.org/specialty/hema.aspx
Oncology Certification http://www.abim.org/specialty/medon.aspx
Hematopathology http://www.abpath.org/CandBkltIndex.htm
Infectious Disease http://www.abim.org/specialty/id.aspx
Neonatology ABP
Neuroradiology http://www.theabr.org/ic/ic_neuro_landing.html
Nephrology http://www.abim.org/specialty/neph.aspx
Pain Management http://www.theaba.org/Home/pain_medicine_initial_certification
Palliative Care http://www.abim.org/certification/policies/imss/hospice.aspx
Psychiatry (Addiction) http://www.abpn.com/ap.htm
Psychiatry (Geriatric) http://www.abpn.com/gp.htm
Pulmonary/Critical Care http://www.abim.org/specialty/pulm.aspx
Sleep Medicine http://www.abim.org/specialty/sleep.aspx
Transfusion Medicine http://www.abpath.org/CandBkltIndex.htm
Rheumatology http://www.abim.org/specialty/rheu.aspx
Vascular Interventional Radiology http://www.theabr.org/ic/ic_vir_landing.html
Vascular Surgery http://home.absurgery.org/default.jsp?certvsqe

Transfer of Residents Policy old

Scope

The policy applies to all ACGME-accredited residency and fellowship programs at DHMC.

Purpose

The institution and its ACGME-accredited training programs are at risk for loss of accreditation if non-eligible residents are accepted into our training programs.
Per ACGME Common Program requirements, residents who apply for transfer from another GME program are subject to all elements in the policies addressing eligibility requirements and the selection process, as well as the additional requirements noted below.

Policy Guidelines

Before accepting a resident transfer from another training program, the DHMC program director must obtain:
- a written or electronic verification of the prior educational experience, and
- a summative, competency-based performance evaluation of the transferring resident.
For any resident transferring from a DHMC training program to another program prior to completion of training, the DHMC program director must:
- provide timely written or electronic verification of residency education, and
- a summative, competency-based performance evaluation for the resident.

Related Policies and Reference Material

ACGME Common Program Requirements at:
http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf

Specific section applicable to this policy:
II.C.1 and II.C.2

Transfer of Residents Policy

Scope

The policy applies to all ACGME-accredited residency and fellowship programs at DHMC.

Purpose

The institution and its ACGME-accredited training programs are at risk for loss of accreditation if non-eligible residents are accepted into our training programs.
Per ACGME Common Program requirements, residents who apply for transfer from another GME program are subject to all elements in the policies addressing eligibility requirements and the selection process, as well as the additional requirements noted below.

Policy Guidelines

Before accepting a resident transfer from another training program, the DHMC program director must obtain:
- a written or electronic verification of the prior educational experience, and
- a summative, competency-based performance evaluation of the transferring resident.
For any resident transferring from a DHMC training program to another program prior to completion of training, the DHMC program director must:
- provide timely written or electronic verification of residency education, and
- a summative, competency-based performance evaluation for the resident.

Related Policies and Reference Material

ACGME Common Program Requirements at:
http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf

Specific section applicable to this policy:
II.C.1 and II.C.2

Institutional Policies

A listing of Dartmouth-Hitchcock Medical Center policies that are of specific interest to residents and fellows.

Code of Ethical Conduct

The Code of Ethical Conduct includes a series of principles and supporting rules that govern our interactions and set the expectation for our behavior. But most importantly, it outlines our core values: honesty, trustworthiness, integrity, respect, personal responsibility, stewardship, compassion and commitment to continuous improvement. These values are the foundation of our culture of integrity. It is vital that we all have a common understanding of our Code of Conduct and hold true to these values.

Code of Ethical Conduct

The mission of Dartmouth-Hitchcock is to advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time. The following core principles of ethical conduct represent values that support and serve this mission:

Honesty, trustworthiness, and integrity.
Respect for the dignity of persons.
Respect for cultural and religious/spiritual beliefs.
Respect for property.
Respect for and adherence to the law.
Respect for the physical and emotional environment in which we work.
Personal responsibility and accountability for actions.
Stewardship of financial, human and other resources.
Compassion.
Commitment to continuous improvement.

The ethical principles inform a Code of Ethical Conduct ("Code"), which specifies behaviors that all individuals who work at, study at, or are affiliated with D-H (including its volunteers, agents, consultants, and vendors) are expected to display. The Code also applies to medical students as well as nursing and other professional allied health students who work or study at D-H.

While the principles that underlie the Code apply to all personnel, certain portions of the Code are more frequently applicable in some disciplines than in others. Certain principles have direct application in clinical settings, while others are applicable to teaching, research, business or support activities.

All staff members at D-H are essential to our mission and are subject to the Code of Ethical Conduct. All professional staff members at D-H have additional ethical obligations that exceed legal and regulatory requirements by virtue of their professional training and because of their positions of responsibility. Professionals have responsibilities to those whom they serve, their colleagues, and the public.

The Code of Ethical Conduct is a series of principles and their subsidiary rules that govern all interactions. The Code consists of two complementary sections: obligations and ideals. "Obligations" refer to necessary behaviors that are required by the ethical foundation that informs our organizational mission as outlined above. "Ideals" refer to desirable behaviors to which D-H personnel and affiliates, at all levels, should aspire.

Failure to meet the obligations described below represents a violation of the Code. Items marked with an asterisk indicate behaviors that may additionally violate federal or state laws. Alleged infractions of the obligations of the Code will be dealt with by the appropriate D-H disciplinary committees and processes.

For ease of obtaining further detail, the Code is cross-referenced to applicable D-H policies that may change over time. For more information on these policies, visit the MHMH/DHC North Combined Policy Manual and the Clinical Policy Library.

Obligations

Practice Respect for Persons
- Treat those whom you serve, with whom you work, and the public with the same degree of respect you would wish them to show you.
- Treat patients and colleagues with kindness, gentleness, and dignity.
- Include patient preferences for treatment in the plan of care to the fullest extent possible.
- Respect the privacy and modesty of patients.
- Do not use offensive language, verbally or in writing.
- Do not harass others physically, verbally, psychologically, or sexually. *
- Do not discriminate on the basis of gender, religion, race, disability, age, sexual orientation, national origin, or marital status. *
Maintain Patient Confidentiality
- Do not share the medical or personal details of a patient with anyone except those health care professionals integral to the well being of the patient or within the context of an educational endeavor. *
- Do not seek confidential data on patients unless you have a professional "need to know." *
- Do not discuss patients or their illnesses in public places where the conversation may be overheard.
- Do not publicly identify patients, verbally or in writing, without permission or adequate justification.
- Do not invite or permit unauthorized persons into patient care areas.
- Do not share your confidential computer system passwords with unauthorized persons.
  For more information, see Records Management/Health Information Services HIPAA - Privacy/Security information
Protect Confidential and Proprietary Information
- Do not share details of employee or staff grievances.
- Do not share the personal compensation data of others beyond those with a need to know.
- Do not discuss personal information about patients or their families, colleagues or coworkers.
- Do not discuss business negotiations outside of the context of the negotiation itself. (Contract terms and conditions of a specific contract may address this)
- Use electronic mail responsibly.
Maintain Personal Honesty and Integrity
- Be truthful in verbal and in written communications.
- Acknowledge your errors of omission and commission to colleagues.
- Do not mislead others.
- Do not cheat, steal, plagiarize, or otherwise act dishonestly.
- When using information that is not your own in verbal or written communication or in medical records, give proper attribution, including the sources and date.
- Do not abuse privileges.
- Be truthful in negotiations and business transactions.
  For more information, see Rules and Regulations of the Professional Staff of Mary Hitchcock Memorial Hospital and Conditions of Participation for Hospitals
Assume Responsibility for Patient Care
- Do not engage in unsupervised involvement in areas or situations where you are not adequately trained unless in an urgent or emergency situation.
- Obtain the patient's informed consent for diagnostic tests or therapies.
- Take responsibility for the patients under your care; when off duty, or on vacation,assure that your patients are adequately cared for by another practitioner.
- Do not abandon a patient. If you are unable or unwilling to continue care, you have an obligation to assist in making a referral to another competent practitioner willing to care for the patient.
- Follow up on ordered laboratory tests and complete patient record documentation conscientiously.
- Charge patients or their insurers only for clinical services provided or supervised.*
- Provide services to all patients regardless of their ability to pay in accordance with the D-H Financial Assistance policy. (Reference policy link)
- Do not abuse alcohol or drugs that could diminish the quality of patient care or academic performance.
- Do not have romantic or sexual relationships with patients; if such a relationship seems to be developing, seek guidance and terminate the professional relationship.*
- Cooperate with other members of the health care team in clinical activities.
- Honestly disclose consequential, unanticipated outcomes to patients or families in accordance with DHMC's Communication of Unanticipated Patient Outcomes policy. (Reference Policy link)
  For more information, see New Hampshire State Board of Medicine and New Hampshire Board of Nursing
Maintain Awareness of Limitations and Opportunities for Improvement and Strive to Improve
- Act in accordance with your authorized role and level of responsibility.
- Be aware of your personal limitations and deficiencies in knowledge and abilities and know when and who to ask for supervision, assistance, or consultation.
- Know when and for whom to provide appropriate supervision.
- Report system problems that may place patients or others at risk of harm.
- Assure that students have all patient workups and orders countersigned by the appropriate supervisor.
- Avoid patient involvement when you are ill, distraught, or overcome with personal problems.
- Keep abreast of new knowledge and policy changes that may relate to your work.
  For more information, see New Hampshire State Board of Medicine and New Hampshire Board of Nursing
Practice Professional Deportment
- Identify yourself and your role to patients and staff; wear your name tag.
- Dress in a neat, clean, manner following local policies that govern accepted attire.
- Maintain a professional composure despite the stresses of fatigue, professional pressures, or personal problems.
- Introduce all students accurately and appropriately, for example, not as "doctor" or "nurse."
- Do not write offensive or judgmental comments in patients' charts.
- If medical or professional decisions of colleagues are questionable, discuss with sensitivity in an appropriate place.
- Avoid the use of first names without permission in addressing adult patients.
- Conduct yourself in a respectable manner as a representative of the organization and your profession.
- Resolve professional disagreements through discussion conducted respectfully.
Avoid Conflicts of Interest
- Maintain your objectivity in all decision making and avoid creating any perceptions of impaired objectivity.
- Follow institutional policies regarding disclosure of real or perceived conflicts of interest in a timely manner.
- Avoid conflicts of interest, but when conflicts of interest exist, always resolve all of them in favor of the patient.
- Follow guidance from the current Conflict of Interest and other applicable policies regarding the acceptance of gifts, participation in commercial incentive programs, accepting "kickbacks" for patient referrals, participation in contract negotiations that would benefit you or family members and other activities that are or could be perceived as a conflict of interest. *
  For more information Vendor-Sponsored Meals & Gift Policy, and Supply Chain Management Policy see Business Ethics Policies Acceptance of Fees by Individuals, Acceptance of Industry/Vendor Sponsored Training and Receipt of Unrestricted Funds
Assume Responsibility for Self and Peer Behavior
- Take the initiative to identify and help rehabilitate impaired students, physicians, nurses, and other employees with the assistance of the Geisel School of Medicine Student Needs and Assistance Program, the Employee Assistance Program, or the employee's supervisor, and report appropriately.
- Report serious breaches of the Code to the appropriate person.
- Indicate disapproval or seek appropriate intervention if you observe less serious breaches.
- Seek input and feedback from patients and colleagues on your own professional behavior, and use it to improve.
  For more information, see Mission, Vision, Goal Statement and Protocol for Reporting Violation of the Code of Professional Conduct
Respect Personal Ethics by Permitting Appropriate Conscientious Refusal
- You are not required to perform or participate in procedures (e.g., elective abortions, termination of medical treatment) that you believe are unethical, illegal, or may be detrimental to patients.
- You have an obligation, however, to inform patients and their families of available treatment options that are lawful and consistent with acceptable standards of medical and nursing care.
  For more information, see Staff Conflict of Care Policy
Respect Property and Laws
- Protect the property of D-H and its components and the property of patients, research participants, students, employees, contractors, and others who work in or are being served by our facilities.
- Adhere to the regulations and policies of Dartmouth College and D-H.
- Adhere to local, state, and federal laws and regulations.
- Do not use computer and telecommunication resources for personal commercial purposes or financial gain or to distribute inappropriate material.
- Report actual or suspected incidents of fraud, waste or abuse in federal health care programs to the appropriate party(ies). Reports can be made anonymously and without fear of retaliation.*
- Do not misappropriate, destroy, damage, or misuse property of D-H.*
- Conduct business in accordance with all pertinent laws and regulations and applicable institutional policies.*
  For more information, see False Claims Act Policy and HITS Manual
Practice Ethical Behaviors in Teaching
- Be knowledgeable about the subject material you are teaching.
- Create and nurture a collegial environment in which students and trainees are valued and respected.
- Foster student and trainee professional growth, lifelong learning, and ethical behavior.
- Encourage intellectual curiosity and rigor.
- Encourage academic freedom and integrity.
Maintain Trust and Integrity in Research
- Respect the autonomy and promote the dignity of each human research participant; ensure just treatment of and create protections for those whose autonomous decision making may be diminished or impaired; design research to minimize potential harm and maximize potential benefits for each human participant.
- Obtain consent for participation in research based on providing adequate information for decision-making to each potential participant.
- Reduce the potential for pain and suffering of research animals to an extent consistent with humane treatment.
- Protect the integrity of scientific design, data collection, and conclusions.
- Report the results of research honestly in scientific and scholarly presentations and publications, and without exaggeration to the public and the media.
- Attribute proper credit to colleagues and others who contribute to the research when publishing and presenting reports of results. Accept co-authorship attribution only when appropriate.
- Recognize that intellectual property has value and respect the ownership rights of others.
- Avoid conflicts of interest in research activities and candidly disclose, on request, sources of income, ownership of equity, and any other relationship that produces or could be perceived to produce a conflict of interest.
- Encourage the free sharing and collegial exchange of research results; foster cooperation and collaboration among research team members.
  For more information, see False Claims Act Policy
Practice Financial Responsibility
- Adhere to laws and institutional policies to protect, spend, and account for money and resources to which we are entrusted.
- Do not offer or accept bribes, kickbacks, or other inducements that may influence a decision, such as the purchase of products and services or patient referrals.
- Adhere to all regulations and policies in spending and accounting for grants and contracts.
- Adhere to accepted regulations governing fair and ethical billing and collection practices; including adhering to D-H's False Claims Act policy.
- Adhere to accepted accounting standards for records and reporting.
Promote Personal and Environmental Health and Safety
- Adhere to institutional regulations and accepted practices governing the safe use of chemicals, drugs, equipment, and products in the workplace.
- Take precautions to safely perform our duties and protect our coworkers.
- Assure that your physical and mental health render you fit to work.
- Promote a healthy work environment for us and our patients.
Promote Diversity, Equal Opportunity, and Respect in the Workplace
- Practice the principles of equal opportunity and non-discrimination.
- Promote an atmosphere in which we can discuss concerns about diversity and equal opportunity without fear of retaliation or retribution.
- Maintain dignity and respect for all persons.
- Discuss and resolve disagreement in the workplace in a professional and respectful manner.
  For more information, see Mission, Vision, Goal Statement
Follow Accepted Business and Legal Standards
- Conduct all business operations in a manner that complies with applicable laws and regulations and merits the trust and respect of those whom we serve.
- Fairly and accurately represent our services and responsibilities to the public.
- Protect privileged information entrusted to D-H from vendors, referral sources, contractors, service providers, and others.
- Do not use inside or privileged information for personal gain for yourself or others.
Follow Rules Governing Personal Political Activities in the Workplace and Public Representation
- Do not use D-H or the Geisel School of Medicine titles or affiliations to support or oppose candidates on public ballots.
- You may use D-H or the Geisel School of Medicine titles or affiliations in public oral or written presentations for purposes of professional identification but not to represent the position of D-H without express permission.
- Do not pursue personal political activities while in the workplace.
- Do not use D-H or the Geisel School of Medicine letterhead or email for personal political activities or for personal commercial purposes.

Professional Ideals

Virtues
- Strive to cultivate and practice virtues, such as caring, empathy, and compassion.
Conscientiousness
- Fulfill your professional and work-related responsibilities conscientiously.
- Notify the responsible supervisor if something interferes with your ability to perform clinical or support tasks effectively.
- Learn from experience and knowledge gained from errors in order to avoid repeating them.
- Dedicate yourself to lifelong learning and self-improvement by implementing a personal program of continuing education and continuous quality improvement.
- Students and trainees should complete all assignments accurately, thoroughly, legibly, and in a timely manner.
- Students and trainees should attend scheduled classes, laboratories, seminars, and conferences except for justified absences.
Collegiality
- Teach others at all levels of education and training.
- Be generous with your time to answer questions from trainees, patients, and patients' family members.
- Be a good D-H citizen by participating in your fair share of the communal work of the organization.
- Adopt a spirit of volunteerism and altruism in teaching and patient care tasks.
- Use communal resources (equipment, supplies, and funds) responsibly and equitably.
  For more information, see Mission, Vision, Goal Statement
Personal Health
- Develop a personal life style of dietary habits, recreation, disease prevention, exercise, and outside interests to optimize physical and emotional health and enhance professional performance.
Objectivity
- Avoid providing professional care to colleagues, family members, friends or to persons with whom you have a romantic relationship, outside the context of a doctor-patient relationship.
Responsibility to Society
- Avoid unnecessary patient or societal health care monetary expenditures.
  For more information, see Mission, Vision, Goal Statement, EMTALA policy, New Hampshire State Statutes, and Conditions of Participation for Hospitals
Advancement of Professionalism
- Strive to further professionalism.

* Behaviors that also may violate federal or state laws.

Social Media and Web-Based Communication

Purpose

To establish guidelines for the use of social media and web-based communication by Dartmouth-Hitchcock (D-H) physicians and staff of Dartmouth-Hitchcock Clinic (DHC), Mary Hitchcock Memorial Hospital (MHMH) and Northern New England Community Practices.

See full policy details at:
http://employees.dartmouth-hitchcock.org/human_resources/social_media_policy.html

Dress Code

Neatness of appearance, personal cleanliness, and wearing appropriate clothing in your professional environment is essential when in contact with patients, visitors, and other employees.

Physician Impairment and Substance Abuse Policy

Mary Hitchcock Memorial Hospital is committed to providing a safe, healthy and secure environment for its employees, residents, patients and visitors. The unlawful or improper presence or use of controlled substances, illicit drugs or alcohol in the workplace presents a danger to everyone. In the interest of promoting health and safety and preventing liability, we have established the following Substance Abuse Policy. Drug and alcohol testing is an integral part of the policy and may be required if there is reasonable concern of drug and/or alcohol abuse.

For the full Substance Abuse Policy, please refer to the Human Resources Policies & Procedures Manual section on Substance Abuse

DHMC supports the New Hampshire Physicians Health Program (NH PHP). NH PHP assists with identification, intervention, referral, and case management of NH physicians who may be at risk for or affected by substance abuse disorders, behavioral/mental health conditions, or other issues impacting their health and well being. NH PHP provides recovery documentation, education, support, and advocacy from evaluation through treatment and recovery.

Electronic Communications

Guidelines for the Use of E-Mail in Clinical Communications

E-mail is a good method for quick and efficient communications among providers and, in a more limited way, among providers and patients. E-mail is easy and convenient, replaces telephone calls and reduces telephone tag. It can be posted and read at any time, and is an integral part of our business because, by increasing efficiency, it contributes to improved patient care.

Read the full D-H Electronic Communications Policy

Environmental Principles

In an effort to promote healthier communities both locally and globally, Dartmouth-Hitchcock Medical Center (DHMC) is committed to improving environmental management throughout the organization. DHMC will manage its operations in a manner demonstrably protective of environmental and human health.

DHMC will constantly seek new and innovative ways to meet its environmental goals through conservation, reduction, reuse and recycling programs, and through partnering with others in the community to safeguard the environment.

DHMC will apply these principles to achieve optimal environmental standards consistent with institutional goals and financial considerations.

In an effort to respect and protect the earth's resources, and to minimize environmental damage, DHMC will:

Manage, minimize and eliminate, whenever possible, the use of hazardous materials.
Use renewable natural resources and conserve non-renewable natural resources through cost efficient use and careful planning.
Use pollution prevention initiatives to reduce negative environmental impacts.
Minimize the generation of waste through source reduction, re-use and recycling programs.
Conserve energy and improve the energy efficiency of our operations and make every effort to use and promote environmentally safe, cost-effective and sustainable energy sources.
Ensure the health and safety of our employees and house staff by promoting safe work practices, reducing exposure, using safe technologies, and implementing effective emergency preparedness programs.
Provide employees and house staff with safety and environmental information through training and education programs in order for them to make work/practice decisions in support of these principles.

Health and Safety Manual

The DHMC Health and Safety Manual is an up-to-date, online policy listing. This replaces the previously provided HITS Manual and contains the following policies: Emergency Management, Occupational Health & Safety, Environment of Care/Joint Commission, Pollution Prevention and Hazard Materials and Waste.

View the Health and Safety Manual on the DHMC intranet.

Inspections

Inspections of Hospital Property

To control shortages, theft and to locate missing items, inspections of work and personal areas may be conducted at any time. Similarly, the hospital may conduct unannounced random inspections for drugs and alcohol on hospital facilities and property such as, but not limited to, hospital vehicles, equipment, desks, file cabinets, or hospital-issued lockers. Individuals who work at the hospital are expected to cooperate in the conduct of such inspections. Inspections of hospital facilities and property may be conducted at any time and do not have to be based on reasonable suspicion.

Inspections of House Staff Property

In addition to routine inspections conducted in accordance with loss prevention policies and practices, inspections of house staff and their personal property such as, but not limited to, vehicles, clothing, packages, purses, brief cases, lunch boxes, or other containers brought into the hospital premises may be conducted when there is reasonable suspicion to believe that the individual may have or has violated the drug or alcohol prohibitions contained in this policy manual.

Intellectual Property

All rights to and interests in discoveries, developments, inventions or other intellectual property resulting from research or investigation conducted in the course of an investigator's work on behalf of Dartmouth-Hitchcock or in connection with the use of Dartmouth-Hitchcock resources shall be the sole and exclusive property of Dartmouth-Hitchcock, and no other person or entity shall have any rights of ownership or interest in such discoveries, inventions or intellectual property.

Jury Duty

The Hospital believes it is the civic responsibility of an employee or house staff member to fulfill their jury duty obligation, and will ensure that he/she does not lose normal pay during that duty. The Hospital will not attempt to have a release from such service. It is expected that, with due consideration to time and travel factors, the employee or house staff member will return to work when a court recess temporarily releases him/her from jury duty.

Reimbursement: The house staff member will be fully compensated by the Hospital for time spent on jury duty. The employee or house staff member may accept any additional pay received from the state for jury duty.

Legal Counsel

If you are approached for any reason by a representative from a law firm, your representation is by the Dartmouth-Hitchcock Medical Center, Mary Hitchcock Memorial Hospital Risk Management office, and you should refer all calls to them at ext. 5-7864.

Non-Discrimination, Equal Opportunity Employment, and Affirmative Action

It is the policy of Mary Hitchcock Memorial Hospital to provide equal employment opportunities for all house staff, employees and applicants, in compliance with our Affirmative Action Plan, as follows:

To recruit, train, hire, transfer, and promote in all job classifications without regard to race, color, religion, age, sex, national origin, physical or mental disability, veteran status, sexual orientation or marital status.
To base decisions on employment in accordance with the principles of equal employment opportunity.
To make promotion decisions in accordance with the principles of equal employment opportunity.
To provide that all other personnel actions and terms and conditions of employment will be administered without regard to race, color, religion, age, sex, physical or mental disability, national origin, sexual orientation, or marital status.

Privacy & Confidentiality of Patient Information

Statement of Purpose

It is our intent to establish policies and procedures governing the privacy of our patients' personal health information and to provide guidelines for the security and appropriately controlled release of such information, consistent with applicable federal and state laws, including the federal privacy rule.

We support the patient's right to privacy (that is, the right to control access to his or her personal health information) and accept responsibility to keep secure and confidential the information collected about our patients during their encounters with us. We also understand that releasing parts or all of that information is appropriate under certain circumstances, such as providing for continuity of care, participating in approved research and educational activities, complying with laws, and assuring reimbursement for services provided, and that such releases provide benefit to the patient and/or to society.

For the entire policy, please see the Dartmouth-Hitchcock Privacy Group Policy Statement on the Privacy and Confidentiality of Patient Information

Security

Security measures are provided within the institution, including foot and vehicle patrol of the facilities and general response to problems that arise. Security also provides a lost-and-found department, assistance with ambulance security, transportation of patients to and from aircraft into the hospital, unlocking doors, escorts to vehicles, and assistance with cars that will not start in the middle of the night.

Sexual Harassment

It is the policy of Dartmouth-Hitchcock Clinic (DHC), Mary Hitchcock Memorial Hospital (MHMH) and Northern New England Community Practices that all Dartmouth-Hitchcock (D-H) employees are to be treated with respect and courtesy. Sexual harassment of any D-H employees by another D-H employee, supervisor or outside party will not be tolerated.

Sexual Harassment in the workplace is unlawful.
It is unlawful to retaliate against a D-H employee for filing a complaint of sexual harassment or for cooperating in an investigation of sexual harassment.
Sexual harassment may include, but is not limited to, unwelcome sexual advances, requests for sexual favors, and other unwelcome verbal, visual, or physical conduct of a sexual nature from supervisors, coworkers, or in some cases non D-H employees.
Sexual harassment complaints will be investigated. Any D-H employee who commits sexual harassment will be subject to disciplinary action up to, and including, discharge.

Any D-H employee who has work place sexual harassment concerns about supervisors, co-workers, or visitors should bring the problem to DHC, MHMH or Northern New England Community Practices attention by calling the Interim Director Education/Employee Relations at (603) 653-1570.

Smoking

It is the policy of Dartmouth-Hitchcock Clinic (DHC), Mary Hitchcock Memorial Hospital (MHMH) and Northern New England Community Practices to maintain a 100% smoke-free environment for the preservation and protection of health of our Dartmouth-Hitchcock (D-H) physicians, staff, patients, volunteers, contract employees, students and visitors.

This policy applies to anyone who enters DHC, MHMH and Northern New England Community Practices owned property or off campus D-H worksites.

The success of this policy will depend upon the thoughtfulness, consideration and cooperation of smokers and non-smokers. All persons share in the responsibility for adhering to and enforcing the policy.

The management of Mary Hitchcock Memorial Hospital and the Dartmouth-Hitchcock Clinic realize that it will be difficult for some employees to refrain from smoking in the workplace. Dartmouth-Hitchcock offers many resources in the area of tobacco cessation, many of which can be found online at the DHMC Quitting Smoking site.

http://policy.hitchcock.org/dspPolicyWindow.cfm?policy_id=4667

Telephone Use

The Communications Department is responsible for providing an efficient, cost-effective telephone system.

Employees are responsible for using the telephone system appropriately, governed by the Rules of Professional Conduct and Confidentiality. Personal phone calls should be kept to a minimum; phone usage is primarily for business purposes.

At the request of Graduate Medical Education , all House Staff are issued a "TDX" authorization number, for business related toll calls. Hospital policy limits the use of Authorization Codes and Calling Cards to business-related long-distance calls. Unless approved by a Department Director or Practice Manager all personal toll calls must be billed to a third party, to a personal calling card, placed collect, or placed at a pay station. GME audits the monthly Call Detail Reports provided by the Communications Department to assure that no unauthorized personal toll calls are placed. If abuse is discovered or suspected, GME will investigate the report and make an inquiry with the resident. Violators will be billed for unauthorized calls at the rate of an operator-assisted call. Abuse of the telephone system constitutes misappropriation of funds and may result in disciplinary action.

Vendor Sponsored Meals and Gifts

Purpose and Scope

This policy establishes practice regarding:

The provision of food/meals by the pharmaceutical, medical device industry or any other vendors to employees of Dartmouth-Hitchcock Clinic or Mary Hitchcock Memorial Hospital
The acceptance of gifts, regardless of value, by any Dartmouth-Hitchcock Clinic or Mary Hitchcock Memorial Hospital employee from any pharmaceutical, medical device, or other vendor

Policy

The provision of food, in the form of "snacks" or full meals, and the acceptance thereof by any employee of Dartmouth-Hitchcock on any Dartmouth-Hitchcock campus is strictly prohibited.
The acceptance of gifts or trinkets of any kind, regardless of value, is prohibited at all times.
Employees are reminded that governmental agencies may be monitoring and publishing documented instances of gift giving (including meals) to physicians and/or others.

For full details, please go to the Clinical Policy Library on the DHMC Intranet
Vendor-Sponsored Meals and Gifts policy.

Disruptive Behavior

Dartmouth-Hitchcock Clinic (DHC), Mary Hitchcock Memorial Hospital (MHMH) and the Community Group Practices in the North and South are committed to excellence in patient care and providing each person the best care, in the right place, at the right time, every time. Our goal is to enable Dartmouth-Hitchcock (D-H) physicians and staff to attain ever-increasing levels of excellence by establishing environments of safety, quality, continuous learning and accountability (1.2). As such, D-H physicians and staff are expected to adhere to promoting and maintaining a spirit of respect, collegiality and teamwork.

See full policy details at:
http://policy.hitchcock.org/dspPolicyWindow.cfm?policy_id=6420

Dartmouth-Hitchcock

Patients & Visitors

Health Care Professionals

Residents & Fellows

Donors & Volunteers

Careers

Employees

Policies & Procedures

Of the Dartmouth-Hitchcock Residency and Fellowship Programs

About GME

Statement of Commitment to Graduate Medical Education

ACGME Competencies

Patient Care

Medical Knowledge

Practice-Based Learning and Improvement

Interpersonal and Communication Skills

Professionalism

Systems-Based Practice

Eligibility & Selection

Eligibility Requirements

Additionally, upon matching with Dartmouth-Hitchcock Medical Center, applicants must meet all of the following requirements:

Selection Process

Selection of House Staff

Visa Policy

Sponsored Visa Categories

J-1

F-1 OPT

H-1B Transfer

ECFMG Certification

Recruitment Documentation Policy

Scope

Purpose

Policy Guidelines

Responsibilities

General Guidelines

Agreement of Appointment

Programs & Benefits

Stipend Levels

GME Stipend Levels

Health & Welfare Benefits

Medical Insurance

Dental Insurance

Life Insurance

Sick Leave/Short Term Disability

Long Term Disability

Health Care Reimbursement Account

Dependent Care Assistance Account

Malpractice Insurance Coverage & Risk Management Program

Related pages

Frequently Asked Questions

What are my responsibilities as an individual insured under the program?

How do I reach Risk Management?

Do I only report adverse events to Risk Management? What about near-misses?

Do I need to report a bad outcome if it was a known risk/complication which was fully discussed and documented in the informed consent process?

What form of malpractice insurance coverage is provided?

What happens when a Resident or Fellow leaves the program?

Will the policy cover me for claims incurred before I began my Residency or Fellowship at MHMH?

Does the insurance program cover me for any eventuality in my practice?

Are all the institutions that participate in the New England Alliance for Health (NEAH) insured under the Dartmouth-Hitchcock insurance program?

Are Residents or Fellows covered while "moonlighting" at institutions that are not insured under the program?

House Staff Groups

The DHMC House Officer Association

Mission Statement

Membership

Meetings

Purpose

Residents' Revolving Loan Fund

Additional Benefits

Vacation

On-Call Meals

Coats/Scrubs

Education Fund

Parking

Child Care

Getting Home Safely

Position Overview

Position Description

A: Purpose and Scope

B. Graded Responsibilities