HOUSE STAFF POLICIES AND PROCEDURES MANUAL
TABLE OF CONTENTS
Introduction --------------------------------------------------------------------------------------- 3
Section 1: House Staff General Responsibilities --------------------------------------------4
Section 2: School of Medicine
Section 3: Summary of Benefits --------------------------------------------------------------- 6
Section 4: Leave Time --------------------------------------------------------------------------- 8
Section 5: Requirements for Appointment ------------------------------------------------ 14
Section 6: Moonlighting ----------------------------------------------------------------------- 21
Section 7: Disciplinary Actions -------------------------------------------------------------- 23
Section 8: Counseling and Support Services ---------------------------------------------- 26
Section 9: Behavioral Health Statement --------------------------------------------------- 26
Section 10: Graduate Medical Education Committees ---------------------------------- 32
Section 11: Personnel Files -------------------------------------------------------------------- 34
Section 12: Other Services -------------------------------------------------------------------- 34
Section 13: Workers' Compensation -------------------------------------------------------- 35
Section 14: Infection Control ----------------------------------------------------------------- 42
Section 15: Equal Opportunity -------------------------------------------------------------- 48
Section 16: Liability Insurance and Risk Management Programs ------------------- 48
Section 17: Standards of Conduct ----------------------------------------------------------- 49
Section 18: The Health Insurance Portability and Accountability Act [HIPAA] -- 49
Section 19: Release of Information to the Media ----------------------------------------- 50
Section 20: Conflict of Interest --------------------------------------------------------------- 50
Section 21: No Solicitation -------------------------------------------------------------------- 50
Section 22: Weapons ---------------------------------------------------------------------------- 51
Section 23: Smoke-Free Workplace --------------------------------------------------------- 51
Section 24: Drug-Free Workplace ----------------------------------------------------------- 51
Section 25: Dress Code ------------------------------------------------------------------------- 52
Section 26: Tips/Gifts --------------------------------------------------------------------------- 52
Section 27: Care and Use of Property/Equipment ---------------------------------------- 52
Section 28: Pastoral Services ------------------------------------------------------------------ 53
Section 29: Security ----------------------------------------------------------------------------- 53
Section 30: Teaching Responsibilities ------------------------------------------------------- 53
Section 31: Department Orientation -------------------------------------------------------- 53
Section 32: Policies on Consensual Teacher-Student Relationships and Sexual Harassment ------ 54
Section 33: Grievance Procedure ------------------------------------------------------------ 55
Section 34: Hearing and Appellate Review Procedures for Termination of a Residency Appointment ----- 58
Appendix A: Policy and Procedure on Resident Eligibility & Selection ------------ 63
Appendix B: Residency Appointment Agreement --------------------------------------- 65
Appendix C: Equal Opportunity Policies ------------------------------------------------- 66
Policy
Statement on Discriminatory Harassment
Formal
Procedures for Handling Complaints of Discriminatory Harassment
Appendix D: Moonlighting Forms ---------------------------------------------------------
74
Appendix E: Professional and General Liability
Insurance -------------------------- 76
INTRODUCTION
Medical education is divided into three major components including undergraduate medical education, graduate medical education and continuing medical education. Each component provides physicians with the requisite knowledge and skills to be an effective practitioner in the art and sciences of medicine.
Pursuant to the educational mission of the
The Board of Trustees of the
Emory University School of Medicine is committed to providing quality graduate
medical education through its residency training programs. The major functions
of the programs are education, patient care, and research. The programs are
administered for the
The purpose of this House Staff Policies and Orientation Manual is to
provide residents and fellows ("residents") participating in Emory
University School of Medicine's Graduate Medical Education with a general
understanding of the policies and procedures governing the training programs.
The policies and procedures described in the Manual supersede and replace all
prior and published and unpublished policies and procedures. While the
information provided in this Manual should help familiarize and inform residents
about the training programs, it cannot detail every situation or answer every
question. NEITHER THIS MANUAL NOR ANY PROVISION IN THIS MANUAL CONSTITUTES A
CONTRACT.
Residents with questions or comments regarding information contained in this manual should contact their Program Director or the OGME.
The Office of Graduate Medical Education is located in
- Completion of forms verifying dates of training for licensure and for medical staff privileges.
- Completion of loan deferment forms
- Upon written request from the Program Director, issues position appointment agreements and completion certificates
- Maintains the permanent administrative record, including immunizations
SECTION 1: HOUSE STAFF GENERAL RESPONSIBILITIES
Each resident participating in the Emory University School of Medicine Residency Training program (TRAINING PROGRAM) has the responsibility to:
1.01 Provide compassionate, timely, and appropriate patient care; accept the duties, responsibilities and rotations assigned by the resident's department Chair or the Chair's designee; abide by the rules, regulations and policies of Emory University, Emory University School of Medicine, and the hospitals to which the resident is assigned; and conform to the ethical and professional standards of the medical profession;
1.02 Develop a personal program of self-study and professional growth with guidance from the teaching staff;
1.03 Participate fully in educational activities, accept and follow direction provided by faculty members and more senior residents and, as directed, assume responsibility for teaching and supervising other residents, medical students, and other health care students;
1.04 Participate, as appropriate, in institutional committees and councils, especially those that relate to patient care review and activities;
1.05 Apply reasonable cost containment measures in the provision of patient care;
1.06 Obtain a GA Temporary Postgraduate Permit or a GA Medical License. Each PGY 1- PGY 7 resident/fellow participating in Emory University Residency Training program has the responsibility to obtain a GA Temporary Postgraduate Training Permit. If you already have a GA Medical License, you are not obligated to get a permit. If you are PGY 8 or higher, you must obtain a GA Medical License. Refer to sections 5.04, 5.05, and 5.06.
1.07 Maintain complete and up-to-date immunity and health records in the OGME (See Section 3);
1.08 Inform OGME and the Program Director of changes in address and personal phone number;
1.09 Inform the Benefits Section of Emory University's Human Resources Department (404.727.7613) of any events requiring a change of benefits or tax status (e.g., change in marital status, birth or the adoption of a child).
SECTION 2: SCHOOL OF MEDICINE
2.01 The ultimate responsibility for the oversight of all aspects of a department's residency training program rests with the Chair of that department. The department Chair may appoint a Program Director that will act in whatever capacity and with whatever authority that is delegated by the Chair. The department Chairs meet regularly as the "Council of Chairs" to address matters affecting the operation of the overall residency training program.
2.02 The Dean of the
2.03 The
2.04 To the extent possible, the
2.05 The
SECTION 3: SUMMARY OF BENEFITS
Each resident attends a comprehensive administrative orientation session at the beginning of the training program. A portion of this orientation session is devoted to reviewing all elements of the benefits package and to answering any questions about these benefits. The benefits package is also summarized on Emory’s Human Resources website at the following address http://emory.hr.emory.edu/rtpbenplans.nsf
The Residency Training program provides each eligible resident, at no cost, the following group benefit plans:
- Health Care Coverage
- Term Life Insurance
- Dependent Term Life Insurance
- Long Term Disability Insurance
- Accidental Death and Dismemberment Insurance
Group Dental and Emory Vision Care Plans are available at a minimal cost.
Each resident may also enroll his/her eligible dependents for health, dental and vision coverage, with the cost paid by deductions from the resident's stipend.
3.01 Life Insurance
The Residency Training program provides each eligible resident: · $50,000 Term Life Insurance · $50,000 Accidental Death and Dismemberment Insurance · $25,000 Term Life Insurance for spouses · $ 5,000 Term Life Insurance for eligible children
3.02 Health Care
Three health care options are provided to residents. EmoryCare is a preferred provider program, which offers a network of primary care physicians and specialists and many hospitals. Use of network providers offers the lowest out-of-pocket expenses. EmoryCare also gives each resident the flexibility to use providers outside of the EmoryCare network at higher out-of-pocket expenses.
Residents can also enroll in EmoryChoice, which is an HMO. EmoryChoice offers residents a core network of primary and specialty care providers. The Aetna US HealthCare national network can also be used at a higher co-pay. If the core EmoryChoice or the Aetna US HealthCare national networks are not used there are no benefits except for emergency or urgent care.
HealthChoice is a Preferred Provider Organization (PPO) that offers the flexibility to use in-network and out-of-network providers.
House staff with family coverage can elect to pay the premiums for their family's coverage on a before-tax or after tax basis. Pre-existing conditions are covered under both options.
Dental Plan
The Emory University Residency Training program offers residents a choice of two dental plans. Details regarding these plans will be reviewed during orientation.
Premiums for the dental plans may be paid by the resident on a before-tax or after-tax basis. Residents must remain in the Dental Plan for one year.
3.03 Flexible Spending Accounts
These accounts are established to enable residents to accumulate money on a before-tax basis to pay eligible out-of-pocket health/dental and dependent care expenses. There are annual minimum and maximum contribution amounts. Flexible spending account details are available during orientation.
3.04 Auto/Homeowners/Renters Insurance
3.05 Long-term Disability Insurance
Eligible residents unable to perform in their program due to a qualifying disability may qualify for long-term disability benefits through the long-term disability insurance coverage. These benefits will be provided to eligible residents in an amount equal to 60% of the resident's stipend, up to a maximum of $5,000 per month. There is a ninety-day waiting period before otherwise eligible residents may receive coverage and payments.
3.06 Retirement Plan
Each resident may contribute to
3.07 Old Age Survivor Disability Insurance (OASDI) and Medicare Participation
Participation in Medicare and the OASDI are conditions of participation in
the residency training program for all residents.
3.08 Parking
The Office of Graduate Medical Education (OGME) pays a monthly fee for each resident
to receive parking privileges at
3.09 Additional Benefits Provided to Residents Include
- Direct Deposit of stipend checks
- Library privileges
- Membership in the Emory
Federal Credit Union (located in the lobby of the
- Benefits for same sex domestic partners
- Use of call rooms at each hospital (the Program Director will provide further information regarding call rooms during department/program orientation)
- Lab coats/scrubs [residents only]
- Meals at hospitals during night and weekend rotations
Residents with questions about any aspect of the Group Benefit Plans should
call the Benefits Office of the Human Resources Division at 404.727.7613. The
main office of the Human Resources Division is located at
SECTION 4: LEAVE TIME
This section outlines general information concerning leave time. Specific questions regarding leave should be directed to the resident's Program Director. Each Program Director is responsible for maintaining accurate records of the amount of leave time his/her residents have used.
4.01 Paid Leave:
Emory University
School of Medicine provides three weeks of paid vacation/holiday leave during
an annual academic contract period to each resident receiving a stipend in the
Graduate Medical Education Program. More
restrictive Board requirements override university permitted leaves. Those
registered in the training program without a stipend are NOT eligible for any
paid vacation/holiday leave time. A resident's unused vacation/holiday leave
during one annual contract period does NOT transfer to the following
appointment year. A resident shall not be paid for unused vacation/holiday
leave if the resident voluntarily or involuntarily leaves the program during
the contract period. Residents MUST follow the policies of their training
program in requesting and scheduling vacation/holiday leave. Failure to follow
departmental policies may result in the request being rejected. In general,
each resident must submit a leave request in writing to his/her Program
Director. Program Directors, or their designees, have the final authority to
approve or reject leave time requests.
4.02 Paid Sick Leave
The
Residents have up to twelve (12) calendar days of paid sick leave during the academic year contract period. More restrictive Board requirements override university permitted leaves. Residents participating in the program on less than a full time schedule have their sick leave determined on a pro rata basis. Unused sick leave does NOT transfer to a resident's appointment for additional training year(s). Residents shall not be compensated for unused sick leave balances upon voluntary or involuntary removal from the program, either during a contract period or at the end of the contract period. It is the responsibility of the resident to follow the policies of their department in using sick leave. The resident will be expected to provide evidence of the need for sick leave as required by his/her Program Director.
4.03 Funeral Leave
Paid funeral leave is provided to residents to attend funeral services for relatives, same-sex domestic partner, or close personal friends. A resident's Program Director may approve up to five (5) days for funeral leave per occurrence. A resident should notify his/her Program Director as soon as possible of the need for funeral leave so that appropriate scheduling may occur. During individual departmental orientation, each resident will be informed of any other departmental requirements in completing the funeral leave request.
4.04 Paid Medical Leave
Paid medical leave is to be used by eligible (i.e., those receiving a stipend) residents who are unable to complete their responsibilities for a prolonged period of time due to serious illness, injury, or pregnancy. This leave is to be used in conjunction with Family and Medical Leave Act (FMLA sub-section 4.05). When a resident qualifies for FMLA leave, the paid medical leave provisions described in this sub-section are used concurrently with the FMLA leave, so that approved time away from the residency training program is credited against a resident's maximum amount of paid medical leave and FMLA leave. A FMLA qualifying resident must apply for FMLA leave when seeking paid medical leave described in this sub-section.
In the event of pregnancy, a disabling illness or injury, an eligible resident may receive up to six weeks paid medical leave for the purposes of recuperation or convalescence. The resident's personal physician must document the condition necessitating leave. The documentation must include (a) a statement that the resident temporarily cannot perform the responsibilities of the training program, (b) an explanation for the resident's needed leave, and (c) the expected length of time before the resident can resume his/her duties. The six weeks of paid medical leave includes the resident's use of all available paid sick leave, followed by the use of two of the three weeks of the resident's vacation/holiday leave (if needed and available). If a resident needs to exhaust vacation/holiday leave for medical reasons, the resident will be granted one week of vacation time after returning from leave if he/she had one or more weeks of vacation/holiday time when the leave began. If the resident has exhausted his/her vacation/holiday time before beginning medical leave, the resident will not have any vacation/holiday leave available when returning from leave. Before returning from leave, the resident must provide documentation from a treating physician verifying that the resident is medically fit to resume responsibilities in the training program. This documentation must be addressed to the resident's Program Director.
4.05 Family and Medical Leave
Family and Medical Leave Act (FMLA) is intended to promote the well-being of residents and their families by allowing eligible residents an unpaid leave of absence for the birth of a child, to care for a new child, seriously ill family member, or for their own recuperation or convalescence.
Residents are eligible for (FMLA) leave if they have been in the residency training program for at least twelve (12) months and have worked in the program at least 1,250 hours during the twelve (12) month period immediately preceding the leave.
Subject to the requirements set forth below, eligible residents may request and receive up to twelve (12) workweeks of leave during a 12-month period (measured backward from the date on which the leave begins) for any of the following reasons:
- the birth and care of a newborn child of the resident;
- the resident's adoption of a child or the placement of a child for foster care in the resident's home;
- the care of the resident's child, spouse/same sex domestic partner, or parent (but not in-laws) with a serious health condition;
- the serious health condition of a resident which renders the resident unable to perform the essential functions of his/her position in the resident training program.
General Provisions
An eligible resident is entitled to up to twelve (12) work weeks of leave during a 12-month period for a qualifying reason. If a resident's spouse is also a resident or employee at Emory, the resident and spouse are limited to a combined total of twelve (12) workweeks of FMLA leave during the period if the reason for the leave is the birth and care of a newborn child, the foster care placement or adoption of a child, or the care of a parent or child with a serious health condition. However, for the purpose listed above, if one of the spouses has a serious health condition, each is entitled to twelve (12) workweeks of FMLA leave.
FMLA leave for the birth/care of a newborn child or for the placement of a child for adoption or foster care must be taken and conclude within twelve (12) months of the birth or placement. Unless specifically permitted, FMLA leave for these purposes cannot be taken on an intermittent basis or reduced leave schedule.
Payment Provisions and Use of Paid Leave
Residents who are granted FMLA leave must use any accrued paid leave beginning with the effective date of the leave. Specifically, in conjunction with the Paid Medical Leave described above, the first six weeks of FMLA leave may run concurrently with any available paid leave. As detailed in the Paid Medical Leave sub-section, the six weeks of paid leave include all accrued, available sick leave and two of the three weeks of vacation/holiday leave, if available. Upon exhaustion of any applicable paid leave, the remainder of any FMLA leave during the academic year will be unpaid. The combination of paid and unpaid leave may not exceed twelve (12) workweeks in the 12-month period.
Required Documentation from the Resident
A resident who foresees that he/she will need a leave for the birth and care of a newborn child or for the foster care placement or adoption of a child must notify his/her Program Director in writing and provide a completed healthcare provider's statement not less than thirty (30) calendar days in advance of the start of the leave, or generally within two (2) working days of learning of the need for leave. If not foreseeable, the resident must provide as much written notice as is practicable under the circumstances. A certification from a healthcare provider is required for leave requests related to the birth and care of a newborn child. Appropriate supporting court documents are required for leave requests related to the foster care placement or adoption of a child.
A resident who foresees that he/she will need a leave due to his/her planned medical treatment or to care for his/her spouse, same-sex domestic partner, child or parent with a serious health condition must notify his/her Program Director in writing as early as possible so that the absence can be scheduled at a time least disruptive to the training program. Such notice should be at least thirty (30) calendar days in advance of the start of leave, unless impracticable, in which case the resident must provide written notice, as early as circumstances permit, generally within two (2) working days of learning of the need for leave. A completed certification of the necessity of the leave from a health care provider is required. Preliminary designation of FMLA leave may be made pending receipt of this certification.
Subject to the limitation and certifications allowed by the FMLA, leaves taken to care for a spouse, same-sex domestic partner, child, parent or for the resident's own illness, may be taken on an intermittent or reduced leave schedule when medically necessary, provided a health care provider certifies the expected duration and schedule of such leave. The resident may be required to transfer temporarily to an available alternative position for which the resident is qualified but has equivalent pay and benefits and better accommodates recurring periods of leave than the resident's regular position.
A resident must inform his/her Program Director every thirty (30) days regarding his/her status and intent to return to the training program upon conclusion of the leave. A resident is required to submit to his/her Program Director a Return-to-work Certification from a health care provider before returning to the training program. Where there is reason to doubt the validity of the health care provider's statement of certification for leaves taken to care for a spouse, same-sex domestic partner, child, parent, or for the resident's illness, Emory may, at its own expense, require second and third opinions, as specified by the FMLA to resolve the issue.
Benefits
A resident on FMLA leave may elect to continue participation in his/her health, dental, and Beneflex and other benefit plans for the duration of the FMLA leave. In that circumstance, the resident will be responsible for paying his/her share of the benefits contributions as if he/she was actively performing in the training program, and Emory will continue to provide the benefits and pay the portion of premiums it provides for the resident when actively participating in the program. Emory will continue to provide its premium contributions and benefits throughout the FMLA leave, whether such leave is paid or unpaid.
While on paid leave, the resident's contributions (if any) will be deducted from his/her stipend check. While on an unpaid leave, the resident will be responsible for submitting his/her premium contributions on or before the date specified by the Human Resources Department. If a resident does not pay the required premium contributions, coverage will be canceled. However, the resident will be given fifteen (15) days notice before coverage is canceled. When a resident returns from FMLA leave, Emory may elect to recover the resident's share of contributions paid by Emory for maintaining coverage(s) for the resident while on FMLA leave.
Residents who elect not to continue benefits' participation while on FMLA leave must notify Human Resources to cancel the coverage. If the resident returns to the program work in an eligible status, the resident has thirty-one (31) days from that date to reinstate coverage.
4.06 Unpaid Personal Leave of Absence
A leave of absence without compensation is intended for those residents who need an extended period of time away from their training program but have no vacation/holiday leave balance and do not qualify for or have expended their sick leave, Paid Medical Leave, and FMLA leave balances. An unpaid personal leave of absence may be requested and granted for compelling personal reasons. Requests for this leave must be submitted, in writing, to the resident's Program Director for his/her consideration. The duration of the unpaid personal leave of absence is limited to the time approved by the Program Director, but in no event longer than 120 days.
During an unpaid personal leave of absence, health care coverage, dental, and life insurance shall be continued ONLY if full payment for this coverage is made by the resident each month while on leave. It is the sole responsibility of the resident to assure that premium payments are made on a timely basis. Coverage arrangements must be made with the Benefits Department of Emory University's Human Resources Division, which may be reached at 404.727.7613.
4.07 Leave for Jury/Witness Duty
Jury/Witness duty leave is provided to residents who are subpoenaed to serve on a jury or as a witness in a litigation proceeding. Each resident must notify his/her Program Director of jury/witness duty by submitting a copy of the subpoena. Jury/witness fees received by the resident for jury/witness duty may be retained by the resident. Time served on jury/witness duty will not count against the resident's vacation/holiday time.
4.08 Leave for Military Duty
Residents will be granted an unpaid military leave of absence to serve or train in the Armed Forces, the Army National Guard, the Air National Guard, or the commissioned corps of the Public Health Services, as required by the federal Uniformed Services Employment and Reemployment Rights Act (USERRA) and state law. Residents may elect to use available paid leave to receive compensation during their military leave until such pay entitlement expires. The resident may be entitled to continue health insurance coverage for a period of time. Residents MUST notify their Program Director as soon as is practicable when military leave will be required, and must provide their Program Director with appropriate documentation of their military service.
4.09 Effect of Leave of Absence on Board Eligibility
To meet the training requirements of various certifying Boards, residents may be required to spend additional time in training to make up training time lost while on a prolonged leave of absence. The residents' Program Director determines if and how much additional residency training time is required in each prolonged leave of absence circumstance.
4.10 Reinstatement after Leave
A resident who obtains a Family Leave of Absence or Unpaid Personal Leave of Absence will be reinstated to the same or equivalent position within the same academic year, except where there has been a reduction in the number of positions during the leave period due to lack of funding, a reduction of, or reorganization in, the clinical service. Reinstatement in the following academic year will require a new letter of appointment.
SECTION 5: REQUIREMENTS FOR APPOINTMENT
All new residents receive a formal offer and appointment agreement to the Emory University Affiliated Hospitals' Residency Training program. The appointment is contingent upon successful completion of all requirements of the Office of Graduate Medical Education prior to assuming training program duties, as well as all requirements specified by the department offering the house staff appointment. See Appendices A and B.
5.01 Appointment/Reappointment
Initial appointments are usually offered within the framework of the National Resident Matching Program (NRMP). The maximum appointment period is twelve months, and residents are typically offered appointments covering a July 1 through June 30 academic year period.
The number of available house staff positions in each training program is
determined each year by the Chair of each department, in consultation with the
Dean of the
The decision not to offer a resident re-appointment may be due to a variety of reasons, including but not limited to the resident's unacceptable performance, unacceptable conduct of the resident, and/or lack of available funding.
5.02 Stipends
The amount of the stipend offered to residents in each post graduate year
level is reviewed annually by the
5.03 Direct Deposit
All residents are required to have direct deposit for their stipend checks. Forms to initiate direct deposit are completed during orientation.
· PGY-1 residents who are enrolled in training programs at Emory University School of Medicine will not be promoted to PGY 2 positions unless they have provided Program Directors evidence by January 1st of the PGY 1 year that they have passed USMLE Step two (2).
· Residents transferring from a program in another institution will not be accepted into a PGY 2 position at Emory University School of Medicine unless they have provided evidence that they have passed USMLE Step 2.
· PGY 3 residents will not be promoted to a PGY 4 position at Emory University School of Medicine unless they have provided evidence that they have passed USMLE Step 3.
· Residents will not be accepted into an Emory PGY 4 or higher position from another program unless they have passed USMLE Step 3.
· If an Emory Residency training program is 3 years in length, then a resident must pass USMLE Step 3 in order to receive a certificate from Emory University School of Medicine signifying satisfactory completion of residency training.
· The GME office does not reimburse for USMLE Step 3.
5.05 Georgia License Requirements
All residents must have a Temporary Postgraduate Training
Permit or a Medical License from the State of
5.06 License Reimbursement Policy
Residents/Fellows (PGY 1- PGY 7) will be reimbursed up to $100 to OBTAIN a Temporary Postgraduate Training Permit to practice as a resident in facilities associated with Emory University School of Medicine Residency Training Program. Residents will be reimbursed up to $50 to RENEW their training permits. Residents will not be reimbursed the cost to issue a new training permit if he/she allowed the permit to lapse.
If a resident/fellow (PGY 1 – PGY 7) elects to obtain a GA Medical License instead of a Postgraduate Training Permit, the resident will be reimbursed up to $100 toward the cost of obtaining the license without additional reimbursements. If a resident has a GA Postgraduate Training Permit and elects to obtain a GA Medical License, there will be no additional reimbursement.
Residents/Fellows (PGY 8 or higher) who are PGY 8’s or higher are required to obtain a license to practice medicine in the state of Georgia even though they remain in training positions at Emory University School of Medicine. Residents/Fellows will be reimbursed up to $400 toward the cost of the license and up to $50 for each renewal period. To receive reimbursements when it is required at the PGY 8 level or higher, the fellow must provide copies of the cancelled check (both sides) and the license.
The GME office will
not reimburse residents who obtain a GA Medical License to moonlight.
To receive reimbursement
for a permit when processed directly, residents must provide the GME office
with a photocopy (both sides) of the personal check used to obtain a
Once a permit is obtained, each resident must maintain a valid permit to participate in the Emory University School of Medicine Training Program throughout his/her residency training for a period not to exceed seven (7) years. Failure to do so will result in disciplinary action up to and including termination from the training program. Also, the GME office will not issue the contract for the subsequent year.
For more information or to obtain application forms for training permits or licensure, visit the website for the Composite State Board of Medical Examiners: www.medicalboard.state.ga.us
5.07 Immunization Records Required at the Start of the Program
All residents entering Emory's training program MUST provide the OGME with documentation indicating vaccinations or serologic data showing immunity to the following:
- MMR (measles, mumps, and rubella) - 2 doses if born after 1957
- diphtheria-tetanus (Td) - within the past 10 years
- hepatitis B (3-dose series) This documentation must come from the student health service at the medical school attended by the resident, from a personal physician or from a county health department.
In addition, residents must be immune to chickenpox-either by previously having the disease or by vaccination. When a resident either believes that he/she is not immune to chickenpox or is uncertain of chickenpox immunity, a serology must be drawn to check the immune status. Residents showing no immunity must be vaccinated with the varicella vaccine (2 doses - four weeks apart).
PPD Testing Requirement
Residents MUST have a PPD skin test completed prior to the start of training at Emory, and must provide proof of such skin test to the OGME. Residents starting training on July 1st , who cannot provide documentation of a timely test or who have not had a recent PPD skin test will be given the test during residency training orientation Residents entering the training program who have not had a PPD done in the past year will need a baseline test done and if that is negative, a second test should be performed in 1 to 4 weeks.
Residents entering the training program who have a previously tested PPD positive must provide documentation of the positive PPD test. This documentation must reflect when and where the skin test was performed and what follow-up action was taken (e.g., chest radiograph date and results and any medications prescribed). Individuals who have a history of a positive PPD skin test and who have received adequate follow-up care will not be required to take any other skin test or further action unless they are, or become symptomatic. However, these residents must seek medical treatment if the following symptoms develop: cough greater than two weeks, weight loss, fever, or night sweats. House staff who previously tested positive for PPD and have not received adequate preventive therapy will be referred to a physician for evaluation.
Subsequent PPD Skin Testing of Residents
All residents who do not have documentation of a prior positive PPD skin test result must be tested annually while participating in Emory's training program. Residents will be notified in writing of the dates and place(s) where the testing will be done. The test must be administered, read and the results documented by a member of the Employee Health Department from one of Emory's five major teaching hospitals.
Residents with a History of BCG
Residents entering the training program with a history of BCG must have a PPD skin test at the start of the training program, regardless of whether they have tested positive in the past. This skin test will be administered in the first week of the resident's participation in the training program. If the test is read as positive, the resident must complete the actions as described in the provisions of the sub-section entitled "Resident Who Convert to a Positive PPD Skin Test". If the test is read as negative, a second test is required 2-4 weeks later. If the second test is negative, the resident must be tested annually.
Residents Who Convert to a Positive PPD Skin Test
Any resident who converts to a positive PPD test while in the training program MUST have a chest x-ray completed within 24 hours of the time the PPD test is documented as positive. If the chest x-ray is abnormal, the resident must be evaluated immediately by an attending physician; if the chest x-ray is unremarkable, the resident must be evaluated for preventive therapy by an attending physician within 2 weeks from the time the test was documented as positive. Any resident converting to a positive PPD must follow through with the treatment plan established by an attending physician.
Failure to Supply Records or Obtain Testing/Immunization
A resident who fails to supply the immunization and health records required by the program or fails to comply with any testing or immunization requirement will be placed on Administrative Notice.
5.08 Advanced Cardiac Life Support (ACLS)
Each new member of the house staff is required to provide his/her training program with documentation that he/she has received advanced cardiac life support training and that such training is up-to-date. To be considered up-to-date, ACLS training must have been completed within two years of the first day of residency training for those incoming residents who are immediate medical school graduates and three years for all others. Each new member of the house staff without prior training is required to obtain training in advanced life support techniques. The OGME provides access to ACLS through residency programs. Each resident is then required to ensure that their ACLS training remains up-to-date throughout his/her residency training.
Additionally, some departments require residents to be certified in other advanced training such as pediatric advanced life support. Residents must contact their Program Director to discuss program specific requirements.
5.09 Medical Records
For every order written, residents are required to: include the date and time; legibly print their name, and; include their pager number (PIC) after their signature. Residents must comply with the medical records completion requirements at each hospital where they train. Residents who do not comply with the medical records completion requirements will be subject to disciplinary action up to and including termination from the training program. All entries into medical records must be legible. Careless, unclear handwriting could negatively impact patient care; e.g., prescription that is for 1.0 mg, if written illegibly, could be interpreted as 10 mg. A resident who displays repeated illegible hand writing may be subject to disciplinary action up to and including termination from the training program.
5.10 Photo Identification Cards
All residents are required to obtain and display an
Residents are prohibited from using either their Grady produced photo ID card or their EmoryCard while moonlighting outside the Grady Healthcare or EMORY HEALTHCARE facilities.
Residents may replace a lost EmoryCard photo ID at the EmoryCard office in
the lobby of the
The EmoryCard identification badge is also used as an access card to enter
the
5.11 Physician Code Number
Upon first entering the graduate medical education program, each resident is
issued an alphanumeric physician code. This code is used at
5.12 International Medical Graduates (IMG)
International Medical Graduates seeking appointment to a residency position
must be certified by the ECFMG and enter the training program on a J-1 or H-1B1
visa, unless a citizen of the United States or holding an Alien Registration
Card. All such documentation must be
verified by the Graduate Medical Education Office before the resident starts in
the training program. For J-1 visas visit the ECFMG website for further
information: www.ecfmg.org. For information
on H-1B1 visas, visit
5.13 Policy on communicating with
residents via email
Email is the primary medium for official communication with
residents/fellows at
Residents/Fellows are expected to maintain their accounts and check their email regularly so that new email can be properly received and read. Certain communications may be time-critical. While residents may redirect email from their official University email address to another address (e.g. @hotmail.com, @aol.com) the University is not responsible for the delivery of email by other service providers.
SECTION 6: MOONLIGHTING:
“Moonlighting” refers to a service performed by a resident in the capacity of an independent physician, completely outside the scope of his/her residency-training program. “External moonlighting” refers to moonlighting at a facility that is not part of the resident’s training program. “Internal moonlighting” refers to moonlighting at an Emory facility or any other facility where the resident is receiving training as part of the residency-training program.
Residents are prohibited from external or internal moonlighting UNLESS they have the written approval of the Chair of the Department or his/her designee. The requirements necessary for such approval are set forth below under “External Moonlighting” and “Internal Moonlighting.”
Residents do not have insurance coverage through Emory’s Residency
Training Program for any moonlighting services, whether external or
internal.
In addition to the requirements below, the Chair or his/her designee’s decision to approve or deny a resident’s request to moonlight will depend on a number of factors including, but not limited to, interference with the resident’s responsibilities in the training program and the individual circumstances of the resident.
6.01 External Moonlighting Requirements:
1. The Resident must submit a written request for approval to externally moonlight by completing the “Request to do External Moonlighting” form obtained either from the Program Director, Program Coordinator or from Appendix D in this House Staff Manual.
2. In order to be considered for external moonlighting, the resident must meet the following requirements:
a) Residents must agree to obtain a signed contract with the external facility and provide a copy of the signed contract to the Program Director. The contract must state that the facility will provide professional liability insurance coverage for the resident’s moonlighting services and that the resident has received privileges. If the facility does not provide insurance coverage, residents must obtain their own professional liability insurance and provide proof of such insurance to the Program Director before moonlighting begins.
b) Residents must be fully licensed to practice medicine in the state where the moonlighting will occur. A residency-training permit is not a license to practice medicine outside the scope of residency training.
c) Residents on J-1 Visas are prohibited from moonlighting.
d) Residents must not wear identifiers as trainees in Emory University School of Medicine residency-training programs.
e) External moonlighting does not count toward the 80-hour limit set by the ACGME. The Chair of the Department and the Program Director are expected and required to assess the resident’s progress in the program and ask the resident to stop moonlighting if performance does not reach an expected level. The resident must be aware of these expected levels of academic and clinical performance before beginning the moonlighting experience.
6.02 Internal Moonlighting Requirements:
1. The Resident must submit a written request for approval to internally moonlight by completing the “Request to do Internal Moonlighting” form obtained either from the Program Director, Program Coordinator or from Appendix D in this House Staff Manual.
2. In order to be considered for internal moonlighting, the resident must meet the following requirements:
a) Residents must agree to obtain a signed contract with the facility and provide a copy of the signed contract to the Program Director. The contract must state that the facility will provide professional liability insurance coverage for the moonlighting services and that the resident has received privileges. If the facility does not provide insurance coverage, residents must obtain their own professional liability insurance and provide proof of such insurance to the Program Director before moonlighting begins.
b) Internal moonlighting services may occur only in an OUTPATIENT SETTING or in the EMERGENCY DEPARTMENT. Federal Medicare regulations are very clear on this point. (42 CFR 415.208)
c) Residents
must be fully licensed to practice medicine in the State of
d) Residents on J-1 Visas are prohibited from moonlighting.
e) Resident must not wear identifiers as trainees in Emory University School of Medicine residency-training programs
f) Residents must assure the Program Director in writing that the total hours in residency training and the moonlighting commitment DO NOT EXCEED the limits set by the ACGME. Fabrication of the duty hour information could result in termination from the training program.
SECTION 7: DISCIPLINARY ACTIONS
The
7.01 Administrative Notice:
Administrative Notice is a remedial action by which a resident is temporarily relieved of clinical duties without pay for violation of university, institutional, or departmental policy pertaining to administrative matters. Examples of inappropriate action triggering an administrative notice include, but are not limited to, failure to maintain an active medical license in the GME office, failure to provide evidence of training in basic life support techniques, failure to obtain PPD tests, and failure to provide OGME with a copy of his/her medical school diploma or ECFMG certificate. Administrative Notice is not necessarily considered censure, and the Chair or Program Director will decide whether it will become a part of the resident's permanent academic file.
The department Chair, Program Director, or their designee may impose an Administrative Notice upon a resident for failure to appropriately discharge his/her administrative responsibilities. Administrative Notice may not be invoked for deficiencies in academic performance, patient care, or any other non-program related administrative action or conduct, as those deficiencies should be addressed through verbal warnings, written warnings, probation, suspension, and/or termination. The resident may not appeal his/her receipt of an Administrative Notice.
The resident will be notified promptly of his/her placement on Administrative Notice. Such notice shall, if possible, be hand-delivered (with the resident signing and dating a copy to acknowledge receipt) or sent by certified mail (return receipt requested) to the resident's address of record. The department Chair, Program Director, or their designee will also, if possible, verbally inform the resident of the action. The Administrative Notice shall clearly delineate the resident's area(s) of deficiency and establish a reasonable period of time no longer than 10 calendar days within which the resident must correct his/her deficiencies. During the period of Administrative Notice, the resident is relieved of all clinical responsibilities without pay. Failure to appropriately address the areas of deficiency in the appropriate time frame as outlined in the letter of notification is considered grounds for additional disciplinary action, up to and including termination from the residency program.
7.02 Verbal Warning
A verbal warning, which may be given to a resident by a departmental Chair, Program Director, or other faculty member, is designed to identify a resident's minor or initial infraction of policies, standards, or expectations. The warning should be firm and fair, with the faculty member assuring that the resident understands the policies, standards, and expectations. A written record of the date and content of the discussion, as well as the underlying situation which precipitated the warning, shall be maintained in the resident's academic file.
7.03 Written Warning (Letter of Reprimand)
A written warning may be issued only by a resident's department Chair or Program Director. A written warning is appropriate when a prior verbal warning has not resulted in the needed improvement or when the initial misconduct violation or performance inadequacy indicates a need for action stronger than a verbal warning. The written warning should note the unacceptable conduct or action that caused the warning, as well as the program's improvement expectations. The written warning must be signed by the resident and a copy given to him/her. A copy must be placed in the resident's academic file.
7.04 Probation
A department Chair or Program Director may place on probation a resident who is unable to meet the academic expectations of the training program (failing to progress at the expected pace), who experiences a serious lapse in complying with the responsibilities of the program, or for other serious misconduct and/or performance problems. A department Chair or Program Director should notify the Associate Dean for Graduate Medical Education or his/her designee before placing a resident on probation.
Probation is usually the second step of a series of disciplinary actions for a resident. Usually a resident will have one or more counseling sessions or receive a verbal or written warning about his/her deficiency prior to being placed on probation. In placing the resident on probation the Chair or Program Director should:
- Review the policies and expectations of the program;
- Identify the area of deficiency;
- Identify the improvement(s) that must be achieved during the probation period;
- Identify the length of the probationary period; and
- Inform the resident what action(s) may be taken if the stated improvements are not met in the established time frame.
A resident will receive this probation notification in writing. Copies of the probation notice will be placed in the residents' academic file and in his/her administrative file located in the Office of Graduate Medical Education. A probation period occurring during training will be noted in all letters of reference.
7.05 Suspension
The Dean of the
When suspending a resident, the Program Director or his/her designee must inform the resident, in writing, of the following:
- Action(s) that precipitated the decision to suspend the resident;
- The length of the suspension;
- The fact that the resident will not be paid while on suspension;
- The fact that the suspension will NOT be counted toward the completion of the training time required to be eligible for board examination(s);
- An indication of what the resident may/may not do while on suspension (for example, no moonlighting);
- The program's expectations for the resident upon his/her return from suspension.
Copies of the suspension notice will be placed in the resident's academic file and in his/her administrative file located in the Office of Graduate Medical Education. Suspensions will be noted in all letters of references.
7.06 Termination
If a residency appointment is terminated during the appointment period, the terminated resident may appeal the decision by following the procedures outlined in Section 33, "Hearing and Appellate Review Procedures for Termination of a Resident."
SECTION 8: COUNSELING AND SUPPORT SERVICES
When a resident needs private counseling or professional assistance to
address an issue which is, or may affect his/her ability to live or work fully
and productively, assistance is available through the Faculty Staff Assistance
Program (FSAP) at the Well House,
A change in productivity, attendance, or behavior is often the first indicator of the need for help. The FSAP offers confidential and professional consulting, brief counseling, education, and referral services covering areas such as:
- Marital, family, or relationship issues
- Health and wellness
- The abuse of alcohol or other drugs
- Financial obligations
- Compulsive or abusive behavior or anger management
- Addictive disorders
- Stress and depression
- Child care and parenting issues
- Career concerns
- Eldercare
- Work systems and quality of work life
- Critical incident stress debriefing (processing traumatic events)
When a resident takes the initiative to call or visit, the FSAP can help the resident:
- Discover and manage available options and resources
- Sort through a problem or concern and identify the core issues
- Develop a plan for dealing with identified issues
- Obtain professional assistance to complete the plan
FSAP is available 24 hours per day, 7 days per week for residents who are in crisis and need assistance during off hours. To reach a counselor on call, residents can call the main number for FSAP at 404.727.4328. Press option “2” to reach the answering service who will page the appropriate counselor.
SECTION 9: BEHAVIORAL HEALTH STATEMENT
The
This Section outlines the Behavioral Health Policy and Procedures adopted by
the
9.01 Behavioral Health Policy and Procedure
The Emory University School of Medicine is committed to providing, through
its Residency Training Program, the highest levels of graduate medical
education, patient care, and research. To realize this commitment, the
The purpose of this policy is to ensure that all residents are fit for duty
and work free from harm to themselves and others. The
When a release from duty is needed in order for the resident to obtain inpatient or outpatient treatment for a behavioral issue, including a psychiatric condition, psychological issue, or substance abuse, such a release shall be requested and processed as stipulated in the provisions of this policy.
The Faculty Staff Assistance Program (FSAP) is available to assist residents as well as Emory faculty and staff in dealing with any issue or concern that is affecting or may affect that individual's ability to live or work in a healthy, productive manner. The FSAP facilitates the ability of its clients to discover options and manage resources that enhance health, productivity, and behavior.
Referral and Assessment Provisions
Emory encourages residents to seek professional assistance at the earliest indication of physical or emotional problems related to job performance or safety. Professional assistance is generally accessed in one of the following ways:
- Self-referral by the resident
- Referral by the resident's department chair or program director
The FSAP is available to provide coaching and consultations on when and how to make a referral, and to assist leadership as well as peers and colleagues on ways to encourage self-referral. Emory reserves the right to mandate a resident's participation in this process where circumstances indicate that a fitness for duty examination is appropriate. Residents are expected to fully cooperate in Emory's efforts to receive a fitness for duty examination. Disciplinary action, including termination from the Residency Training Program, may result from a resident's refusal to cooperate with the process.
When a resident comes to the FSAP through self-referral or other means, the FSAP will work with the resident in confidence, to the extent appropriate or permitted by law, to assess the nature of the concern or issue, to determine the cause, and to identify a plan of action. When the result of an assessment leads to the determination that a release from duty is indicated to obtain further evaluation, inpatient or outpatient treatment for a substance abuse, psychiatric, or behavioral health issue, the following provisions will apply.
Requesting a Release from Duty - Procedure
It is the responsibility of the resident to request in writing an authorized release from duty as soon as possible. The request shall be submitted to the resident's department chair or program director, shall be accompanied by a certification from the health care provider attesting to the medical necessity of the release, and shall specify the beginning date of the time away from duty and the anticipated return date.
The request shall also acknowledge that the resident is aware of and will
follow the policy and provisions set forth by the
Authorizing a Release from Duty
The resident's department chair shall review the request and supporting documentation, and determine whether to grant the resident's request for a release from duty. In the absence of a specific request, the department chair or program director may release a resident from duty where objective evidence suggests that the resident's continuation of work would pose a direct threat to him/herself or others. In such circumstances, the resident shall be referred to the FSAP for a fitness for duty evaluation as otherwise described in this policy. The resident is expected to fully cooperate in these efforts to obtain a fitness for duty evaluation. Disciplinary action, including termination from the Residency Training Program, may result from a resident's lack of cooperation.
9.02 Return to Duty Policy
When an Emory University resident is absent from the training duties of his/her residency training program (RTP) to obtain assistance for behavioral health concerns, including inpatient or outpatient psychiatric treatment, psychological treatment, treatment for substance abuse (including but not limited to treatment for alcohol abuse), or a similar condition that may impact job performance or safety, that resident may resume duties in the RTP based on medical evidence demonstrating the ability to perform the essential functions of his/her duties. Each qualifying resident may be required to submit a return to duty plan prior to his/her return to the RTP in the event that medical evidence demonstrates an ongoing restriction that may impact job performance. This plan must be developed and approved in accordance with the guidelines provided in this policy. The FSAP will serve as the liaison between the resident, the RTP, and the resident's treatment team during the development, implementation, and management phases of the return to duty plan.
Creation and Approval of the Return to Duty Plan
The chairperson of the resident's department or the resident's RTP
program director by designation of the chairperson will work with the FSAP in
developing any applicable return to duty plan. The chairperson, program
director, and FSAP may consult with the Associate Dean for Graduate Medical
Education or his/her designee of
Content of the Return to Duty Plan
At a minimum, each return to duty plan should include some, or all, of the following elements, as appropriate to the particular resident's needs and the needs of the RTP:
- the resident's commitment to ongoing care for an appropriate period of time with an addictionologist, psychologist, psychiatrist, or other appropriate professional, chosen by the resident and endorsed by the FSAP and with whom the resident agrees to fully cooperate
- the resident's agreement to submit to clinical testing and/or serum levels as deemed appropriate
- participation by the resident in an appropriate support group, such as the Caduceus Club, another impaired-professionals group, or another appropriate group endorsed by the treatment provider when applicable
- the resident's acknowledgment of responsibility to assure that his/her treating provider supplies the FSAP and the RTP chairperson (or the resident's program director by designation) with timely and sufficiently detailed status reports concerning the resident's ongoing ability to safely and effectively train within the RTP if applicable, at intervals to be determined by the FSAP, the chairperson, and the treatment provider
- commitment by the resident to perform each of his/her training duties and to conduct himself/herself in a satisfactory manner, and commitment by RTP to periodically evaluate the resident to assure that the resident's performance and conduct are satisfactory and render him/her eligible to continue training within the RTP
- commitment to maintain full
compliance with
- if the resident has received treatment for substance abuse, the resident's commitment to abstain from all mind altering substances, including prescriptive medicine, that are not approved in writing by the resident's substance abuse recovery program treatment provider
- agreement by the resident and the RTP to work cooperatively with the Composite State Board of Medical Examiners in all matters involving the Board to assure compliance with any additional or different restrictions or requirements placed on the resident by the Board.
Responsibility of Resident
Any resident who is absent from his/her training duties to obtain psychiatric, psychological or substance abuse treatment and who desires to return to the RTP may be required to meet the following responsibilities. Any resident desiring to return to the RTP may be required to arrange to have his/her treatment provider release in a timely manner information to the chairperson, program director, and the FSAP concerning the nature and scope of the resident's condition as it relates to job performance, any limitations on the resident's ability to perform essential job functions, evidence suggesting that the resident may pose a direct threat, and the provisions of the resident's continuing care program as it relates to or impacts his/her RTP duties. This information will be used to assist the determination of whether the resident is eligible to resume training in the RTP. The resident's failure to meet these responsibilities will result in his/her inability to return to the RTP.
If a resident is allowed to return to the RTP and if that resident has a return to duty plan, he/she must comply with each provision in the return to duty plan until he/she has fulfilled the requirements for release from any continuing care program and any other treatment coordinated by the resident's treatment provider. In addition, the resident must comply with each provision of his/her continuing care program, as developed by the resident's treating provider, and must have arranged to have the treating provider release information to the resident's chairperson, program director, and FSAP concerning the resident's compliance with the continuing care program, if applicable. The RTP and FSAP will make reasonable efforts to coordinate the resident's training schedule and responsibilities with his/her continuing care program commitments. Finally, the returning resident is expected to meet each of the RTP's performance and conduct standards. The resident's failure to meet any of these responsibilities may result in discipline, up to and including the dismissal of the resident from the RTP.
Residency Credit
Upon returning to the RTP after receiving treatment, each resident's eligibility to receive credit for any portion of the residency year in question will be evaluated by the resident's chairperson and program director. In determining the resident's qualification to receive training credit, the chairperson and program director will evaluate the resident's performance prior to receiving treatment, the length of time the resident performed within the residency year prior to leaving the RTP for treatment, the length of the treatment, the length of time remaining in the residency year upon the resident's return to duty, the training received by the resident, and the training missed by the resident while receiving treatment.
Confidentiality
All medical information concerning the resident's absence from the RTP to receive treatment and his/her subsequent return to the RTP, including information provided by the resident's treating provider, will be treated as a confidential record. Medical information concerning the resident, including psychiatric and/or psychological information, will only be disclosed by the chairperson, program director, and FSAP to the resident's other supervisors when, and if, an accommodation or work restriction may be needed by the resident. However, the chairperson, program director, and FSAP will continue to have the right and may have the duty to disclose additional medical information to the appropriate entities and individuals for any other lawful purpose.
Record Keeping
All medical records and other documentation concerning the resident's absence from the RTP to receive treatment and the resident's return to the RTP, including information from the resident's treating provider, will not be maintained in the resident's personnel file, Graduate Medical Education file, or RTP file. Instead, the documentation will be collected and maintained in a separate medical file, which is secured in a locked area in the University's Department of Human Resources or the FSAP.
SECTION 10: GRADUATE MEDICAL EDUCATION COMMITTEE
10.01 Structure - GMEC/Executive Committee/Internal Review Committees
The Graduate Medical Education Committee (GMEC) serves as the organizational vehicle for the house staff. The missions of the GMEC are:
- To serve as a forum to discuss concerns and issues identified by the house staff;
- To evaluate and monitor the activities and quality of the training programs ;
- To advise the Office of Graduate Medical Education on matters involving the administration of the training program; and
- To advise and make recommendations to the Dean on all aspects of Graduate Medical Education.
GMEC recommendations approved by the Dean which will materially change the program are presented by the Dean to the Council of Chairs for their final approval.
An Executive Committee of the GMEC will meet at least quarterly to review Internal Reviews completed in the previous quarter, to review letters sent to or received from ACGME during the quarter and to take any action needed between routinely scheduled meetings of the GME Committee. The Chair of the Executive Committee will be elected from the GMEC. The Executive Committee will consist of five members in addition to the Chair. These members shall include three Program Directors from the GMEC, one resident elected from the GMEC, the Assistant and Associate Deans for GME. Actions taken by the Executive Committee shall be reviewed at the next regularly scheduled meeting of the GMEC.
Internal Review Committees will be formed from members who serve on the GMEC and others faculty and residents as necessary. The purpose of these committees is to complete internal reviews on all training programs and to report their findings to the Executive Committee and the Associate Dean for Graduate Medical Education.
Other sub-committees of the GMEC may be formed from time to time to address the needs of the residency training program. Two standing committees are utilized when required to review programs requests to extend work hours and approve international graduates training in non-standard program.
10.02 Membership
The GMEC has a minimum of 34 members and
is chaired by the Associate Dean for GME. The Committee composition includes
the Program Directors, residents from larger residency training programs, and
fellows in any training program. Resident and fellow members of GMEC must be
peer elected and can be from any level of training. Additional members of the
Committee include: the Assistant Dean for GME; the COO of the Emory
Hospitals, or his designee; the Senior Vice President for Medical Affairs of
Grady Memorial Hospital, or his designee; the Assistant Chief of Staff for
Education from the VA Medical Center, or his designee; the Project Director of
Medical Affairs at CHOA; Associate Dean for Clinical Services at Grady and the
Chief Medical Resident of Grady Hospital. All members of the Committee have
full voting privileges. The names of the Committee members are presented to the
Dean for final approval of all Committee appointments. At his discretion, the
Dean may appoint others to serve on the Committee.
10.03 Meeting Schedule/Agenda
The GMEC meets at
10.04 Open Meeting
Committee meetings are open to all residents, Program Directors and faculty. Residents should contact their Program Director and the Committee Chair regarding their plans to attend.
10.05 Records and Minutes
All minutes of the GME Committee meetings, along with associated reports and records, are available for review by members of the house staff, Program Directors and faculty. Please contact the Assistant Dean for Graduate Medical Education at 404.727.5658 to schedule a time to review this material.
10.06 Residents' Suggestions
Residents are invited and encouraged to contact the Assistant or Associate Dean for GME to discuss any issue related to the School's policies for graduate medical education or the overall quality of the GME programs.
SECTION 11: PERSONNEL FILES
A resident may review his/her administrative file by making an appointment with the Assistant Dean for Graduate Medical Education.
The resident should understand that information in his/her file might be reported to licensing board or hospitals when the resident is applying for medical staff privileges. Information that may be reported includes any disciplinary action including, but not limited to, action taken as a result of delinquent medical records, conduct, clinical and academic performance and non-compliance with hospital or University policy or procedure.
SECTION 12: OTHER SERVICES
12.01 Child Care - Elder Care - Family Care Referral
The Faculty Staff Assistance Program (FSAP) contracts with a work/family consulting firm, to assist residents in finding solutions to child care and elder care needs. The FSAP provides these family referral services at no charge. Interested residents should call 404.727.FSAP for more information.
12.02 Clifton
Child Care
Center
12.03 George
W. Woodruff
Physical Education
Center
The Woodruff Physical Education Center is a state-of-the art physical
fitness center located on the
12.04 Earle B. & Stephanie
S. Blomeyer
Health Fitness
Center
The Earle B. & Stephanie S. Blomeyer Health Fitness Center is another Emory University-related fitness center located in the Emory 1525 Clifton Road Building. Interested residents should call the Earle B. & Stephanie S. Blomeyer Health Fitness Center at 404.727.4600 for membership details.
12.05 Emory Shuttle
Emory provides a shuttle service between the
12.06 Dobbs
University Center
The Dobbs University Center (DUC) offers discount tickets to many area attractions, concerts, and amusement parks as well as video rentals and TicketMaster tickets. Call 404.727.TICK.
12.07 Emory Federal Credit Union
Residents may wish to open an account at the Emory Federal Credit Union. Call 404.329.6415 or 404.686.2559 for more information on available financial services.
SECTION 13: WORKERS' COMPENSATION
13.01 General Information and Procedures
Residents in the Emory training program are covered under Emory Healthcare and Emory University Workers' Compensation program. All incidents, regardless of type, should be documented and reported when the event occurs. Types of injuries include, but are not limited to, sprains and strains, lacerations, abrasions, burns, needle sticks, blood and body fluid exposures, tuberculosis conversions, chemical exposures and occupationally related dermatitis. It is extremely important to notify Emory Healthcare, Employee Health/Workers’ Compensation department as soon as possible. This ensures that the resident receives appropriate treatment through the approved panel of physicians if indicated, and services provided under workers' compensation paid.
13.02 Commonly asked Workers' Compensation Questions
1. WHAT IS WORKERS' COMPENSATION?
Workers' Compensation is an accident insurance program that provides medical
and income benefits to employees/residents injured on the job.
2. WHEN ARE RESIDENTS COVERED UNDER WORKERS' COMPENSATION?
A resident's coverage begins on his/her first day of training in the residency
training program.
3. WHEN SHOULD A JOB INJURY OR ILLNESS BE REPORTED?
Any training program related injury or illness should be reported immediately
to
4. HOW DOES THE RESIDENT SEEK TREATMENT?
Initially, injured residents are to complete an Emory Employee Incident report
form and report to the Employee Health Nurse Practitioner for assessment and
treatment. If further evaluation is needed, the resident will choose a panel
physician. Listings of our panel physicians are posted in various locations
throughout
5. WHAT MEDICAL TREATMENT WILL BE PAID?
For work-related injuries and illness, all AUTHORIZED doctors' bills and
hospital bills are paid. Medications, testing or diagnostic procedures, and
rehabilitation appointments such as physical therapy are also paid if ordered
by the treating "panel" physician or Employee Health Nurse
Practitioner.
QUESTIONS?
See section 13.04, Workers’ Compensation Contact Information for any
questions.
13.03 Illness/Injury Reporting Directions
If a resident has a work-related injury or illness, he or she must:
1. Complete an Emory Employee Incident Report form, regardless of forms required
at the facility where the work-related injury occurred. This form is available
from the GME office, Suite 111 WHSCAB, or at
2. Notify the Residency Program Director/Coordinator.
1. If emergency treatment is needed, report to the Emergency Department in the facility where the injury occurred. If a blood/body fluid exposure occurs after hours and the source is HIV+ or has HIV risk factors, seek immediate treatment in the emergency room. A consult with an Infectious Disease physician must be sought prior to initiating PEP treatment. Failure to do so may result in non-payment of medications.
3. After initial emergency treatment, follow-up with the Nurse Practitioner in Employee Health at either EUH (HB 53) or ECLH (WW Orr Building, 6th floor) to notify them of the incident and any information regarding work status changes.
4. If additional treatment is needed, the Employee Health Nurse Practitioner will coordinate any medical follow-up required.
5. If non-emergent treatment is needed, contact either Employee Health at EUH 404-686-8589 or ECLH Employee Health at 404-686-2537.
6. For questions regarding benefits information, please contact Covenant, the third party administrator for Workers’ Compensation at 678-258-8327.
7. Incident reports, medical reports and all work status documents should be faxed to 404-727-5405. Please bring originals with you to Employee Health/Workers’ Compensation or mail them to Emory University Hospital, Employee Health, Room HB 53; 1364 Clifton Road, NE, Atlanta, GA 30322. This should be done as soon as possible after the incident occurs.
8. All authorized medical treatment in connection with a work-related injury or illness, including emergency room treatment, will be covered under the workers' compensation program. For the purposes of this program, authorized medical treatment must be from one of the physicians posted on the Pink Panel of Physicians.
9. Refer questions regarding bills to the Workers' Compensation Case Manager @, (404) 686-7780 or (404) 686-9237.
13.04 Contact Persons in the
Questions
related to your treatment, medications, or follow-up, Emory Healthcare,
Employee Health/Workers’ Comp has 24/7 on-call coverage to assist you.
(404) 686-5500 Pic # 50464
Residents, injured on the job, should report to Employee
Health/Workers’ Compensation for evaluation, treatment and follow-up.
DAVID PATTON,
RN, NP-C, MSN
Employee Health
Nurse Practitioner
Located: Employee Health/Workers’
Compensation, ECLH, WW
Office: (404)
686-7106
Fax: (404)
686-4938 PIC # 10675
Paula Desroches, MS, RNC, ANP
Employee Health Nurse Practitioner
Located: Employee Health/Workers’ Compensation at EUH, Room HB 53.
Office: (404)
686-2382
Fax: (404)
727-5405 PIC # 12367
Connie Wilbanks, RN, COHN-S
OCCUPATIONAL NURSE CASE MANAGER
Located: Employee Health/Workers’ Compensation, ECLH, WW Orr Building, 6th floor
Office: (404) 686-7780
Fax: (404) 686-4938 PIC # 12208
CASEY JONES, RN, BSN
OCCUPATIONAL NURSE CASE MANAGER
Located: Employee Health/Workers’ Compensation at EUH, Room HB 53
Office: (404) 686-9237
Fax: (404)
727-5405 PIC # 14781
CINDY HALL, RN, COHN-S/CM
EMPLOYEE HEALTH NURSE MANAGER
Located: Employee Health at
Office: (404) 686-7947
Fax: (404)
686-4938 PIC # 12605
PAM HAWKINS, RN, COHN
EMPLOYEE HEALTH NURSE MANAGER
Located: Employee Health at
Office: (404) 686-7066
Fax: (404) 727-5405
TRAVIS BROWN,
RN, NP-C, MSN, MBA
DIRECTOR, EMPLOYEE HEALTH/WORKERS’
COMPENSATION
Office: (404) 686-7941
Fax: (404) 686-4938 PIC # 12514
TAMMY WOODY
CLAIMS ANALYST, THE
COVENANT GROUP
The Covenant Group handles payments for all workers’ compensation claims.
Claims questions and inquiries on Georgia
Located
off-site
Office: (678) 258-8327
Fax: (678) 258-8393
FOR BLOODBORNE PATHOGEN EXPOSURES (E.G., NEEDLE STICKS) REPORT TO ANY NURSE IN EMORY HOSPITALS EMPLOYEE HEALTH.
Injury Flowchart PDF ( If you need to print this flowchart use the link at left to download a PDF version.)
SECTION 14: INFECTION CONTROL
A. NEEDLE
STICKS AND OTHER BLOOD/BODY FLUID INJURIES
1. Always observe Standard Precautions (Universal Precautions).
2. If you have a significant exposure to blood or other body fluids (e.g., needle stick, cut), immediately clean the wound with soap and water.
3. Exposed oral and nasal mucosa should be decontaminated by vigorously flushing with water. Exposed eyes should be irrigated with clean water or sterile saline.
4. Follow the protocol of the hospital in which the incident occurred (through the hospital's Employee Health Service). It is especially important that you report your exposure to the hospital's Employee Health Service as soon as possible so that a timely evaluation can be performed. If prophylactic medications are indicated, it is recommended they be initiated as soon as possible after the exposure.
5. IF PEP is indicated following a BBP exposure, the Hospital Epidemiologist (or ID service if Hospital Epidemiologist is not available) will be consulted (see list below). If you have any questions about the management of your exposure, call the Emory Healthcare, Employee Health Nurse on-call, at (404) 686-5500 pic # 50464. The on-call nurse can help with questions or help in the collaboration with Epidemiology.
6. Acute serology should be drawn to establish your baseline antibody titers to hepatitis B virus (if you have not previously been determined to be HBsAb positive [immune to Hepatitis B]) and, if indicated, to HIV and/or Hepatitis C Virus (if the source patient is HIV-positive or HCV-positive).
7. Depending on the results of your serology and the baseline serology of the patient (from which the incident occurred), you may need follow-up serologies.
8. If the source patient is HIV-infected, the administration of post-exposure prophylaxis ("prophylactic" antiretroviral medications) to decrease the risk of patient to health care worker transmission should be strongly considered. If used, these medications should be taken as soon as possible after the needle-stick or blood-borne pathogen exposure. The hospitals have protocols and will counsel you and give advice as needed. PEP regimens are complicated; therefore be sure that the individual who manages your exposure consults with the Hospital Epidemiologist.
9. You must complete an Emory Employee Incident Report form regardless of the facility where the exposure occurred. Please see Section 13.03, #1.
10. The following list of specific areas and/or individuals should be contacted at the facility in which the exposure occurs:
Emory Healthcare, Employee
Health/Workers’ Compensation has 24/7 coverage for any questions or
assistance with coordinating care. (404)
686-5500 pic # 50464.
GRADY
Daytime hours, Monday thru Friday:
Employee Health Service call 404-616-7849 (STIX)
or 404-616-4600
After hours and on weekends: Occupational Health Services
Call 404-616-7849 (STIX)
Dr. Henry Blumberg, Hospital Epidemiologist; Division of Infectious Diseases
Office: 404-616-6145; Pager: 404-686-5500; ID# 15029; Home: 404-377-5095
Dr. Susan Ray,
Office: 404-616-6139, Pager: 404-837-8946; Home: 404-373-8537
If you are unable to reach any of the above individuals, ask the paging operator at 404-616-4307 to contact the Infectious Diseases Attending on call; if not available contact the Infectious Diseases Fellow on call.
VA
Daytime hours, Monday thru Friday:
Infection Control/Employee Health,
Room 611, Debbie Hawkins RN: 404-321-6111, Ext. 6471
After hours and on weekends: Emergency Room 404-321-6111, Ext. 6640
Dr. David Rimland, Division of Infectious Diseases
Office: 404-321-6111, ext. 6165; Pager: 404-722-3122; Home: 770-393-8951
Dr. William Blake, Division of Infectious Diseases
Office: 404-321-6111, ext. 2093; Pager: pic 16136; Home: 404-248-0362
If you are unable to reach any of the above individuals, ask the paging operator at 616-4307 to contact the Infectious Diseases Attending on call; if not available contact the Infectious Diseases Fellow on call.
Daytime hours, Monday thru Friday (
Employee Health/Workers’ Compensation-WW Orr Building, 6th
floor, (404) 686-2537
After hours, and on weekends:
Page Administrative Nursing Supervisor (PIC#11917)
Dr. James Steinberg, Division of Infectious Diseases
Office: 404-686-8909; Pager: 404-686-5500, ID# 15770; Home: 404-876-4717
If you are unable to reach any of the above individuals, ask the paging
operator at 404-686-1000 to contact the Infectious Diseases Attending on call;
if not available, contact the Infectious Diseases Fellow on call by dialing
404-686-5500, PIC# 11350.
Daytime hours, Monday thru Friday (
Employee Health / Workers’
Compensation,
HB 53 Emory Hospital (404)
686-8589
After hours and on weekends:
Page Administrative Nursing Supervisor (PIC#13087)
Emergency Room 404-712-7100
Dr. Bruce Ribner, Hospital Epidemiologist,
Office: 404-727-1580; Pager: 404-686-5500, PIC# 15326; Home: 404-417 0225
If you are unable to reach any of the above individuals, ask the paging operator at 404-727-4611 to contact the Infectious Diseases Attending on call; if not available, contact the Infectious Diseases Fellow on call.
CHILDREN'S HEALTHCARE OF
Daytime hours, Monday thru Friday:
Employee Health, Digital Pager 1-800-682-4549 or Needlestick Hotline (ext 4444
at Egleston and ext 824444 at Scottish Rite)
After hours and on weekends: same as above.
Dr. Harry Keyserling, Pediatric Infectious Diseases
Office: 404-727-5642; Digital Pager: 770-839-5679; Home: 404-377-8535
If you are unable to contact any of the above individuals, ask the paging
operator at
404-325-6000 to page the Infectious Diseases Fellow on call.
11. Any of the following physicians may be contacted for assistance and
additional advice, but the injury should first be reported as outlined in #9,
above, for immediate help.
Henry M. Blumberg, M.D., Grady Memorial Hospital, 404-616-6145
Harry Keyserling, M.D., Egleston Hospital, 404-727-5642
Susan M. Ray, M.D., Grady Memorial Hospital, 404-616-6139
David Rimland, M.D., VA Medical Center, 404-321-6111, Ext. 6165
Bruce Ribner, M.D., M.P.H. Emory University Hospital, 404-727-1580
Jonas A. Shulman, M.D., Medical School Administration, 404-727-5655
James Steinberg, M.D., Crawford Long Hospital, 404-686-8909
12. The cost of the follow-up and necessary medications will be borne by Emory University Affiliated Hospitals.
SECTION 15: EQUAL OPPORTUNITY
The requirements and protections of
SECTION 16: LIABILITY INSURANCE AND RISK MANAGEMENT PROGRAMS
Residents enrolled in a GME sponsored residency training program are provided with professional and general liability insurance for activities falling within the course and scope of their training program. The Emory Liability Program also responds to a claim made after a resident leaves the training program, so long as the claim arises out of an activity that fell within the course and scope of the training program. The Emory Liability Program will not respond to a claim arising out of an incident or activity that precedes the resident's enrollment in the Emory training program even if the claim is made once the resident has begun his or her training at Emory.
Residents rotating within the Emory system have a responsibility to report any adverse occurrence or circumstance to an Emory Healthcare Risk Manager as well as their Program Director and Department Chair.
A Risk Manager can be contacted at the following numbers, after hours and weekends call the paging operator at 404-686-1000 and ask for the Risk Manager on call:
|
|
404.686.2470 |
|
|
|
Fax: |
404.712.7941 |
|
|
|
|
|
|
404.686.2470 |
|
|
|
Fax: |
404.686. 5901 |
|
|
|
|
|
The Emory Clinic, Inc. |
404. 686.2470 |
|
|
|
Fax: |
404.778.7935 |
|
|
|
|
|
Wesley Woods |
404.686.2470 |
|
|
|
Fax: |
404.712.7941 |
|
|
|
|
Currently, Emory residents assigned to
Requests for verification of coverage must be submitted in writing to Ms. Lori Gamble-Wood at Emory Healthcare, Office of Risk &
Insurance Services,
Requests for claims history information should be submitted in writing to
Ms. Glinia Beebe at Emory Healthcare, Office of Risk
& Insurance Services,
SECTION 17: STANDARS OF CONDUCT
As a leader of the health care team, each resident is expected to maintain the highest level of professional and courteous conduct when working with patients, families, faculty, other residents, staff, and visitors. The action, inaction, or other conduct of any resident that is unprofessional, discourteous, disruptive, illegal, or that adversely affects the patient care environment or is considered an illegal activity may result in disciplinary action, up to and including termination from the residency training program.
SECTION 18: The Health Insurance Portability and Accountability Act
The information collected from and about a
patient is very sensitive. It is used to care for the patient and should be
shared only with those involved in the patient’s care. The School of Medicine
The Health Insurance Portability and Accountability Act of 1966 [HIPAA] provides federal patient privacy and security rules. Residents should all be familiar with these rules and the policies regarding patient confidentiality, privacy and security. Residents will be provided information regarding HIPAA during orientation.
Patients have rights to keep health care information about themselves from being inappropriately used and/or disclosed.
CONFIDENTIALITY is the responsibility for limiting use or disclosure of private matters such as health care matters and releasing the information with the authorization of the patient.
PRIVACY is the right to be free from intrusion into one’s private affairs and to maintain control over personal information.
SECURITY is the ability to control access to patient information and protect it from destruction, loss or unauthorized access.
Failure to abide by the policies regarding patient confidentiality, privacy or security are grounds for discipline up to and including termination from the residency training program.
If you have questions or concerns about patient confidentiality, privacy or security, call the office of compliance programs @ 404-778-2757.
SECTION 19: RELEASE OF INFORMATION TO THE MEDIA
No resident may communicate any patient- or hospital-related information to newspapers, radio, television, or other media without prior approval from hospital administration or an authorized public relations representative of the relevant hospital. A resident must also receive permission from a patient before making any patient-related statements to the media.
SECTION 20: CONFLICT OF INTEREST
The
SECTION 21: NO SOLICITATION
To avoid any disruption of health care operations and/or disturbance of patients, the following rules apply to solicitation and distribution of non-medical literature on the property of any of the Emory-affiliated hospitals through which residents rotate. Non-residents and persons not employed by the hospital may not solicit or distribute literature on the hospital property at any time, for any purpose. Residents may not solicit or distribute literature during working time for any purpose. Working time includes any period during which either the resident doing the soliciting or distributing or the resident to whom the solicitation and distribution is aimed is or should be on hospital property engaged in the performance of residency training programs duties. Break periods and lunch periods are not working time. Residents may not solicit or distribute at any time for any purpose in immediate patient care areas such as patients' rooms, operating rooms, places where patients receive treatment, x-ray and therapy areas, or corridors in patient treatment areas and rooms used by patients for consultations with physicians or meeting with family or friends.
Residents may not distribute non-medical literature at any time for any purpose in the working areas. Working areas are all areas in the hospital where employees, residents and other health care providers are performing work, except cafeterias, staff lounges, lobbies and parking areas.
This policy does not apply to the solicitation or distribution of material by or through residency training program sponsored activities.
SECTION 22: WEAPONS
SECTION 23: SMOKE-FREE WORKPLACE
To promote the health, safety, and comfort of all individuals, smoking is
prohibited within
SECTION 24: DRUG-FREE WORKPLACE
As a recipient of federal grants and contracts, Emory adheres to the
provisions of the federal Drug-Free Workplace Act of 1988 and the
SECTION 25: DRESS CODE
Residents are expected to be neat, clean, and orderly at all times during the performance of training program activities. Residents are expected to dress according to generally accepted professional standards appropriate for the resident's particular program. Where safety is a factor, residents should use common sense in choosing clothing and shoes for training activities. Jewelry, clothes, and hairstyle should be appropriate for the performance of duties in the hospitals. Program Directors may require a particular, reasonable dress code for their residents, depending on the needs of the service, for public image, and safety. Photo identification tags must be worn at all times while on duty.
SECTION 26: TIPS/GIFTS
Residents are not allowed to accept gifts of significant monetary value
(defined by Emory as in excess of $40.00) from patients, or patient family
members. Gifts from industry to individual residents should be primarily for
the benefit of patients or educational in nature and should not be of
extraordinary value. Accordingly, textbooks, modest meals and similar gifts are
appropriate. Cash payments should not be accepted. Diagnostic equipment
primarily benefits the patient and therefore such gifts are permissible as long
as they are not of extraordinary value. Individual gifts of minimal value such
as pens and notepads are permissible as long as the gifts are related to the
physician’s work. Scholarships or other special funds to permit residents
and fellows to attend major educational conferences may be permissible as long
as selection of the residents who attend is made by their academic Department
and the subsidy is provided to the Department rather than to the individual resident.
The general guiding principles that apply are those of
SECTION 27: CARE AND USE OF PROPERTY/EQUIPMENT
Residents are responsible for the proper care and use of hospital equipment and supplies. Any damaged or unsafe equipment, repairs, and replacements should be reported to the appropriate hospital manager. Computer hardware and software are the property of the applicable hospital. Illegal copying of software and unauthorized entry into the data processing system is prohibited. Software originating from an external source must be examined for viruses and approved by Information Services department staff of the appropriate hospital before installing on hospital systems and networks.
Residents are not permitted to share computer sign-on security codes with each other or other health care providers.
SECTION 28: PASTORAL SERVICES
The pastoral services department at
SECTION 29: SECURITY
The Emory University-affiliated hospitals have public safety departments
with officers on duty twenty-four hours each day. Residents are encouraged to
notify the Public Safety Department at 404.712.5598 (
SECTION 30: TEACHING RESPONSIBILITIES
Residents are responsible for teaching and supervising other residents, medical students, and other health care professionals. Each resident has the responsibility to participate fully in all educational activities.
SECTION 31: DEPARTMENT ORIENTATION
Individual department/program orientation will familiarize each resident with his/her program-specific responsibilities, departmental processes, and systems for each of the hospitals where the residents will be assigned. Each Program Director will inform their residents of the details regarding this orientation session. It is each resident's responsibility to participate in department orientation and to clearly understand the training program's expectations of the resident as well as the resident's specific responsibilities.
SECTION 32: POLICY ON CONSENSUAL TEACHER (FACULTY OR RESIDENT)-STUDENT (RESIDENT OR STUDENT) RELATIONSHIPS
The relationship between teacher and student is the foundation of the academic mission of the University. This relationship vests considerable trust in the teacher, who, in turn, bears the responsibility to serve as mentor, educator, and evaluator. In discharging this responsibility, teachers are accountable for behaving in a manner that reflects the highest levels of professional responsibility, recognizes the dignity and worth of each person at the University, and protects the integrity of the student-teacher relationship.
Teacher-student relationships carry risks of conflict of interest, breach of trust, abuse of power, and breach of professional ethics. For these reasons, teachers must not engage in any consensual sexual relationships with a student while the teacher is in a position of supervisory academic authority with respect to the student. Nor may a teacher assert any supervisory academic authority with respect to a student who was the subject of a previous consensual sexual relationship. This prohibition extends to consensual sexual relationships between a graduate or professional student and an undergraduate when the graduate or professional student has some supervisory academic responsibility for the undergraduate, to consensual sexual relationships between department Chairs and students in that department, to consensual sexual relationships between graduate advisors, Program Directors, and all others (each of whom is considered a teacher) who have supervisory academic responsibility for a student and that student.
When a teacher-student consensual sexual relationship exists, has previously existed, or develops, the teacher must decline to participate in any evaluative or supervisory academic activity with respect to the student.
The deans, department Chairs, and other administrators should respond to reports of prohibited sexual relationships by inquiring further and, if such reports appear to be accurate, initiating appropriate disciplinary action or remedial measures against the teacher involved. Egregious breach of this policy is adequate cause for termination under paragraph 12(C) of the Statement of Principles Governing Faculty Relationships.
Non-consensual sexual relationships are prohibited by the non-discriminatory harassment policy.
SECTION 33: GRIEVANCE
A resident who has an unresolved significant dispute or complaint with the residency training program, his/her Program Director, or other faculty member may grieve the dispute or complaint in the manner described in the following Grievance Procedure. A resident may use the Grievance Procedure outlined in this Section only when he/she is a participant in an ACGME or Board accredited, Emory University School of Medicine graduate medical education program and possesses a valid, signed currently applicable GME contract for such participation. Once the grieving resident’s participation in the relevant Emory graduate medical education program ends via expiration of contract term or otherwise, the resident’s right to initiate or to continue this Grievance Procedure ends, and the Grievance Procedure immediately terminates regardless of any pending status of the grievance process. If the resident’s participation in the Emory graduate medical education program ends while the grievance is being considered at a particular step outlined below, that consideration will immediately terminate, and any decision reached by the immediately prior decisionmaker in the Grievance Procedure will be the final, non-appealable resolution of the grievance.
Only residents currently undergoing training in Emory’s graduate medical education programs may utilize this Grievance Procedure. Therefore, a former Emory University School of Medicine resident is not eligible to initiate or to utilize this Grievance Procedure.
Note that this Grievance Procedure does not cover controversies or complaints arising out of the termination of a resident from an Emory graduate medical education training program during a contract period. Residents may appeal a residency appointment termination during a contract period pursuant to the procedures described in Section 34 of this Manual. Equal Opportunity Policies and procedures found in Section B of this Manual address the manner in which a resident may raise a complaint of discriminatory harassment.
33.01 Grievance
Procedure
The Grievance
Procedure has an Informal Resolution Process and a Formal Resolution
Process. Each of these processes is
explained below. The resident must
utilize the Informal Resolution Process first, and then, if needed, advance to
the Formal Resolution Process. Once the
resident has used the informal and formal processes as described below, the
resident cannot re-initiate the process for the same issue.
A. Informal
Resolution Process
An aggrieved resident shall notify his/her Program Director, in writing, of the grievance. If the resident's grievance is with the Program Director, the resident should submit his/her grievance to the Chair of the Department. If the Chair of the Department is the subject of the grievance, the resident should submit his/her grievance to the Associate Dean for Graduate Medical Education. If the Associate Dean for Graduate Medical Education is the subject of the grievance, the resident should submit his/her grievance to the Executive Associate Dean for Clinical Affairs.
This notification shall include all pertinent information and evidence that supports the grievance. The resident and the Program Director, the Chair, the Associate Dean of Graduate Medical Education or Executive Associate Dean of Clinical Affairs, as appropriate, hereinafter (“the Informal Resolution Process Decisionmaker”) or his/her designee shall set a mutually convenient time to meet to discuss the grievance and to attempt to reach a resolution. The aggrieved resident and the Informal Resolution Process Decisionmaker should make a good faith effort to resolve the grievance at this informal level. Additional meetings may be scheduled either with the resident or with others during the Informal Resolution Process to attempt to resolve the grievance.
The Informal Resolution Process of this Grievance Procedure shall be deemed complete when the Informal Resolution Process Decisionmaker informs the aggrieved resident, in writing, of his/her decision concerning the grievance. A copy of this decision shall be sent to the Program Director, Department Chair and the Associate Dean for Graduate Medical Education.
B. Formal Resolution Process
Upon completion of the Informal Resolution Process, the aggrieved resident may choose to proceed to the Formal Resolution Process.
1. The aggrieved resident must start the Formal Resolution Process by presenting his/her grievance, in writing, along with all pertinent information and evidence related to the grievance, to the Department Chair within fifteen (15) days of the conclusion of the Informal Resolution Process. [If the Department Chair is a subject of the resident’s complaint or was the Informal Resolution Process Decisionmaker, the aggrieved resident should submit the written grievance to the Associate Dean for Graduate Medical Education within the time deadline, and the Associate Dean for Graduate Medical Education, or his/her designee, will take the actions described in this sub-section in the place of the Chair. If the Associate Dean for Graduate Medical Education is a subject of the resident’s complaint or was the Informal Resolution Process Decisionmaker, the resident should submit his/her grievance to the Executive Associate Dean for Clinical Affairs by the deadline.]
A resident’s failure to submit the grievance within the fifteen-day deadline will result in the resident's waiving his/her right to proceed further with this Grievance Procedure. In this situation, the decision of the Informal Resolution Process Decisionmaker would be final.
Upon timely receipt of the written grievance, the Department Chair or his/her designee will contact the aggrieved resident to set a mutually convenient time to meet to discuss the resident’s complaint. The Chair or his/her designee will review and carefully consider the material presented by the resident. In addition, the Chair/designee may engage in any further investigation and gather and review any additional information he/she believes to be appropriate and relevant when considering the resident’s complaint. Ultimately, the Department Chair/designee will provide the aggrieved resident with a written grievance determination within a reasonable period of time after the meeting.
2. Any individual who is unsatisfied with the Chair's written decision regarding the grievance may seek an appeal by submitting all grievance-related material and a written appeal request to the Associate Dean of Graduate Medical Education within fifteen (15) days after receipt of the Chair’s written decision. [If the Associate Dean of Graduate Medical Education assumed the role of Chair as outlined in sub-section B.1., the individual should submit his/her grievance appeal to the Executive Associate Dean for Clinical Affairs. If the Associate Dean of Clinical Affairs assumed the role of Departmental Chair in sub-section B.1., the grievance appeal should be submitted to the Office of the Dean.] Failure to submit the grievance appeal within fifteen days after receipt of the Chair’s written decision will result in the individual waiving his/her right to proceed any further with this Formal Grievance Procedure. Upon timely receipt of the grievance appeal, the Associate Dean of Graduate Medical Education or designee will review relevant information and may ask the aggrieved individual to meet and discuss the claims. The review and meeting, if desired, will be done within a reasonable time period, and the Associate Dean of Graduate Medical Education or designee will thereafter make a grievance appeal determination after taking any additional desired steps to review and address the grievance appeal.
3. Any
individual who is unsatisfied with the grievance appeal determination may seek
a final review by submitting all grievance-related material to the Dean of the
SECTION 34: HEARING AND APPELLATE REVIEW PROCEDURES FOR TERMINATION OF A RESIDENCY APPOINTMENT
I. Right to Hearing and Appellate Review
These procedures apply only to the termination of a residency appointment during the annual position agreement period. A resident whose appointment is terminated during the annual position agreement period shall be entitled to a hearing before the Residency Review Committee. The Residency Review Committee shall be an ad hoc committee appointed by the Associate Dean for Graduate Medical Education, or the Dean's designee, and shall consist of the Associate Dean or the Dean's designee, one department Chair, one faculty member other than a department Chair, and two (2) residents. The Associate Dean for Graduate Medical Education, or the Dean's designee, shall serve as Chairperson of the Residency Review Committee. A quorum shall be three members, one of whom must be a resident.
II. Initiation of Hearing
A. The Chairperson of the Residency Review Committee shall give the resident against whom a termination action has been taken written notification of the action by certified or registered mail, return receipt requested, or by hand delivery. The notice shall:
- Advise the resident of the action taken;
- Advise the resident of the grounds upon which the action is based;
- Advise the resident of the right to a hearing;
- Specify the number of days (not less than 30) following the date of receipt of notice within which a request for a hearing must be submitted;
- State that failure to request a hearing within a specified time period shall constitute a waiver of the right to a hearing and to appellate review of the matter;
- Advise the resident that he/she has the right to representation by counsel; to have a record made of the proceedings; to call, examine, and cross-examine witnesses; to present evidence; and to submit a written statement at the close of the hearing; and
- State that upon receipt of a timely hearing request, the resident shall be notified of the date, time and place of the hearing.
B. A resident shall have no more than thirty (30) calendar days following the receipt of the notice of termination to file a written request for hearing. The request must be delivered to the Associate Dean for Graduate Medical Education either by hand delivery or by certified or registered mail. Failure to request a hearing within the specified time period shall constitute a waiver of the right to a hearing and to appellate review of the matter.
III. Hearing Prerequisites
A. Within seven (7) calendar days after receipt of a timely hearing request from a Resident entitled to a hearing, the Associate Dean for Graduate Medical Education, or the Dean's designee, shall schedule a hearing and shall give written notice to the resident of the time, place and date scheduled. The hearing shall be scheduled not less than thirty (30) calendar days from the date of receipt of a timely request for hearing. The notice of hearing shall state in concise language the grounds for the termination of the Resident, a list of specific or representative charts being questioned, and/or the other reasons or subject matter forming the basis for the adverse action which is the subject of the hearing, and shall provide a list of witnesses (if any) expected to testify at the hearing in support of the adverse action. This list may be supplemented at any time prior to three (3) business days prior to the hearing date.
B. No staff member who participated in the residency termination shall serve as a member of the hearing committee.
IV. Hearing Procedures
A. The personal presence of the resident who requested the hearing shall be required. If the resident fails, without good cause, to appear and proceed at the hearing, the resident shall be considered to have waived all rights hereunder in the same manner and with the same consequences provided above in connection with failure to request a hearing.
B. The Chairperson of the Residency Review Committee shall be the Presiding Officer of the hearing. The Presiding Officer shall maintain decorum and assure that all participants in the hearing have a reasonable opportunity to present relevant oral and documentary evidence. The Presiding Officer shall determine the order of the proceedings and shall make rulings on procedure and the evidence to be considered.
C. The hearing provided for in these procedures is for the purpose of resolving matters bearing on professional competency and conduct of the resident in the residency training program. Nevertheless, the affected resident, the department or entity involved, and/or the Committee shall be entitled to representation by an attorney or other person of their choice at any hearing held pursuant to these procedures. Likewise, the resident, the department or entity involved, and/or the Committee shall have the right to use legal counsel in preparing for the initial hearing or for appellate review.
D. During the hearing, each of the parties shall have the following rights: to call and examine witnesses, to present exhibits, to cross-examine any witness on any matter relevant to the issue, and to rebut any evidence. If the resident who requested the hearing does not testify, he or she may be called and examined by any member of the Committee or by the representative of the department or entity whose action prompted the hearing.
E. The hearing need not be conducted according to rules of law relating to examination of witnesses or receipt of evidence. Any matters deemed relevant by the Presiding Officer may be admitted regardless of the admissibility of this evidence in a court of law. Evidence merely cumulative or not so deemed relevant may be excluded. Each party shall, prior to, during, or at the close of the hearing, be entitled to submit memoranda concerning any issue, and these memoranda shall become a part of the hearing record. The Presiding Officer may, but shall not be required to, order that oral evidence be taken only on oath or affirmation administered by any person designated by the Presiding Officer and entitled to notarize documents in the State of Georgia. The hearing shall be tape-recorded or, at the discretion of the Presiding Officer, be reported by a qualified court reporter. Copies of the tape recording or transcript may be obtained by the Resident upon payment of any reasonable charges associated with the preparation thereof.
F. The department recommending the residency termination shall have the initial obligation to present evidence in support of the termination showing that the termination action has been taken in the reasonable belief that it furthers the quality of health care or that the resident's conduct or actions were otherwise unacceptable. The resident then shall have the burden of supporting the challenge to the termination by showing that the evidence presented lacks any substantial factual basis or that such basis or the conclusions drawn therefrom is arbitrary, unreasonable, or capricious.
G. A quorum of the Committee must be present throughout the hearing and deliberations. If the Presiding Officer determines that a Committee member was absent from a substantial portion of the proceedings, that member shall not participate in the deliberations or the decision of the Committee.
H. Requests for postponement of a hearing shall be granted by the Committee Chairperson only upon a showing of good cause and only if the request for postponement is made as soon as reasonably practicable.
I. The Committee may recess the hearing and reconvene without additional notice for the convenience of the participants or to obtain new or additional evidence or consultation. Upon conclusion of the presentation of oral and written evidence, the hearing shall be closed. The Committee shall thereafter, at a time convenient to the members, conduct its deliberations. Deliberations shall not be recorded. Unless the Committee upholds the termination by a majority vote, the resident shall be reinstated. Upon conclusion of Committee deliberations, the Presiding Officer shall declare the hearing finally adjourned.
V. Hearing Committee Report and Further Action
Within ten (10) calendar days after the final adjournment of the hearing, the Residency Review Committee shall make a written report of its findings and decision on the matter and the Chairperson of the Committee shall send a copy of the findings and decision to the Resident and the department involved.
VI. Initiation of Appeal
A. A resident shall have seven (7) calendar days following receipt of the notice of an adverse decision of the Committee to file a written request for appellate review. The request shall be delivered to the Dean of the Emory University School of Medicine, by hand or by certified or registered mail, return receipt requested. Likewise, in the event of a ruling favorable to the resident, the department initiating the termination shall have seven (7) calendar days following receipt of notice of the ruling to file a written request for appellate review. The department's written request for appellate review shall be delivered to the Dean by hand.
B. If the resident or the department fails to request appellate review within the time period and in the manner specified above, any right to review the Resident or department might otherwise have had shall be deemed waived.
C. Upon receipt of a written request for appellate review from the resident or department, the Dean shall schedule appellate review which shall occur not less than fourteen (14) calendar days nor more than thirty (30) calendar days after receipt of the request. Irrespective of whether appellate review is initiated by a resident or a department, at least seven (7) calendar days prior to the appellate review, the Dean shall send, by hand, or by certified or registered mail, to the resident and Chairperson of the Department, written notice of the time, place and date of the review. The time scheduled for the appellate review may be changed for good cause by the Dean. All appellate review shall be conducted by the Dean, or the Dean's designee, alone, or if the Dean so desires, by a duly appointed ad hoc advisory appellate review committee, appointed by the Dean, consisting of no less than two (2) faculty members and one Resident. If a committee is appointed, the Dean shall be a member of the committee and shall serve as Chairperson or shall designate a member to serve as Chairperson.
VII. Appellate Review Procedure
A. Proceedings by the Dean or by the ad hoc advisory appellate review committee shall include, but not be limited to, consideration of the record of the hearing before the Residency Review Committee, that Committee's findings, and subsequent actions thereon. The Dean, or the committee, shall also consider any written statements that are submitted. Such review shall be for the purpose of determining whether the adverse decision against the Resident or the department was made in accordance with these procedures and not arbitrarily or capriciously.
B. As part of the request for appellate review, the resident or Chairperson of the department seeking review shall submit a written statement detailing the findings of fact, conclusions and procedural matters with which the resident or department disagrees and reasons for such disagreement. This written statement should cover any matters raised at any step of the hearing process, and Legal counsel may assist in its preparation. Prior to the appellate review, a written statement in reply may be submitted by the Chairperson of the department, where review is sought by a resident, or by the resident, where the department seeks review. The Dean shall provide a copy of the statements to the opposing parties.
C. The Dean or the ad hoc advisory appellate review committee shall allow the parties and their attorneys, if any, to appear personally and make oral statements in favor of their positions. Any party or representative so appearing shall be required to answer questions asked by the Dean or any member of the Committee.
D. The Dean or the Chairperson appointed by the Dean, shall be the Presiding Officer and shall determine the order of procedure during the review, make all required rulings, and maintain decorum.
E. New or additional matters of evidence, not raised or presented during the original hearing or in the hearing report, and not otherwise reflected in the record, shall be introduced at the appellate review only at the discretion of the Dean, or the appointed Chairperson, following an explanation by the party requesting the consideration of such matter or evidence as to why it was not presented earlier.
F. The appellate review shall not be deemed to be concluded until all the procedural steps provided above have been completed or waived.
VIII. Final Decision
A. Within fourteen (14) calendar days after the conclusion of the appellate review, the Committee, or the Dean, if acting without an advisory committee, shall deliberate and make a final decision in the matter, and shall send written notice thereof to the department or other entity involved and to the affected Resident.
B. Notwithstanding any other provision of these procedures, no resident shall be entitled to more than one hearing and one appellate review of the same matter.
IX. Reinstatement
Compensation and fringe benefits shall terminate as of the date on which the termination decision is made. Where a resident is reinstated by virtue of proceedings hereunder, the resident shall receive all back pay to which the resident would have been entitled but for the termination action and shall be reinstated to all fringe benefit programs, unless the resident elects to waive reinstatement. In such event, the resident shall receive the equivalent of back pay from the date of the termination decision until the date on which notice of the outcome of the hearing, if there is no appellate review, or if appellate review is sent to the resident, less any amounts received by the resident in a training program at another institution, and shall be deemed to have resigned from the Residency Program.
APPENDIX A: POLICY AND PROCEDURE ON RESIDENT RECRUITMENT & APPOINTMENT
Policy:
This policy sets forth Emory University School of Medicine's ("Emory's") guidelines regarding resident recruitment and selection. This policy is intended to establish valid, fair, effective, and ethical criteria for the recruitment and selection for Emory's graduate medical education program.
Procedure:
I. Resident Recruitment
- Applicants are required to meet one of the following qualifications to be eligible for a position in the graduate medical education program at Emory.
- Graduates of
medical school in the
- Graduates of
colleges of osteopathic medicine in the
- Graduates of
medical schools outside of the
- Graduates of
medical schools outside of the
II. Resident Appointment
- Eligible applicants will be considered for an appointment based on:
- academic credentials
- ability
- overall preparedness
- communication skills
- aptitude
- personal qualities (such as motivation and integrity)
- other written criteria developed by the Program Director and approved by the Associate Dean for Graduate Medical Education.
- In selecting from qualified applicants, Emory may participate in an organized matching program such as the National Resident Matching Program.
- In determining resident eligibility and appointment, Emory will not discriminate with regard to a resident's gender, race, religion, color, creed, national origin, disability, sexual orientation or veteran status.
- On behalf of Emory as the sponsoring institution, the Office of Graduate Medical Education will be responsible for periodically reviewing whether resident selection activities are consistent with this Policy. The Office of Graduate Medical Education may delegate these review activities to individual Program Directors or their designees.
V. Questions regarding this Policy and Procedure should be directed to the Office of Graduate Medical Education.
APPENDIX B
RESIDENCY
APPOINTMENT AGREEMENT
Contingent upon your timely satisfaction of the
following conditions,
1) Receipt of a
Georgia Temporary Postgraduate Training Permit (pursuant to O.C.G.A.43-34-47
and Rules 360-2.09 through 360-2.12 and the House Staff Policies and
Orientation Manual) prior to July 1, 2005 (you must submit a completed
application for training permit to Emory=s Office
of Graduate Medical Education at least 60 days prior to appointment date);
or
2) Receipt of a
Georgia Medical License (pursuant to
O.C.G.A. 43-34-26(5) & 43-34-27, and
the House Staff Policies and Orientation Manual) prior to July 1, 2005 (proof
of which you must submit to Emory=s Office
of Graduate Medical Education at least 60 days prior to appointment date). Georgia Medical Licenses are required for all
residents who are PGY 8 or higher;
THESE LICENSURE/PERMIT OBLIGATIONS ARE CONTINUING
THROUGHOUT THE TERM OF THIS AGREEMENT.
The revocation or termination of your Georgia Temporary Post Graduate
Training Permit or Georgia Medical License will constitute adequate grounds for
the immediate termination of this Agreement.
You are offered an appointment as a Postgraduate Year
in the Department of effective for a period of ,
beginning and ending . Compensation shall be paid in monthly
installments at an annual compensation rate of . If less than a month is worked, compensation
for that month shall be computed on a daily rate based on the compensation
schedule in effect at that time.
All residents/fellows must follow the guidelines
established by the ACGME and by the training program regarding resident duty
hours.
The specific terms and conditions of your appointment
as a resident/fellow in the Emory University School of Medicine residency
program are described in and governed by the provisions of the House Staff
Policies and Orientation Manual. A
current copy of this manual can be found on
http://www.emory.edu/WHSC/MED/GME/index.html. This Agreement, together with the House Staff
Manual, shall also govern your relationship with each of the Affiliated
Hospitals to which you are assigned. All
items in Section III.D of the ACGME Institutional requirements are addressed in
the House Staff Manual. Any conditions
or provisions described in the Manual which are dependent upon the availability
of resources beyond the control of
_____________________
James R.
Zaidan, M.D., M.B.A. Date
Associate
Dean for Graduate Medical Education
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
I accept the above-described position in the Emory
University School of Medicine Residency Training Program. I agree to abide by the rules and regulations
of
_______________________
Signature Date
_______________________
Name Social Security Number
APPENDIX C Equal Opportunity Policies
POLICY STATEMENT ON DISCRIMINATORY HARASSMENT
It is the policy of
Discriminatory harassment includes conduct (oral, written, graphic, or physical) directed against any person or group of persons because of race, color, national origin, religion, sex, sexual orientation, age, disability or veteran's status and that has the purpose or reasonably foreseeable effect of creating an offensive, demeaning, intimidating, or hostile environment for that person or group of persons. Such conduct includes, but is not limited to, objectionable epithets, demeaning depictions or treatment, and threatened or actual abuse or harm.
In addition, sexual harassment includes unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when:
• submission to such conduct is made either explicitly or implicitly a term or condition of an individual's employment or a student's status in a course, program, or activity.
• submission to or rejection of such conduct by an employee or student is used as the basis for employment or academic decisions affecting that employee or student.
• such conduct has the purpose or effect of unreasonably interfering with an employee's work performance or a student's academic performance or creating an intimidating, hostile, or offensive employment, educational, or living environment.
All University Vice Presidents, Deans, and Division and Department Chairpersons should take appropriate steps to disseminate this policy statement and inform employees and students of procedures for lodging complaints. All members of the student body, faculty, and staff are expected to assist in implementing this policy.
The scholarly, educational, or artistic content of any written, oral, or other presentation or inquiry shall not be limited by this Policy. It is the intent of this paragraph that academic freedom be allowed to all members of the academic community. Accordingly, this provision shall be liberally construed but shall not be used as a pre-textual basis for violation of this Policy.
Any student or employee with a complaint of discriminatory harassment should contact the Associate Vice President of Equal Opportunity Programs to obtain information on the procedure for handling such complaints. Any questions regarding either this policy statement or specific fact situation should be addressed to the Emory University Office of Equal Opportunity Programs.
FORMAL PROCEDURES FOR HANDLING COMPLAINTS OF DISCRIMINATORY HARASSMENT
I. Introduction
The University, in recognition of its commitment to maintain an environment free of discrimination and discriminatory harassment, has developed a policy which prohibits harassment on the basis of race, color, sex, age, religion, veterans status, national origin, disability, and sexual orientation.
Persons feeling aggrieved under the policy against discriminatory harassment are encouraged to seek informal resolution through the office of the Associate Vice President for Equal Opportunity Programs. Informal procedures may result in any outcome to which the parties agree.
When informal procedures have not achieved an outcome satisfactory to the parties, these formal procedures may be used. It is not necessary that informal procedures be tried first. A sanction may be imposed (as opposed to agreed) upon a member of the University community only after a hearing in accordance with these procedures.
Because of the special nature of a university community and the importance of principles of academic freedom, Emory here reiterates that part of the policy which provides "The scholarly, education, or artistic content of any written, oral, or other presentation or inquiry shall not be limited by this Policy. It is the intent of this paragraph that academic freedom be allowed to all members of the academic community." These procedures are to be used to enforce the policy in its entirety, including its insistence on the protection of academic freedom.
The procedures provided herein shall apply to complaints against faculty and non-faculty. Complaints against students shall be resolved per II below. Because of the difference in role in the University community of each of these groups, this document provides certain special supplementary procedures in addition to procedure applicable to all. A complaint against a principal administrative officer, dean, or equivalent division head shall be resolved by the President on an ad hoc basis in a manner that replicates these procedures as nearly as possible. Complaints against student organizations shall be resolved as prescribed by the Vice President and Dean for Campus Life.
II. Students
Complaints against students, (including post-doctoral fellows and house staff) shall be resolved under the conduct code provided by that student's school or college (unless the student's school or college conduct code provide otherwise). Any initial investigation of a complaint against a student shall be conducted by the Associate Vice President for Equal Opportunity Programs, or his/her designee, who shall report his/her findings and recommendations to the Vice President and Dean for Campus Life and the dean of the school or college in which the student is enrolled.
III. The Panels
There shall be a standing panel elected as hereinafter provided consisting of not fewer than 40 members. There shall be four categories of members: category A — faculty; category B — students; category C — non-faculty employees; category D — other. Each category shall have not fewer than 10 members. Category A shall be elected in the same numbers and manner as provided for elected faculty members of the University Senate in the bylaws of the University Senate; category B shall be elected annually by the members of the Student Government Association, in consultation with the Graduate Student Senate and College Council, in a manner that assures that there is at least one student from every division of the University and at least one post-graduate student; category C shall be elected annually by the members of the Employee Council from among its own membership; category D shall be selected by the Associate Vice President for Equal Opportunity Programs on an ad hoc basis but shall include at least one post-doctoral fellow and two or more residents. All members of the standing panel shall be educated about the policies and procedures concerning discriminatory harassment by the Office of the Associate Vice President for Equal Opportunity Programs.
A hearing panel, as hereafter provided, shall consist of five persons randomly selected by the dean or equivalent division head of the unit of the respondent until there are three persons of the same category, at least one of whom is from the same school, college, or division as the respondent and two persons of the category, at least one of whom is from the same school, college, or division, of the complainant. Any member of the standing panel who has participated in any earlier stage of the case or who is likely to be a witness shall be disqualified and another member of the standing panel meeting the above qualifications shall be randomly selected. Any member of the standing panel who is unavailable or unable to serve on the particular case shall be replaced by the next randomly selected person who meets the category qualifications and is not otherwise disqualified. In the event that an inadequate number of the standing panel is qualified and available to hear the case, the President of the University Senate may select an additional person(s) in category A, the President of the Student Government Associate may select an additional person(s) in category B, and the President of the Employee Council may select an additional person(s) in category C, meeting the category requirements, on an ad hoc basis.
Individuals who are principal administrative officers, deans, equivalent division heads, personnel of the division of Human Resources, the Office of the General Counsel, and members of the Senate Committee on Faculty Relationships shall be ineligible to serve on the standing panel or any hearing panel.
IV. General Procedures
A. Formal Complaint
A formal complaint shall be initiated by signing a formal complaint and delivering it to the Associate Vice President for Equal Opportunity Programs. If the complaint is oral, it shall be reduced to writing by the recipient of the complaint and signed by the complainant. A formal complaint may be received by any dean, associate dean, assistant dean, a hospital CEO or associate or assistant director, a division head or associate or assistant division head or any member of the professional staff of the Office of the Associate Vice President for Equal Opportunity Programs. At the time of filing a formal complaint, the complainant shall be advised in writing by the Associate Vice President for Equal Opportunity Programs of the informal alternatives available. In the event that the complaint is initiated by one other than an alleged victim, the alleged victim shall be immediately notified and counseled by the Equal Opportunity Programs office on his/her options (e.g. mediation, attempts at informal resolution). If the alleged victim declines to participate in the process, the complaint may be dismissed, but in accordance with applicable law, the Associate Vice President may recommend to the appropriate dean any action s/he, in consultation with University Counsel, deems necessary to protect the University community or the legal interests of the University. A complainant or alleged victim may, at any stage of the procedure, have present a lay advisor of his/her own choosing from the University community who shall provide moral support, but shall not be an active participant in the proceeding. A lay advisor may be any person.
A formal complaint must be initiated within 180 days of any event contended to violate the policy. However this shall not restrict evidence or consideration of conduct which may have occurred prior to the 180 day period.
B. Preliminary Investigation
Upon receipt of a formal complaint, the Associate Vice President for Equal Opportunity Programs will, within thirty days, investigate the circumstances involved in the allegations. At any time during the formal process, the dean or equivalent division head of the unit of the University to which respondent is assigned may take interim emergency action (not involving reduction of compensation) until the conclusion of the proceedings.
In the event the Associate Vice President for Equal Opportunity Programs determines that attempts at mediation or other efforts to resolve the matter informally should be attempted, s/he shall seek such a resolution and the time periods provided for herein shall be suspended. The Associate Vice President for Equal Opportunity Programs may at his/her own initiative at any stage of the process and shall, if the complainant requests following dismissal of a complaint, consult with the General Counsel of the University.
At the conclusion of the investigation, but not more than thirty days from the filing of the complaint, the Associate Vice President for Equal Opportunity Programs shall inform the complainant and respondent, in writing, or his/her decision. If the decision is that a hearing is warranted, the hearing panel, as described above, shall be formed within five working days of the decision.
C. Hearing
The hearing panel shall elect a Chairperson from among the three persons of the respondent's category who shall convene the panel within 3 working days to hear all witnesses and other evidence presented by the complainant, the respondent, any alleged victim or victims who are identified and available, the Associate Vice President for Equal Opportunity Programs and any other interested party whom the hearing panel requests to testify.
All hearings shall be closed and shall be tape recorded and the tapes indexed to permit, as easily as practicable, location of specific testimony. No party shall be represented by legal counsel during the hearing. The respondent and complainant shall each be entitled to be present at all stages of the hearing (other than deliberations of the hearing panel) and also to have present a lay advisor from the University community to provide moral support. Both the respondent and the complainant shall have the right to ask questions of all witnesses. This right may not be delegated to the lay advisor. In the interest of fairness and order the Chairperson of the hearing panel shall have the right to limit and direct questions by the parties. All witnesses before the hearing panel shall have the right to be accompanied by a lay advisor from the University community to provide moral support while presenting evidence to the hearing panel.
Except as specified herein, the hearing panel shall determine its own procedures. Panel members shall have the right to question witnesses freely. Rules of evidence in the courts shall not apply. All decisions of the hearing panel shall be by majority vote. The University will provide the complainant, respondent and the panel with reasonable access to University records pertinent to the allegations made, consistent with applicable law. The reasonableness and pertinence of the request for records will be determined by University Counsel.
The complainant shall have the obligation to establish that it is more likely than not that the respondent has violated the policy against discriminatory harassment. The hearing panel shall review the evidence from the point of view of a reasonable person in the position of the complainant. At any stage of the proceedings, the hearing panel may seek clarification from a member of the professional staff of the Office of the General Counsel or from the Office of the Associate Vice President for Equal Opportunity Programs. During the hearing, a member of the professional staff of the Office of the General Counsel shall be present if reasonably available and requested by the hearing panel, but will not participate except to provide advice to the hearing panel when directly and specifically requested by one or more members.
D. Report
Within 10 working days of the close of the evidence, the hearing panel shall make a written report, including findings and recommendations, and to include any recommended sanctions, to the dean or equivalent division head of the school, college, or division to which the respondent is assigned. Copies of the findings and recommendations will be furnished to the Associate Vice President for Equal Opportunity Programs, the complainant and the respondent. Names of witnesses and other information which may be protected by law (e.g., grade roles) shall not be included in, or shall be obliterated from, the copies of the findings and recommendations sent to complainant and respondent. The hearing panel Chairperson shall consult with the Office of General Counsel regarding such legal requirements.
In the event that the hearing panel recommends that the charges be dismissed. The complainant may, within three working days of receipt of the findings and recommendations, request that the hearing panel consult with the General Counsel of the University regarding the procedures and outcome.
The hearing panel shall so consult and determine whether its findings or recommendations should be reconsidered.
E. Decision
Prior to making a decision, the dean or equivalent division head or his/her designee may request further investigation or clarification from the hearing panel, conciliation by the Associate Vice President for Equal Opportunity Programs, or any third party deemed appropriate. The dean or division head or his/her designee will make the decision promptly (i.e., not more than three working days from receipt of the recommendation which time shall be suspended during further investigation or conciliation, but in no event longer than ten working days), including any appropriate sanction, which will be communicated in writing to the hearing panel, the Associate Vice President for Equal Opportunity Programs, the complainant and the respondent. Decision of the dean or division head may vary from the findings and recommendation of the hearing panel; however, the recommendation of the hearing panel shall be presumptively appropriate and any deviation therefrom shall be explained in the writing.
The complainant may, within five working days of being advised of the decision, deliver to the decision maker a written request for reconsideration which shall specify the basis therefor with particularity. Grounds for reconsideration shall be limited to material irregularities or inappropriateness of the sanction or lack thereof. The decision maker shall consider such request as promptly as possible, but in no event more than three working days, and render his/her final decision, which shall be communicated as above.
F. Miscellaneous
The respondent shall have a right of review from the decision of the dean or division head. Procedures for review are hereafter provided in the Supplementary Procedures.
At any stage of the proceedings, the complainant may abandon the formal procedure and seek informal resolution. If this occurs, the formal procedure may be discontinued or suspended. Reinstitution of the formal procedure shall require a written request of the complainant delivered to the Associate Vice President for Equal Opportunity Programs. Such request must be made within a reasonable time.
When a time limit is specified in these procedures, the hearing panel shall have the power to set a different time limit when necessary.
Supplemental Procedures (Faculty)
Where a faculty member is suspended, transferred, or terminated by the dean or division head, the faculty member shall have a right of review by the Senate Committee on Faculty Relationships in accordance with paragraph 13 of the Statement of Principles Governing Faculty Relationships. The faculty member shall within seven working days of receipt of the decision of the dean or division head, advise the Provost in writing of his or her request for such review. The provisions of paragraph 13 shall thereafter apply.
Where a sanction other than suspension, transfer or termination is imposed, the faculty member may, within seven working days of receipt of the decision of the dean or division head, file a written request for review with the Provost which request shall specify the basis therefor. Such review shall be limited to a determination of whether any material procedural defects existed in the process and/or in appropriateness of the sanction. If a material procedural defect is found, the Provost shall return the case to the stage of the proceeding at which the defect existed or may request that the entire case be reheard. If an inappropriate sanction is found, the Provost may modify the sanction, but shall consider the recommendation of the hearing panel presumptively valid. The decision of the Provost shall be final unless s/he shall impose a sanction then subject to review pursuant to paragraph 13 of the Statement of Principles.
Supplemental Procedures (Non-Faculty)
Within seven working days from receipt of the decision, the respondent may seek review of the decision by the immediate superior of the dean or division head. The request for review shall be in writing and state the basis therefor. Grounds for review shall be limited to material procedural defects in the process and/or inappropriateness of the sanction. If a material procedural defect is found the reviewing administrator shall return the case to the stage of the proceedings at which the defect existed or may request that the entire case be reheard. If an inappropriate sanction is found, the reviewing administrator may modify the action, but shall consider the recommendation of the hearing panel presumptively appropriate. The decision of the reviewing administrator shall be final.
The use of the phrase "division head" in these procedures and supplementary procedures as applicable to persons other than faculty shall mean the University administrator whose immediate superior is the Vice President for Academic Affairs, the Vice President for Health Affairs, or the Executive Vice President.
Appendix D – MOONLIGHTING
Request to Moonlight at a facility outside the Grady Healthcare system or
EMORY HEALTHCARE
·
I submit this request to be
approved to moonlight during the period __________________
(The period may not be longer than
six months);
·
I agree to have a signed
contract to moonlight at ____________________________(Name of hospital(s) or
other facility). The contract must state
that the facility will provide professional liability insurance coverage with
respect to the services that I provide during my moonlighting assignment or
that I have my own personal professional liability insurance to cover this
moonlighting.
·
I am fully licensed to
practice medicine in the state where the moonlighting will occur;
·
I am NOT in training on a
J-1 visa;
·
I agree NOT to wear
anything identifying me as a trainee in the Emory training program (including, but not
limited, to Emory photo ID cards, uniforms, lab coats);
·
I agree not to exceed any
restrictions the training program has regarding the total number of hours I may
work per week;
·
I acknowledge any
activities, including moonlighting, which interfere with residency training or
impact on my performance in the training program may be grounds for
disciplinary action up to and including my dismissal from the residency
program;
By
signing below, I attest to the completeness and accuracy of the above
information.
___________
Signature
of resident requesting permission to moonlight Date
_____________________________________________
Print name of resident/ PGY
Request
for moonlighting is is not (circle one) approved
______________________________________
____________
Signature of Program
Director Date
Request to Moonlight in the EMORY HEALTHCARE system
·
I submit this request to be
approved to moonlight during the period__________________
(The period may not be longer than
six months);
· I agree to have a valid contract to moonlight at______________________( Name of Emory Healthcare facility). The contract must state that the facility will provide professional liability insurance coverage with respect to the services that I provide during my moonlighting assignment.
·
I am fully licensed to
practice medicine in the state where the moonlighting will occur;
·
I am NOT in training on a
J-1 visa;
·
I agree not to exceed any
restrictions the training program has regarding the total number of hours I may
work per week;
·
I acknowledge any
activities, including moonlighting, which interfere with residency training or impact on my performance in the training
program may be grounds for discipline up to and including my dismissal from the
residency program;
·
I understand I may moonlight
only in outpatient settings or in the Emergency Department;
By
signing below, I attest to the completeness and accuracy of the above
information.
_____________________________________________ ____________
Signature
of resident requesting permission to moonlight Date
___________________________________________
Print name of resident/ PGY
Request
for moonlighting is is not (circle one) approved
____________________________________________ ______________
Signature
of Program Director Date
APPENDIX E
EMORY RESIDENTS
PROFESSIONAL &
GENERAL LIABILITY INSURANCE
Insurance Company: Clifton Casualty Insurance Company Ltd.
Policy No.: 1-00001-HE 2003
Limits: Professional
Liability: $5,000,000 per claim
General
Liability: $1,000,000 per claim
Policy
Aggregate: Unlimited
Type: Claims Made
Policy Period: 09/01/04-09/01/05
Conditions: Coverage
applies only when residents are acting within the course and scope of their
duties as outlined by the Emory University Residency Training Program.
Other Info: Questions
regarding Emory insurance coverage verification should be directed to Cheryl
France, Director of Insurance and Loss Control Programs, at 404-778-7939. Verification of coverage must be requested in
writing to Emory Healthcare, Office of Risk and Insurance Services,
Requests for individual
claims history information should be made in writing to Emory Healthcare,
Office of Risk and Insurance Services,