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ResidentManual
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Bluefield Regional Medical Center
Osteopathic Graduate M...
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House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
House Staff Manual - Bluefield Regional Medical Center
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Transcript of "House Staff Manual - Bluefield Regional Medical Center"

  1. 1. Effective 2/15/10 ResidentManual Lastprinted 1/30/2015 2:38:00 AM Bluefield Regional Medical Center Osteopathic Graduate Medical Education House Staff Policy & Procedure Manual Document Owner(s) Project/Organization Role Signature Ronnie Martin,DO,FACOFP-dist Director of Medical Education Resident Manual Version Control Versio n Date Author Change Description 1 08/24/07 Dawn Stull New 2 10/2/07 Dawn Stull Updated 3 8/11/08 Dawn Stull Revised 5.2 4 12/17/08 Dawn Stull Revised 4.1 5 2/15/10 Dr. Martin Reviewed and Revised Note The content of a manual does not constitute nor should it be construed as a promise of employment or as a contract between Bluefield Regional Medical Center and any of its employees. Bluefield Regional Medical Center at its option, may change, delete, suspend, or discontinue parts or the policy in its entirety, at any time without prior notice. OMNEE is a proud sponsor of the Bluefield Regional Medical Center.
  2. 2. House Staff Policy & Procedure Manual Effective 02/15/10 Page 2 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. TABLE OF CONTENTS 1 INTRODUCTION ............................................................................................................8 1.1Welcome......................................................................................................................9 1.2 Changes in Policy .................................................................................................9 2 APPOINTMENT ............................................................................................................11 2.1 Eligibility and Selection ......................................................................................11 2.2 Resident Contract ..............................................................................................12 2.3 Educational Stipend ...........................................................................................14 2.4 Re-Appointment and Issuance of New Contracts ...................................................15 2.5 Non-Renewal of Contract/Appointment ...............................................................16 2.6 Completion of Training.......................................................................................17 2.7 Program Closure or Reduction.............................................................................18 2.8 Restrictive Covenants .........................................................................................18 2.9 Visa Policies & Procedures for Foreign/US Medical School Graduates......................18 3 EMPLOYMENT POLICIES .............................................................................................20 3.1 Equal Employment Opportunity/Diversity ...........................................................20 3.2 Americans with Disabilities Act ...........................................................................20 3.3 Employee Background Check ..............................................................................20 3.4 Pre-Employment Evaluation................................................................................20 3.5 Post Enrollment Requirements: Years 1:4 ..............................................................22 3.6 Criminal Records................................................................................................23 3.7 Controlled Substance (DEA)................................................................................23 3.8 Physician Impairment & Substance Abuse ............................................................24 3.9 Licensure...........................................................................................................25 3.10 Certificates ........................................................................................................26 3.11 Change of Personal Data .....................................................................................26
  3. 3. House Staff Policy & Procedure Manual Effective 02/15/10 Page 3 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 3.12 Chain of Communication ....................................................................................27 3.13 Safety................................................................................................................27 3.14 Personal Property...............................................................................................27 3.15 Professional Activities Outside the Program .........................................................27 3.16 Visitors in the Workplace....................................................................................28 3.17 Weather-related and Emergency-related Closings .................................................28 4 DISCIPLINARY PROCESS .............................................................................................30 4.1 Performance ......................................................................................................30 4.2 Summary Suspension..........................................................................................33 4.3 Automatic Suspension ........................................................................................33 4.4 Resident Appeals Process ....................................................................................34 4.5 Grievance and Due Process Procedure..................................................................37 4.6 Maintaining Discipline among Patients, Nurses and Employees ..............................42 5 STANDARDS OF CONDUCT..........................................................................................44 5.1 General Guidelines .............................................................................................44 5.2 Duty Hours and Work Load Limitations ...............................................................44 5.3 On-Call Activities...............................................................................................47 5.4 Absence from Duty and Unscheduled Absence .....................................................48 5.5 Harassment Policy..............................................................................................48 5.6 Sexual Harassment Policy ...................................................................................49 5.7 Violence in the Workplace ..................................................................................49 5.8 Confidential Information and Nondisclosure ........................................................49 5.9 Ethical Standards ...............................................................................................50 5.10 Dress Code ........................................................................................................50 5.11 Use of Equipment...............................................................................................51 5.12 Use of Computer, Phone, and Mail.......................................................................51
  4. 4. House Staff Policy & Procedure Manual Effective 02/15/10 Page 4 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 5.13 Use of Internet and Email ...................................................................................52 5.14 Use of Computer Software...................................................................................53 5.15 Smoking Policy ..................................................................................................53 5.16 Alcohol and Substance Abuse ..............................................................................53 5.17 Subpoenas, Claims, & Other Requests ..................................................................54 5.18 Disputes between Residents & Medical Supervisors ...............................................54 5.19 Corporate Communications ................................................................................55 5.20 Corporate Compliance ........................................................................................55 5.21 Obligation to Treat.............................................................................................55 5.22 Moonlighting.....................................................................................................56 5.23 Departing Residents ...........................................................................................57 5.24 Hospital Property ...............................................................................................57 6 RESPONSIBILITIES OF RESIDENT, FACULTY, ADMINISTRATION, STUDENTS AND OTHER STAKEHOLDERS ....................................................................................................58 6.1 Faculty ..............................................................................................................58 6.2 Program Director ...............................................................................................58 6.3 Osteopathic Graduate Medical Education Committee............................................59 6.4 Administrative ...................................................................................................60 6.5 Director of Medical Education .............................................................................61 7 COMPENSATION/INSURANCE POLICIES ....................................................................65 7.1 Payroll/Stipend ..................................................................................................65 7.2 Auxiliary Benefits ...............................................................................................66 7.3 Insurance ..........................................................................................................67 7.4 Relocation .........................................................................................................68 7.5 Housing ............................................................................................................68 7.6 Malpractice Insurance ........................................................................................68
  5. 5. House Staff Policy & Procedure Manual Effective 02/15/10 Page 5 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 7.7 Timekeeping Procedures.....................................................................................69 8 TIME-OFF BENEFITS ....................................................................................................70 8.1 Vacation Time ...................................................................................................70 8.2 Family Medical Leave .........................................................................................71 8.3 Maternity/Paternity Leave...................................................................................72 8.4 Extended Leave of Absence .................................................................................72 8.5 Bereavement Leave.............................................................................................73 8.6 Sick Leave..........................................................................................................74 8.7 Military Reserves or National Guard Leaves of Absence..........................................75 8.8 Jury Duty...........................................................................................................75 8.9 Professional Leave of Absence .............................................................................75 8.10 Additional Benefit & Leave Considerations ...........................................................76 9 INSTITUTIONAL POLICIES ..........................................................................................77 9.1 Policy & Procedure Manuals ................................................................................77 9.2 Communicable Diseases .....................................................................................78 9.3 Reporting Requirements for Communicable Diseases ............................................78 9.4 Advocacy Efforts ................................................................................................78 10 EVALUATIONS .............................................................................................................80 10.1 Evaluation of Faculty ..........................................................................................80 10.2 Evaluation of Resident’s Performance...................................................................80 10.3 Evaluation of Training Programs..........................................................................82 11 MEDICAL RECORDS.....................................................................................................83 11.1 Guidelines for Use of Medical Records..................................................................83 11.2 Guidelines for Documentation in the Medical Record ............................................83 11.3 Medical Record Completion Guidelines ................................................................84 11.4 Protected Health Information..............................................................................85
  6. 6. House Staff Policy & Procedure Manual Effective 02/15/10 Page 6 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 11.5 Medical Staff Rules & Regulations ........................................................................86 11.6 Physician’s Orders ..............................................................................................86 11.7 Service to In-patients..........................................................................................87 12 INSTITUTIONAL RESOURCES ......................................................................................88 12.1 Blood Bank ........................................................................................................88 12.2 Child Protection Program ...................................................................................89 12.3 Employee Health Service.....................................................................................89 12.4 Employee Assistance ..........................................................................................90 12.5 Nursing Department...........................................................................................90 12.6 Nutrition Services...............................................................................................91 12.7 Pharmacy ..........................................................................................................92 12.8 Security.............................................................................................................93 12.9 Rehabilitation Services........................................................................................93 12.10 Social Work .......................................................................................................94 12.11 Communications/Information Services ................................................................94 12.12 Transport of Patients ..........................................................................................95 12.13 Paging System....................................................................................................95 13 RESIDENT RESOURCES................................................................................................97 13.1 Conferences, Rounds, Lectures ............................................................................97 13.2 Resident Participation on Hospital Committees ....................................................97 13.3 Computer Use and Support .................................................................................97 13.4 Food Services................................................................................................... 100 13.5 Interpreter Services .......................................................................................... 100 13.6 Library Facilities............................................................................................... 101 13.7 Out Rotations, Housing and Meals..................................................................... 101 13.8 On-Call Rooms ................................................................................................ 101
  7. 7. House Staff Policy & Procedure Manual Effective 02/15/10 Page 7 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 13.9 Uniforms & Laundry ......................................................................................... 101 14 UNIVERSAL PRECAUTIONS ....................................................................................... 103 14.1 Basic Elements of BSI........................................................................................ 103 14.2 Nurses & Other Direct Care Providers Role in BSI System .................................... 104 14.3 Precautions for Patients with Airborne Diseases .................................................. 105 14.4 Supplies Needed for BSI.................................................................................... 107 14.5 Other BSI Procedures ....................................................................................... 108 15 EMPLOYEE COMMUNICATIONS................................................................................ 109 15.1 Open Communication ...................................................................................... 109 15.2 House Staff Meetings........................................................................................ 109 15.3 Bulletin Boards ................................................................................................ 109 15.4 Suggestions ..................................................................................................... 110 15.5 Closing Statement ............................................................................................ 110 16 ACKNOWLEDGMENT................................................................................................. 111 17 APPENDICES .............................................................................................................. 112 17.1 Approved Abbreviations ................................................................................... 112 17.2 Non-Approved Abbreviations ............................................................................ 112 17.3 Communicable Diseases ................................................................................... 112 17.4 Directory......................................................................................................... 112 17.5 Resident Contract ............................................................................................ 112 17.6 Clearance Sheet................................................................................................ 112
  8. 8. House Staff Policy & Procedure Manual Effective 02/15/10 Page 8 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 1 INTRODUCTION This document has been developed by the Department of Medical Education in order to familiarize house staff with Bluefield Regional Medical Center and provide information about working conditions, key policies, procedures, and benefits affecting employment at Bluefield Regional Medical Center. Throughout this Osteopathic Graduate Medical Education House Staff Policy & Procedure Manual (herein referred to as “Manual”), the terms “Resident,” “House Officer” and “House Staff” refer to Residents and to Interns unless specifically noted to apply to only one group of OGME trainee’s and their terms intern and resident are interchangeable, with policies and procedures that apply to one apply to the other unless specifically noted. In addition, OGME-1 refers to both Interns and first year Residents. Residents have an obligation to the patient care program of the institution and to the effectiveness of the educational program to which they have been appointed. The primary purpose of the program is to advance the medical competency, knowledge and skills of the trainee with a goal of excellence in the graduates of the program. The most important criterion for the performance of duty and evaluation of the Intern or Resident is the performance of their patient care and educational functions in a professional manner. Professionalism includes placing the needs of the patient central to all actions, knowledge of and the ability to apply up-to-date and scientifically valid knowledge and skills for the benefit of the patient, honesty in action, word and deed, integrity and adherence to ethical standards and practices, individual responsibility, timely response to obligations, adherence to policy and procedures of the program, respect for self and others, and compassion in your care of patients and interactions with colleagues and peers. The proper discharge of the responsibilities of the Intern or Resident, as a professional, requires their fulltime effort and attention while on duty. All Residents shall remain within the Hospital as required by their duty hours and patient care responsibilities and shall be immediately available if on call. The Director of Medical Education (DME) and Program Directors have the
  9. 9. House Staff Policy & Procedure Manual Effective 02/15/10 Page 9 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. responsibility and authority at all times to assure the Interns’ or Residents’ effectiveness in the programs. As part of the Bluefield Regional Medical Center, the Osteopathic Graduate Medical Education Program is a component of a long established community hospital and shares its mission to integrate its educational program with the mission of the hospital to provide access to the highest quality medical care for the sick and injured, to advance knowledge regarding the cause, prevention and treatment of disease and disability, and to educate men and women in the healing professions. 1.1 Welcome Welcome to Bluefield Regional Medical Center! We are happy to have you as a new member of our family! The mission of Bluefield Regional Medical Center is: Our Mission: Bluefield Regional Medical Center exists to provide our community with caring, quality healthcare at home. Our Vision:  BRMC is a financially viable, efficient and effective healthcare provider earning the trust and confidence of our community.  BRMC is the first choice for healthcare services, providing an appropriate range of services, quality physicians and technology to meet the majority of the healthcare needs at home.  BRMC meets the expectation for healthcare excellence in our community, eliminating the need to leave home except for highly specialized care.  BRMC is the provider of choice for physicians and the employer of choice for healthcare workers.  BRMC is an important contributor to the quality of life in our community. 1.2 Changes in Policy This manual supersedes all previous residency manuals and memos. While every effort is made to keep the contents of this document current,
  10. 10. House Staff Policy & Procedure Manual Effective 02/15/10 Page 10 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. Bluefield Regional Medical Center at its option, may modify, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the Resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department as well as on the Medical Education website (www.brmcgme.org) and in New Innovations. Any changes in this manual shall apply to existing as well as to future Residents. Bluefield Regional Medical Center reserves the right to modify, suspend, or terminate any of the policies, procedures, and/or benefits described in the manual with or without prior notice to employees. Top of the Document
  11. 11. House Staff Policy & Procedure Manual Effective 02/15/10 Page 11 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 2 APPOINTMENT Purpose of this manual: The information contained in this Manual is presented for the benefit of the Residents of Bluefield Regional Medical Center (BRMC). The intent of this Manual is to provide and direct the Resident to necessary information concerning the policies, procedures and practices of BRMC. Bluefield Regional Medical Center reserves the right to revise, withdraw, suspend or discontinue its policies, procedures and practices at any time. Except as may be set forth in the sections below, referred to as Grievance Procedures, Corrective Action/Appeal Process, Summary Suspension, Automatic Suspension and Resident Appeals Process and the contract of employment between BRMC and the Resident, this Manual is not intended to and does not enlarge or create any additional rights of employment. It does, however, set forth and direct the Resident to many matters that the Resident is obligated to obey or observe. In no way should this Manual be considered as the only, or final, source of information on the policies, procedures and practices of BRMC. Residents are to refer to the specific BRMC hardcopy Policies and Procedures Manual for issues concerning employment or patient care, and are encouraged to ask the DME/ADME for additional information or clarification on any such matters. 2.1 Eligibility and Selection The following is the policy of BRMC regarding the recruitment, eligibility and selection of Residents. Each applicant must file an application through the training program’s respective match process, provide three reference letters, a Dean's letter, board scores, medical school transcripts, medical school diploma; and, finally, appear for a series of interviews. A. Eligibility. Applicants must meet the following qualifications to be eligible for appointment to an AOA residency program: 1. Graduate of an AOA accredited College of Osteopathic Medicine. 2. Have successfully passed all examinations as deemed required by each training program. 3. Have a full and unrestricted license (training certificate) to practice medicine in a U.S. licensing jurisdiction.
  12. 12. House Staff Policy & Procedure Manual Effective 02/15/10 Page 12 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 4. Gain the support of the program director, DME and OGME committee after a personal interview. B. Selection. 1. Intern and Resident programs at BRMC select from among eligible applicants on the basis of their likelihood to advance the mission and vision of the hospital, their individual preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities including professionalism and integrity and other relevant qualities pertaining to OGME. 2. BRMC programs do not discriminate with regard to gender, race, age, religion, color, national origin, disability, sexual orientation or veteran status. In selecting from qualified applicants, programs participate in an organized matching program, where available, such as the Intern and Resident Matching Program (NRMP). Eligibility and Selection Top of the Document 2.2 Resident Contract Upon completion of the “match”, BRMC’s Department of Medical Education will send to the matched Residents, the institutional Resident contract. The Resident must return this contract within 30-days of issuance for the contract to become valid. In the event a resident is selected outside of the “match” during one of the “scramble periods” or based on independent application after completion of the “match”, the resident will be presented a contract upon recommendation of the DME and/or OGME Committee and shall have no more than 24 hours to return the contract or the offer may be suspended. AOA policy, which is followed by BRMC states that a Resident who breaches the Resident contract may not serve an AOA-approved residency, residency or fellowship program for a period of twelve (12) months following the date of the breach. Contract requirements must be met in full. An Intern or Resident failing to pass Complex Part II prior to the start of residency will result in a breach of the contract and immediate termination of the Resident. In the same vein, an Intern or Resident’s failure to pass COMLEX Part III prior to the start of the OGME-II year is grounds for revocation of any extended or signed
  13. 13. House Staff Policy & Procedure Manual Effective 02/15/10 Page 13 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. contract and dismissal from the program. Violation of any of the provisions of the contract by a Resident may result in disciplinary actions including but not limited to; administrative leave, suspension, loss of pay and benefits, being assigned extra call, repetition of rotations for completion of the program, the loss of credit for time or rotation previously completed in the program or removal from the program. All appointments are for one year or less, and may be renewed at the discretion of the institution, upon continued evidence of satisfactory performance and progress as a physician, compliance with program policies and procedures, recognition of professional potential upon completion and the recommendation of the program director, the DME and the OGME committee. The Resident contact shall reference: (these items shall be outlined in detail in the House Staff Policy & Procedure Manual) 1. Resident responsibilities 2. Duration of appointment 3. Financial support 4. Conditions under which living quarters, meals, laundry are provided 5. Conditions for reappointment and promotion 6. Grievance and due process procedures 7. Professional liability insurance 8. Liability coverage for claims filed after program completion 9. Health and disability insurance 10. Leave of absence policy 11. Sick leave policy 12. Policy on effects of leaves on satisfying criteria for program completion 13. Duty hours policies and procedures 14. Policy on moonlighting 15. Policy on other professional activities outside the Program Director Counseling, medical, psychological support services 16. Policy on physician impairment and substance abuse 17. Policy on sexual harassment 18. Policy closure of hospital/training programs or reduction in approved Resident positions 19. Educational requirements of the program
  14. 14. House Staff Policy & Procedure Manual Effective 02/15/10 Page 14 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 20. Administrative and record keeping requirements of the program The contract will be maintained in the individual trainee’s personnel file. Human resource policies of BRMC in many cases are applicable to residents of the training program. Employee benefits for residents may vary from those of other employee categories at BRMC as detailed and described. Resident Contract Top of the Document 2.3 Educational Stipend Each intern will be allocated a specific dollar amount as outlined in the letter of appointment to be used for educational expenses during the internship year. These dollars will not carrier over into the next academic year. Funds will be available at the start of the internship year. Will be Approved: Will NOT be Approved: Medical Textbooks Digital Camera Medical Journal Subscriptions CD Burner Computer Office Supplies PDA (Palm Pilot) Lab coat altering/dry cleaning Medical computer software Flash drives Computer printer Computer/Palm batteries Computer scanner Cell phones Medical conference registration *Airfare, hotel, meals (medical conference related) State licensing fees Board application fees AOA/ACOI/ACOFP dues Board review audio/video tapes Gas mileage (rotations, meetings) *****Educational stipends may be subject to applicable taxation***** The resident is responsible for obtaining permission to expend stipend funds in advance to ensure that the goods, services, and/or educational
  15. 15. House Staff Policy & Procedure Manual Effective 02/15/10 Page 15 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. event, qualifies for reimbursement. The resident is responsible for speaking with the Director of Medical Education prior to the purchase of such items. To be reimbursed for educational expenses, the resident must complete an “Employee Expense Form”, sign and attach the original receipt(s). Return completed form and receipts to the Medical Education Office for further processing and tracking of educational expenses. Note: Educational stipends may be subject to applicable taxation. 2.4 Re-Appointment and Issuance of New Contracts All Residency reappointment contracts carry the condition that Residents must complete their present year of training in a satisfactory manner, demonstrate satisfactory performance and progress as a resident physician, be in good standing, demonstrate compliance with program policies and procedures, gain recognition of professional potential and the recommendation of the program director, the DME and the OGME Committee. Reappointments normally occur at the beginning of the new academic year beginning July 1. In the case of a resident that is “off cycle” in the training program, reappointment may occur when all of the requirements for the previous training year are satisfactorily completed. Advancement to the next OGME level is based upon the recommendation of the Program Director of each training program and the recommendation of the DME, with conformation by the OGME committee. Contracts for the next year of training will be issued in April of each year upon satisfactory performance during the current year. Under qualifying circumstances, residencies may be extended through leave of absence, FMLA or approved extension or alteration of time. All leaves must be reported to the Program Director and the Director of Medical Education, the OGME Committee, Human Resources and the subcommittee on Residency Training of the American Osteopathic Association. All additional time taken off during residency must be made up at the end of the contract year and prior to entering or having a contract in effect for the next level of training. The following are perquisites for promotion of the Resident to the following year of training: 1. Complete all rotations with a passing grade as per rotation schedule.
  16. 16. House Staff Policy & Procedure Manual Effective 02/15/10 Page 16 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 2. ALL required administrative, record keeping, evaluation activities, including medical record obligations, case studies, presentations, case logs, rotation and faculty evaluations, annual, semi-annual and quarterly evaluations, and time logs are completed and turned in to the appropriate Director(s) of the resident’s program. 3. The resident is in good standing and has demonstrated compliance with policy and procedures of the program and the AOA and has no ongoing or unresolved disciplinary actions of professional or personal behavioral issues. 4. Evaluations demonstrate an acceptable performance for Residents at his/her academic level for advancement. 5. Successful completion of the COMLEX Step III exam prior to the start of the PGY II. 6. Complies with all standards for participation and satisfactory compliance with the training programs evaluation and didactic program per program requirements. Re-Appointment Top of the Document 2.5 Non-Renewal of Contract/Appointment If at any time a Program Director determines that an Intern or Resident is not meeting the standards of performance, compliance, personal conduct or professionalism expectations of the program, he/she may recommend non- renewal of the Resident’s appointment, or contract. Circumstances which might result in non-renewal of appointment are outlined in the Corrective Action section of this Manual. The Program Director must submit the recommendation for non-renewal in writing to the Director of Medical Education, and will include the basis on which the action is being taken. If the Director of Medical Education determines that there is sufficient reason not to renew the contract, he/she will notify the Program Director, who will so inform the Resident in writing no later than two months prior to the end of the Resident's current contract. A Resident receiving notice of non-renewal of contract/appointment may implement his/her right to due process through the Appeals Process, as presented in this Manual.
  17. 17. House Staff Policy & Procedure Manual Effective 02/15/10 Page 17 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 2.6 Completion of Training Before departing BRMC at the conclusion of your internship or residency training, you must complete obligations to your Program Director and also to the institution. An official clearance sheet must be completed and turned into the Department of Medical Education Director along with your ID badge. This form can be obtained from the Medical Education office. It will show evidence of your completed medical records, and that you have returned all hospital property such as keys, equipment, parking pass, radiation dosimeter, keys, scrubs, etc. The form also requests a forwarding address, and reminds you of your right to continuing health insurance coverage through COBRA. BRMC’s official certificates of completion are presented to departing residents by the Director of Medical Education. BRMC is justified in withholding such certificate if the Resident fails to complete the residency program or if the Resident’s performance has been such as to indicate that the Resident is not yet prepared for the practice of medicine or if in the opinion of the program director, the DME and the OGME committee, the resident has failed to demonstrate the appropriate ethical and professional traits required or the professional potential for the practice of osteopathic medicine. In the event of the Resident’s withdrawal from training prior to completion of the requirements of the program, or in the incidence of a resident with a administrative or voluntarily leave of absence resulting in failure to complete the program, the Hospital may properly issue a certificate to include the period of training completed or arrange for additional training at a later date to complete the training. In cases of early termination of a Resident contract, the DME shall provide the Resident with documentation regarding which rotations, if any, were completed satisfactorily. In cases of early termination or unsatisfactory completion of a Resident contract, the AOA Postdoctoral Division must be promptly notified and the terminated contract submitted to the AOA. If the resident is accepted into another resident training program, that program’s DME has the authority to determine which, if any, rotations from previous AOA-approved programs will be accepted for advanced standing. A checklist of graduation requirements must be completed prior to issuing a final paycheck and graduation certificate. This will be sent to the Resident during the last six-weeks of training.
  18. 18. House Staff Policy & Procedure Manual Effective 02/15/10 Page 18 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 2.7 Program Closure or Reduction If BRMC finds it necessary to reduce the size of, or close a residency program, the institution will inform the Residents as soon as the decision has been finalized. In the event of such a required reduction or closure, the institution will make every effort to allow Residents already in the program to complete their education. If any Residents are displaced by the closure of a program or a reduction in the number of Residents, the institution will make every effort to assist the Residents in identifying a program in which they can continue their education. 1. The training institution will immediately notify the AOA, its OPTI and its trainees of a program closure or reduction in positions, which would impact trainees prior to program completion. 2. If BRMC reduces in size or closes a program, every attempt will be made to permit the current Residents enrolled in the program to complete their training prior to such an action. 3. In the event of the hospital or program closure or reduction in positions which, would impact trainees prior to program completion, BRMC will immediately notify the OPTI to aid in placement of the enrolled Residents in other AOA approved programs within that OPTI structure. Severance pay shall be provided for two months if institutional program closure or reduction decisions prevent the Residents from having the opportunity for program completion at BRMC or another geographically proximate program arranged by the institution and/or the OPTI. Top of the Document 2.8 Restrictive Covenants BRMC strictly prohibits the request for any Resident to sign non- competition guarantees. 2.9 Visa Policies & Procedures for Foreign/US Medical School Graduates It is policy of BRMC to comply with the immigration laws of the United States, and all Residents must obtain and maintain an immigration status that permits employment by the Hospital in a clinical capacity if applicable.
  19. 19. House Staff Policy & Procedure Manual Effective 02/15/10 Page 19 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. All offers of employment are contingent on verification of the candidate’s right to work in the United States. On the first day of work, every new employee will be asked to provide original documents verifying his or her right to work and, as required by federal law, to sign Federal Form I-9, Employment Eligibility Verification Form. Top of the Document
  20. 20. House Staff Policy & Procedure Manual Effective 02/15/10 Page 20 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 3 EMPLOYMENT POLICIES 3.1 Equal Employment Opportunity/Diversity BRMC is committed to diversity that will build on the strengths of our current workforce and continually enhance the diversity of our organization. Members from the Medical Education Committee will attend a number of hospital days throughout the year. All Resident candidates are encouraged to apply for the residency program through the National Resident Matching Program. Bluefield Regional Medical Center is an equal opportunity employer and does not discriminate on race, color, citizenship status, national origin, ancestry, gender, sexual orientation, age, weight, religion, creed, physical or mental disability, marital status, veteran status, political affiliation, or any other factor protected by law. 3.2 Americans with Disabilities Act It is the policy of BRMC to comply with all the relevant and applicable provisions of the Americans with Disabilities Act (ADA). BRMC will not discriminate against any qualified employee or job applicant with respect to any terms, privileges, or conditions of employment because of a person’s physical or mental disability. 3.3 Employee Background Check Prior to making an offer of employment, BRMC may conduct a job-related background check. A comprehensive background check may consist of prior employment verification, professional reference checks, education confirmation, and criminal check. Refer to BRMC Human Resource Policy & Procedure Manual. 3.4 Pre-Employment Evaluation All employees of BRMC are required to pass a pre-employment physical. Arrangements for a pre-employment physical will be scheduled during the week of orientation. Record of immunizations and other health information will be maintained in the Employee Health Record. BRMC is commitment to the health and safety of its employees, as well as its patients. This includes the assurance of a drug and alcohol-free work
  21. 21. House Staff Policy & Procedure Manual Effective 02/15/10 Page 21 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. environment. The Hospital has, therefore, implemented a substance abuse policy that applies to all BRMC employees, making mandatory drug screening a regular part of the pre-employment physical. Any refusal of a Resident to complete, or failure to satisfactorily pass this screening will be turned over to the Committee of Impaired Physicians for review. The pre-employment examination will include a urine drug screen and a blood alcohol test. Residents are required to take an annual TB test and as often as requested by the institution. Prior to starting residency training, residents are required to provide evidence of vaccination, immunity, or proof of medical/religious exemption. Immunizations to include the following:  Rubeola (measles): If born before 1957, documentation of one (1) measles vaccination and a recent titer (within one (1) year of matriculation) showing sufficient levels of measles antibodies. If born after 1957, documentation of two (2) live measles vaccination or one (1) after 1979 measles vaccination and recent titer within 1 year.  Rubella: Proof of immunity by laboratory evidence or recent immunization documented.  Mumps: Documentary evidence of immunization or proof of immunity by laboratory evidence. History of the disease is not acceptable.  Polio: Documentary evidence of immunization.  Tetanus/diphtheria: Date of last vaccination. If none in the past ten (10) years, then vaccination is needed.  Herpes Zoster (Chickenpox): Evidence of vaccination or a titer performed within one year demonstrating immunity.  Tuberculosis: Results of an annual tuberculin skin test within six months prior to matriculation and yearly thereafter. Every new employee is required to have a physical examination provided by the hospital. Employment will be conditional dependent on the results of the physical. Physician trainees may be required to submit to periodic medical tests when warranted by the hospital during employment.
  22. 22. House Staff Policy & Procedure Manual Effective 02/15/10 Page 22 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 3.5 Post Enrollment Requirements: Years 1:4  Hepatitis B: All physicians in training should be immunized (series of three {3} injections against hepatitis b virus) or provide serologic proof of immunity (titer) as part of their preparation for clinical work. Anyone electing not to take the hepatitis b vaccine will be required to sign an informed denial form on a yearly basis.  Tuberculosis: Yearly results of tuberculin skin test. Monitoring Requirement: 1. Written proof of required immunizations must be documented through the use of health care monitoring form prior to or at the time of enrollment of new, transferring or visiting trainees. A copy of the official immunization records that document certain immunizations may be attached to the form. Please do not send originals. 2. A yearly statement of results of the tuberculin skin test signed by a physician or other appropriate health care provider only, will be accepted. 3. Any trainee electing not to receive hepatitis b vaccine must sign a hepatitis b informed denial statement. 4. Immunization requirements may be waived if medical or other appropriate documentation prohibits vaccination. 5. The immunization status of all physicians in training will be confidentially stored and monitored. Release of information will be at the individual’s consent and/or as required by the other community and clinical teaching hospitals/sites. 6. It shall be the responsibility of the trainee to notify the Director of Medical Education in the event of exposure to or having been diagnosed with a communicable disease, which could pose risks to patients. Failure to Comply with this policy will result in the individual being withheld from clinical activity, possible suspension and could result in dismissal from the program. Drug and Alcohol Testing: It is the policy of BRMC to balance the need to provide a safe environment for physicians, employees and patients with a willingness to assist physicians, employees and patients who are working to
  23. 23. House Staff Policy & Procedure Manual Effective 02/15/10 Page 23 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. overcome chemical dependency problems. The unlawful use, possession, distribution, dispensation, manufacture, sale or transportation of controlled substances or alcohol is strictly prohibited at BRMC. BRMC will require all residents to pass a post offer physical, which includes a urine drug screen and a blood alcohol test. A licensed lab off-site will perform post offer tests. In addition, BRMC will require all physician trainees to be tested for controlled substances and/or alcohol whenever there is reasonable suspicion of a violation of this policy. Reasonable suspicion tests will be performed in the ER at BRMC.  Residents with chemical dependency problems will be encouraged to seek appropriate treatment for these problems, and the appropriate leave will be provided. Residents returning to duty from a leave of absence related to chemical dependency problem will be required to sign a return-to-work agreement providing for random drug and/or alcohol tests. 3.6 Criminal Records When appropriate, a criminal record check is performed to protect BRMC’s interest and that of its employees and clients.  All BRMC entities conduct criminal background checks on all final candidates for employment. The results of criminal background checks may take several weeks to be processed. Residents are permitted to begin work before the results are received. In the event that a disqualifying conviction is returned on a Resident, he/she will be subject to separation from the Hospital and terminated from the Residency Program. This separation will occur even if the Resident has successfully completed some period of the residency program before the results are received. The Resident’s contract will then become Null and Void. Criminal Records Top of the Document 3.7 Controlled Substance (DEA) Controlled Substance Licensure: Each Intern and Resident must have a Drug Enforcement Administration (DEA) Controlled Substance Registration Number. A temporary DEA number, which is issued to each Resident by the Hospital and terminates at
  24. 24. House Staff Policy & Procedure Manual Effective 02/15/10 Page 24 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. the conclusion of the Resident’s training, is a combination of the Hospital DEA and the Resident's unique alphanumeric suffix. Federal law mandates that use of this temporary DEA is strictly limited to the care of patients served by Residents in the medical center or one of the medical center’s owned clinics and as part of their training program. During orientation, each Resident will sign two (2) Prescription Signature Verification cards before the temporary DEA number can be used. The numbers will be kept on file in the Department of Pharmacy Services. To obtain a permanent DEA number, contact the Drug Enforcement Administration in Washington D.C., at (202) 633-1000. Prescribing Controlled Substances over the Telephone: It is the policy of BRMC and it training programs that under no circumstances shall a Resident prescribe or refill controlled substances over the telephone for any patient. The appropriate response to a telephone request for controlled substances from anyone claiming to be the patient of a BRMC attending physician is as follows: 1. Take the patient’s name and phone number, and the name of the patient’s attending physician; 2. Call the attending physician with the information; and 3. Let the attending physician instruct you on how to respond to the request. Controlled Substance (DEA) Top of the Document 3.8 Physician Impairment & Substance Abuse To provide a safe environment, BRMC Resident’s have a responsibility to report to work in a fit condition. In keeping with federal drug-free regulations, BRMC is committed to a drug and alcohol free work environment. As a health care provider, we are aware of our responsibility to our patients, visitors, employees, and medical staff to ensure that our facilities are drug and alcohol free. Therefore, the use, sale, purchases, negotiation of sale, manufacture, distribution, dispensation or possession of illegal drugs or the abuse of legal drugs and alcohol is prohibited. This policy is designed to ensure a drug and alcohol free work environment while protecting the privacy of employees and applicants with respect to personal health information. Residents are required to meet the Hospital’s requirements as defined in Human Resources Policy and Procedure.
  25. 25. House Staff Policy & Procedure Manual Effective 02/15/10 Page 25 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. Fitness for Duty – A confidential and mandatory referral for evaluation process, which evaluates an employee’s ability to perform his/her job functions when changes which negatively impact his/her work performance, are demonstrated. Fit employees are those physically and mentally able to perform the standards required of his/her position. Types of impairment covered by Fitness for Duty include: 1. Psychological Impairment. Significant changes in behaviors and/or psychological state. This may include but not be limited to: threats of harm against self or others, destruction of property or threats of destruction, dramatic mood swings, explosive anger or acting-out behaviors, extreme disclosure of personal information, and disorganized thoughts. 2. Physical Impairment. Significant changes in physical ability to perform job duties and meet the physical standards that impact current job responsibilities. They may include, but are not limited to, diminished ability to walk, lift, climb, operate equipment, see, hear, or any physical deterioration that compromises and Resident’s ability to perform his/her job. Refer to Medical Staff Bylaws. 3.9 Licensure An individual pursuing a residency in the State of West Virginia must be licensed by the State of West Virginia Medical Board. The individual may either hold a Certificate (permanent license) to practice medicine and surgery in West Virginia, or apply to the Board for a Training Certificate (temporary license). The Medical Education office will provide the necessary application forms for the Training Certificate and will pay the filing fee for the Training Certificate. A Training Certificate is valid only for a period of one year, but may be renewed annually for a maximum of five years. The Training Certificate allows Residents to follow the schedule of prescribed services, rotations, and clinical activities that have been issued by their Program Directors. Please be advised of the following limitations regarding temporary licensure: A Resident without a permanent license cannot “moonlight.” All OGME-1 residents are prohibited from “moonlighting”
  26. 26. House Staff Policy & Procedure Manual Effective 02/15/10 Page 26 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. Permanent licensure can be initiated by contacting the Medicine Board of West Virginia Board of Medicine (304) 558-2921. The Office of Medical Education must be kept informed of any change in licensure status. Fees related to permanent licensure are the sole responsibility of the residents. Licensure Top of the Document 3.10 Certificates Each Intern or Resident, at the completion of service, will receive a certificate certifying that the Resident has successfully completed all the requirements set forth by the American Osteopathic Association, the OGME Committee, Faculty, Administration of BRMC and the appropriate college of each specialty training program. The Hospital is justified in holding such a certificate back if the Resident fails to satisfactorily complete the internship, residency or fellowship program requirements including compliance with all policies and procedures, completion of all educational and administrative requirements and demonstration of professional potential consistent with an osteopathic physician in the opinion of the OGME committee. Under no circumstances will the hospital arbitrarily refuse to issue such a certificate. In the event of illness or other conditions necessitating the Resident’s withdrawal or absence from the training resulting in failure to complete fully the requirements of the program, the hospital may properly issue a certificate to include the period of training completed or arrange for additional training at a later date to complete the training. The certificate of completion will include: Name of Institution Name of OPTI Resident’s Name Dates of Completion (start/end) Type of program Signatures of Institution, OPTI, Program Director & DME Top of the Document 3.11 Change of Personal Data It is the responsibility of each Resident to ensure that their contact information is current and report any changes in name, address, email or phone number to the Department of Medical Education and their respective residency training program in a timely manner. Contact for
  27. 27. House Staff Policy & Procedure Manual Effective 02/15/10 Page 27 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. patient care requirements, efficient distribution of W-2 forms, benefits information, and other important hospital mailings is dependent upon the data an employee has provided and timely submission of reimbursement items as well as end-of-year tax information. 3.12 Chain of Communication Residents shall follow the “Chain of Communication” policy of Bluefield Regional Medical Center (Hospital’s Policy and Procedure Manual). When necessary the CEO presides over all areas and is the final step in the chain of command. When issues/problems occur, the Residents should contact/speak with: 1. Attending or Faculty Physician 2. Program Director 3. Director of Medical Education 4. Chairperson of OGME Committee 5. Vice President of appropriate area 6. CEO 3.13 Safety BRMC strives to provide its employees, patients, and visitors with a safe and healthy environment. Should conditions or hazards be identified that pose an immediate threat to life, health or safety, the situation must be immediately and appropriately addressed and report to the Safety Officer at extension 1567. 3.14 Personal Property BRMC assumes no risk for any loss of or damage to personal property and recommends that all employees have personal insurance policies covering the loss of personal property left in the Department of Medical Education. 3.15 Professional Activities Outside the Program Residents may be required to attend educational programs based on the Residency Program’s requirements.
  28. 28. House Staff Policy & Procedure Manual Effective 02/15/10 Page 28 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. Residents may be required to participate in health delivery activities organized and supervised by BRMC as a component of their training requirements. Top of the Document 3.16 Visitors in the Workplace For safety, insurance, and other business considerations, only authorized visitors are allowed in the workplace. When making arrangements for visitors, employees should request that visitors enter through the main reception area and sign in. The hours and regulations for visiting are published and given to all patients. Recommendations for individual exceptions to the regulations should be made to the Nursing Supervisor. Family members or personal relationships of the resident should not be in the hospital except for brief periods of visitation such as meal time or break time while the resident is on duty or in the hospital except as a patient. Under no circumstance should the individual spend the night at the hospital with the resident or should the hospital serve as the location for supervision or care of children, parents or other members of a resident’s family. Residents have the obligation to discuss and answer questions about a patient’s condition only with those who have a legal right to know consistent with HIPPA regulations and standards for patient privacy and security. Information concerning a patient is privileged and confidential and should not be divulged to anyone except individuals specifically designated by the patient. Non-designated friends, relatives and visitors are not entitled to such information, but their inquiries must be handled in a friendly and tactful manner. Top of the Document 3.17 Weather-related and Emergency-related Closings At times, emergencies such as severe weather, fires, or power failures can disrupt company operations. In such instances, Executive Staff will decide on the closure and Human Resources will provide the official notification to the employees. Residents should plan to be present in the hospital unless personally notified by the program director or DME in the event of an
  29. 29. House Staff Policy & Procedure Manual Effective 02/15/10 Page 29 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. emergency to ensure that medical care is available to the patients of the hospital and community. Assistance in reaching the hospital will be provided in the event travel is not possible or not advised. Top of the Document
  30. 30. House Staff Policy & Procedure Manual Effective 02/15/10 Page 30 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. 4 DISCIPLINARY PROCESS 4.1 Performance At any time during the Residency Training Program, the Residency Program Director, or Director of Medical Education may determine that the Resident is not meeting the standards of the program or the profession, for reasons that may include, but are not limited to: 1. Lack of professional competence, insufficient medical knowledge, or technical skills needed to carry out their duties and responsibilities; 2. Lack of professional potential to meet the requirements of a competent osteopathic physician; 3. Demonstration of a lack professionalism or the ethical conduct expected of an osteopathic resident and/or physician; 4. Any conduct that is detrimental or potentially detrimental to BRMC patients or employees; 5. Demonstrated inability to work with others or behavior that is reasonably likely to be disruptive to the function of the graduate medical education program or Hospital operations; 6. Violations of criminal or civil law that would place the hospital in disrepute, or issues of moral turpitude; 7. Activities or professional conduct that are reasonably likely to be in violation of the Medical Staff Bylaws, Medical Staff Rules and Regulations, Violation of policies and procedures of the graduate education program or any other Hospital policies and procedures; and, If the Residency Program Director or Director of Medical Education believes that corrective action is warranted, he/she may do one or more of the following: 1. A written reprimand will either be given to or mailed to the Resident, and a copy will be placed in the Resident's file. 2. If a remedial program is required, the Resident shall be so informed in a meeting with the Residency Program Director or the Director of Medical Education. At that meeting, the Resident's deficiencies will be identified, a remedial program will be established, and a time frame for completion of the remedial program will be discussed and documented.
  31. 31. House Staff Policy & Procedure Manual Effective 02/15/10 Page 31 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. A copy of this document will be given to the Resident, and a copy will be placed in the Resident's file. The remedial plan may include, but is not limited to, limitations or restrictions on the amount and level of the Resident's patient care activities or requirements for supervision, repetition of educational programs or rotation, requirements for outside educational programs or courses, psychological evaluations and therapy each at the residents expense. Such action may necessitate extension of the Resident's educational program. At the end of the remedial period, the Resident evaluation and outcomes will be reviewed by the program director and DME. At that time, the Residency Program Director or Director of Medical Education may or may not take further corrective action. 3. Recommend Leave of Absence, Suspension or Dismissal of the Resident. The Residency Program Director or Director of Medical Education/ may recommend an administrative Leave of Absence, temporary Suspension, or Dismissal of the Resident. An Administrative Leave of Absence may be with or without pay. Suspension shall be without pay. Such recommendation will be made in writing, accompanied by any written documents necessary to support the recommendation, and will be filed with the Director of Medical Education. The recommendation will include a time frame for a Leave of Absence or Suspension. The Director of Medical Education, or his designee, will convene an Initial Review Panel within 10 calendar days of the recommended action, which will include the Director of Medical Education (who will chair the Panel), the Residency Program Director (or representative), and representatives of the Legal and Human Resources departments of the hospital. Prior to the meeting, the Panel Chair will review the submitted documents, and determine a list of individuals who the Panel may wish to interview. These individuals will be notified to be available in the event the Panel wants to interview them. The Panel will present its findings to the Director of Medical Education, who will promptly issue a decision on the recommendation for Leave of Absence, Suspension or Dismissal of the Resident. In the event the Director of Medical Education upholds such recommendation, the action shall become effective immediately. During the period of Suspension without pay, or Leave of Absence without pay, the Resident will not receive any cash, or other compensation. Health-related benefits will continue if the Resident elects to pay for them directly. In all cases of Suspension or Leave of Absence, the Resident will not be permitted any Hospital privileges,
  32. 32. House Staff Policy & Procedure Manual Effective 02/15/10 Page 32 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. nor be permitted to attend Conferences or Rounds. The period of Leave of Absence or Suspension will result in an extension of the Resident’s educational program. In the event the Director of Medical Education rejects the recommendation, and the Director of Medical Education imposes no other sanction or action, the record of the event will be expunged from the Resident’s file. 4. Recommend non-renewal of the Resident’s contract. If a Residency Program Director determines that a Resident is not meeting the standards of the program or the profession, he/she may make a recommendation for non-renewal of the Resident’s contract. The recommendation must be submitted in writing to the Director of Medical Education, and will include the basis on which the action is being taken, along with any written documents necessary to support the recommendation. All written information regarding the recommendation will become part of the Resident’s file. If the Director of Medical Education/ determines that there is sufficient reason not to renew the contract, he/she will notify the Program Director, who will so inform the Resident in writing. Recommendations for non-renewal should be made no later than two months prior to the end of the Resident’s current contract. If the primary reason(s) for non-renewal occur(s) within the two months prior to the end of the current contract, the program will provide the Resident as much written notice of the non-renewal as circumstances will reasonably allow. A Resident receiving notice of non-renewal of contract may implement his/her right to due process through the Appeals Process, as presented in this Manual. In the event the Director of Medical Education rejects a recommendation for non-renewal of contract, the Resident’s contract will be renewed for the following year. 5. No appeal is available when the action is to reprimand or institute a remedial program for the Resident. A decision to impose a leave of absence, suspend, dismiss, or fail to renew the Resident’s contract shall entitle the affected Resident to the Appeals Process contained in this Manual. Where a Resident receives notice of a corrective action under the terms in this House Staff Policy & Procedure Manual, inclusive of any amendments to this Manual that are in effect on the date of receipt of the notice, this Manual shall govern, irrespective of any later amendments or revisions to the Manual.
  33. 33. House Staff Policy & Procedure Manual Effective 02/15/10 Page 33 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. Revised: 01/30/10 Performance Top of the Document 4.2 Summary Suspension The Residency Program Director, OGME Committee or Director of Medical Education shall have the authority, whenever action must be taken immediately in the best interest of patient care, personal safety or the danger of damage to the reputation, operations or personnel of the Hospital, to summarily suspend all or any portion of the privileges of a Resident, and such summary suspension shall become effective immediately upon imposition. At the discretion of the Director of Medical Education, such suspensions may be with or without pay depending on the allegations and the facts and status of any applicable investigation. The Director of Medical Education will convene an Initial Review Panel within 10 calendar days of the suspension. The Panel will include the Director of Medical Education (who will Chair the Panel); the Director of Human Resources, the Residency Program Director (or representative); the Clinical Department Chairman (or representative); and a representative of Human Resources. The Panel may request an interview with the suspended Resident. Whoever summarily suspended the Resident will provide written documents necessary to support the recommendation. The panel will decide whether to reverse, modify, or sustain the Summary Suspension. A Resident who has been summarily suspended shall be entitled to all of the rights provided in the Appeals Process contained in this Manual. 4.3 Automatic Suspension A suspension of a Resident shall be imposed automatically if action by the West Virginia Medical Board results in revocation or suspension of the Resident’s license or temporary certificate. Such automatic suspension shall become effective immediately upon action by the West Virginia Medical Board. During the suspension, the Resident will be on “unpaid leave status” and, in order to continue employee benefits, including health benefits, will need to pay the premium directly since, in the absence of a paycheck, deduction of that premium is not possible. If the license or temporary certificate is reinstated, the Resident may apply for readmission into the program. If readmission into the program is denied, the Resident is entitled to all the rights provided in the Appeals Process contained in this Manual.
  34. 34. House Staff Policy & Procedure Manual Effective 02/15/10 Page 34 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. Top of the Document 4.4 Resident Appeals Process A. Whenever a Corrective Action that can be appealed (Leave of Absence, Suspension, Summary Suspension, Dismissal, Failure to Renew Contract, Failure to be Re-accepted into Program after Termination of Automatic Suspension) is imposed on a Resident, the Residency Training Director or Director of Medical Education shall provide written notification to the Resident, either in person or by certified mail, return receipt requested, of the Corrective Action. Such notice shall contain a specific statement of the grounds for such Corrective Action and shall refer to the Resident’s right of appeal as set forth below. B. To appeal a Corrective Action, the Resident must submit, within ten (10) calendar days after receiving such notice, a written request either in person or by certified mail, return receipt requested to the Director of Medical Education/ for a hearing before an Appeals Committee. No electronic requests will be accepted. C. Upon receipt of a written request for a hearing, the Director of Medical Education shall appoint an Appeals Committee consisting of seven individuals, five of whom will have a vote. The Director of Medical Education will Chair the committee, have voice but no vote. If the Resident requesting the Appeal Hearing is from the same Department as the Director of Medical Education, the Vice President of Medical Affairs or his/her designee will function as the Chair. The voting members will include: a. An Resident who is a member of the Medical Education Committee or a Chief Resident from a Clinical Department different from that of the Resident requesting the Appeal Hearing; b. One Residency Program Director from a different Departments than that of the Resident requesting the Appeal Hearing; c. A representative from Human Resources; and, d. Two Medical Staff Members from a different Clinical Department than that of the Resident requesting the Appeal Hearing and that of the Program Director on the Committee.
  35. 35. House Staff Policy & Procedure Manual Effective 02/15/10 Page 35 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. The non-voting members will be: a. The Director of Medical Education; and, b. A Resident, from a different Department, at a similar level of training as the Resident who filed the Appeal. The non-voting Resident member may participate in all aspects of the deliberations prior to the vote. D. The Director of Medical Education will appoint a Secretary, who will keep minutes of the meeting. The Director of Medical Education, or his/her designee, will determine the date, time, and place of the meeting. E. No later than ten (10) business days after receipt of the Resident's request for a hearing, the Director of Medical Education or his/her designee, shall notify the Resident by certified mail, return receipt requested, of the date, time, and place of the hearing. F. The appeal hearing for a Resident who is under suspension shall be held as soon as the arrangements may reasonably be made, but not later than forty-five (45) calendar days from the date of receipt of the residents request for a hearing, unless extended by mutual consent. G. From the date upon which the Director of Medical Education receives the Resident's request for a hearing until the date of the hearing, the Residency Program Director or Director of Medical Education, or his/her designee, shall permit the Resident, upon his/her request, to examine and duplicate any written materials that relate in any way to the suspension, termination, or corrective action. No later than ten (10) business days prior to the scheduled hearing date, the parties shall provide each other with a list of witnesses that each intends to call at the hearing. A maximum of 3 witnesses each may be called by the Resident and by the Program Director to appear in person. An unlimited number of witnesses, however, may be called by the Appeals Committee or submit written testimonials for review by the Appeals Committee. H. At the hearing, the Resident's personal presence is required. The Resident may be aided or represented by another Resident in the Hospital's graduate Medical Education program or by a member of the Hospital's Medical Staff. None of the parties to the appeal shall be aided or represented at this hearing by an attorney.
  36. 36. House Staff Policy & Procedure Manual Effective 02/15/10 Page 36 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. I. At the hearing, both the Residency program Director and the Resident may make opening statements. The Residency Program Director shall then present his/her case supporting the corrective action. The Resident shall then present his/her case opposing such suspension, termination, or corrective action. Both the Residency Program Director or Director of Medical Education and the Residents may make closing arguments. Opening and closing statements by each of the parties shall be limited to no more than 15 minutes in duration and cause presentation by each of the parties shall not exceed 60 minutes in length. Testimony of each witness shall not exceed 30 minutes in duration. J. At the hearing, both the Residency Program Director and the Resident may present written evidence, examine witnesses, and cross-examine witnesses. The Rules of Evidence that govern proceedings in a court of law shall not apply and the ruling of the chairperson shall prevail during the healing. K. Within five (5) business days after the hearing, the Committee Chair (i.e., the Director of Medical Education or V.P. or Medical Staff) shall prepare and send to both the Residency Training Director (or Director of Medical Education in the event of a intern or member of the DME’s clinical department) and the Resident, by certified mail, return, receipt requested; a written decision which shall affirm, modify or reverse the Resident's corrective action. This decision shall be by a majority vote of the Committee's members and shall be based solely upon the written and oral evidence presented by the Residency Training Director and the Resident at the hearing. The Director of Medical Education shall receive a copy of the written decision. L. The decision of the Committee shall be final and binding upon both the Residency Program Director or Director of Medical Education and the Resident. M. A Resident who has been suspended or dismissed from the Hospital's Medical Education Program, and who has instituted an appeal as provided herein, may resume clinical practice only if recommended in writing by the Appeals Committee. N. The Resident's failure to exercise any right provided by the Appeals Process shall constitute an irrevocable waiver of such right. Resident Physician Appeals Process Top of the
  37. 37. House Staff Policy & Procedure Manual Effective 02/15/10 Page 37 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. Document 4.5 Grievance and Due Process Procedure The following Grievance Procedure is available to all Residents who are members of the Resident Staff and Graduate Medical Education Department of BRMC. It is not applicable to Residents from other affiliated institutions that are on rotation at BRMC. A. Complaint procedures are established to protect the integrity and the maintenance of educational standards, the integrity of the hospital, public safety and the rights of the resident. B. To provide a mechanism for concerned individuals or organizations to bring to the attention of the accrediting agency information concerning specific actions and programs that may be in noncompliance with the AOA’s educational standards. C. To recognize the responsibility of the AOA to provide responsible complainants the opportunity to use the AOA as a vehicle to address specific grievances. 1. Grievances. If a Resident has reason to believe that established Hospital policies and procedures including applicable personnel policies (with the exception of any action, policy, practice or procedure connected with the periodic evaluation of Resident, corrective action or appeals, as set forth in this Resident Manual) have been denied him/her or have been erroneously applied to him/her, or if a Resident has a problem (collectively, hereinafter a “Grievance”) with any employee of the Hospital, any member of the Hospital’s Medical Staff, or any other individual affiliated or associated with the Resident’s residency training program, the following procedure has been established for the discussion and resolution of such a Grievance. 2. Meeting with the Administrative Director of Medical Education. Make an appointment to discuss the Grievance with the Administrative Director of Medical Education (“ADME”). The ADME will explain the established policies and procedures to assist the Resident in determining whether a formal Grievance should be filed. The Resident shall maintain authority over the final decision as to whether a Grievance exists and/or whether a formal Grievance should be filed. 3. Filing Grievance Notice. If, after discussing the Grievance with the ADME, the Resident believes that a Grievance exists, then the Resident must submit a written notice (the “Grievance Notice”)
  38. 38. House Staff Policy & Procedure Manual Effective 02/15/10 Page 38 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. of the Grievance to the ADME and the Resident’s respective Program Director. All Grievance Notices must be set forth in reasonable and sufficient detail an explanation of the Resident’s Grievance. All Grievance Notices must be properly filed by the respective Resident no later than (30) calendar days after the Resident discusses the Grievance with the ADME. 4. Form of Filing and Disclosure of Grievance. A properly filed Grievance Notice is one that is either: (1) personally delivered by the Resident to each of the appropriate parties and for which the Resident obtained a time stamped copy (reflecting the date and time of delivery of the Grievance Notice) from each party to whom the Resident personally delivered the Grievance Notice; or (2) mailed by certified mail, return receipt requested to each appropriate party. The ADME may provide copies of all Grievance Notices to the following individuals: (1) the Resident’s Program Director; (2) the DME; and (3) the Director of Human Resources. 5. Filing Grievance Notice with Alternate Parties and Chiefs of Staff. If due to the nature of the Grievance, the Resident reasonably believes that it would be inappropriate to file the Grievance Notice with the Program Director, then the Resident shall so inform the ADME who shall then instruct the Resident to file the Grievance Notice to the Director of Medical Education. In lieu of filing the Grievance Notice with the ADME or Program Director, the Resident may, for good cause, file the Grievance Notice directly to the Director of Medical Education. “Good cause” shall be determined by the Director of Medical Education in his/her sole discretion and he/she reserves the right to redirect the Resident to the file the Grievance with any other party deemed appropriate by the Director of Medical Education. 6. Discussion with the Program Director. If the Resident filed the Grievance Notice with his/her respective Program Director pursuant to Step 3, above, then the Resident and the Program Director shall meet to discuss the Grievance. Unless the Resident otherwise agrees, such meeting shall occur no later than five (5) business days after the Program Director’s receipt of the Grievance Notice. If the Resident chooses, the ADME may accompany him/her to this meeting to assist in the discussion of the Grievance. The Program Director shall reply in writing to the Resident’s Grievance within five (5) business days after their meeting. 7. Program Director Grievance Review. At any time before, during or after a Resident meets with his/her respective Program
  39. 39. House Staff Policy & Procedure Manual Effective 02/15/10 Page 39 Version 5 Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future residents. Director, such Program Director may request the Resident to submit the names of two other Residents from his/her service whom the Program Director may want to ask about the Grievance or specific aspects thereof. In addition, the Program Director may ask the Resident’s respective Chief Resident to answer questions relating to the Grievance and/or to be present at any meeting pertaining to the Resident’s Grievance. In the event the Grievance concerns an incident that is not directly related to the Resident’s training program, the Program Director may request the Resident to submit the names of two Hospital employees who witnessed the incident. If a person identified as a witness leaves the employ of the Hospital prior to resolution of the Grievance, that person shall nevertheless be recognized and accorded an opportunity to be heard during the Grievance Process set forth herein, provided that such person left the Hospital in good standing. 8. Follow-Up after Discussion with the Program Director: Filing of Continuation Notice. If the Resident is not satisfied with the Program Director’s resolution, and desires to follow through on the Grievance to the next step, the Resident shall meet with the ADME. The ADME will help the Resident with a further review of the Grievance to enable the Resident to make an appropriate decision whether to pursue his/her Grievance. If the Resident desires to pursue the Grievance, then he/she shall file a written notice (the “Continuation Notice”) that he or she wishes to continue to pursue the Grievance. This Continuation Notice may include a restatement of the Grievance Notice, but it must also further expand or explain the Resident’s reasons for continuing to pursue the Grievance. This Continuation Notice must be filed with the ADME within thirty (30) calendar days after the Program Director issues his/her written resolution. 9. Discussion with the Director of Medical Education. After a Resident meets with his/her respective Program Director, if the Resident desires to pursue the Grievance, then he/she shall meet with the Director of Medical Education. Unless the Resident otherwise agrees, such meeting shall occur no later than five (5) business days after the Director of Medical Education’s receipt of the Grievance Notice. If the Resident chooses, the ADME may accompany him/her to this meeting to assist in the discussion of the Grievance. The Director of Medical Education shall reply in writing to the Resident’s Grievance within five (5) business days after their meeting.

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