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SECTION ONE – SELECTION/PROMOTION PROCESS

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SECTION ONE – SELECTION/PROMOTION PROCESS

  1. 1. Interventional Cardiology Policies UMDNJ ROBERT WOOD JOHNSON MEDICAL SCHOOL DIVISION OF CARDIOVASCULAR DISEASES & HYPERTENSION INTERVENTIONAL CARDIOLOGY FELLOWSHIP GRADUATE MEDICAL EDUCATION POLICY AND PROCEDURE MANUAL July 2004 ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL Abel E. Moreyra, MD Interventional Cardiology Program Director -1-
  2. 2. UMDNJ ROBERT WOOD JOHNSON MEDICAL SCHOOL DIVISION OF CARDIOVASCULAR DISEASES & HYPERTENSION INTERVENTIONAL CARDIOLOGY FELLOWSHIP POLICY & PROCEDURE MANUAL July 2004 (REVISED 2/23/2004)
  3. 3. Interventional Cardiology Policies University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School Interventional Cardiology Program Policy and Procedures (Section Numbering corresponds to RWJMS GME Policy Manual) SECTION ONE – SELECTION/PROMOTION PROCESS.........................................................................................3 POLICY I.1: SELECTION OF INTERVENTIONAL CARDIOLOGY RESIDENT..............................................3 POLICY I.2: PERFORMANCE EVALUATION ....................................................................................................7 POLICY I.3: ACADEMIC EVALUATION OF INTERVENTIONAL CARDIOLOGY RESIDENTS ................8 POLICY I.4: TERMINATION OF APPOINTMENT............................................................................................12 SECTION THREE – WORK SCHEDULES...............................................................................................................14 POLICY III.1: MOONLIGHTING..........................................................................................................................14 POLICY III.2: DUTY SCHEDULES .....................................................................................................................16 POLICY III.3: BACK UP .......................................................................................................................................18 SECTION FOUR – TIME OFF....................................................................................................................................19 POLICY IV.1: MEDICAL LEAVE AND FAMILY LEAVE................................................................................19 POLICY IV.2: BEREAVEMENT ..........................................................................................................................21 POLICY IV.3: HOLIDAY TIME ...........................................................................................................................22 SECTION FIVE – RESPONSIBILITIES & SUPERVISION.....................................................................................24 SECTION FIVE – RESPONSIBILITIES & SUPERVISION.....................................................................................25 POLICY V.1: DELINEATING INTERVENTIONAL CARDIOLOGY FELLOWS RESPONSIBILITIES........25 POLICY V.2: FACULTY ATTENDING SUPERVISION....................................................................................27 POLICY V.3: MEDICAL ORDERS WRITING.....................................................................................................28 POLICY V.4: NON-TEACHING PATIENTS ......................................................................................................29 SECTION SIX – GRIEVANCE PROCEDURE..........................................................................................................30 POLICY VI.1: RESOLUTION OF PROBLEMS .................................................................................................30 SECTION EIGHT – HUMAN RESOURCES/ADMINISTRATION POLICIES.......................................................32 POLICY VIII.1: EMPLOYEE ASSISTANCE PROGRAM..................................................................................32 POLICY VIII.2: PHYSICIAN IMPAIRMENT/SUBSTANCE ABUSE POLICY ..............................................35 POLICY VIII.3: SEXUAL AND OTHER TYPES OF HARASSMENT .............................................................39 POLICY VIII.2: TRAINEE IMMUNIZATIONS .................................................................................................49 section-one-selectionpromotion-process780.doc ii 2/9/2006
  4. 4. Interventional Cardiology Policies University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School Graduate Medical Education INTRODUCTION: The fundamental purpose of the postgraduate training programs at the University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School is education. The Medical School is accredited by the Liaison Committee on Medical Education (LCME) and the sponsored residency programs are accredited by the Accreditation Council on Graduate Medical Education (ACGME). The Office of Graduate Medical Education has the responsibility for responding to the ACGME mandate, “Institutions that sponsor graduate medical education programs must be appropriately organized for the conduct of such education in a scholarly environment and be committed to excellence in both medical care and education.” The Medical Education Policy and Procedure Manual was prepared to serve as a guide for the Program Director and subspecialty trainees. These guides are in response to the General Requirements of the ACGME and have been reviewed and recommended to the Dean of the Medical School for adoption by the Medical School’s Graduate Medical Education Committee. These are general descriptions of University and Medical School Policies and Procedures. They are subject to change and modifications according to University guidelines. The Graduate Medical Education Policy Manual for Robert Wood Johnson Medical School is located on the web at The Office of Policy and Project Management maintains University level policies at Policies related directly to the Department of Human Resources are located on the web at http://www.umdnj.edu/hrweb/pol.html. section-one-selectionpromotion-process780.doc 1 2/9/2006
  5. 5. Interventional Cardiology Policies University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School Institutional Commitment to Graduate Medical Education Medical education is a major component of the mission of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School. As such, our graduate medical education programs must further our mission of providing the highest quality medical care to our patients and support our mission of educating future generations of physicians to serve our community and the State of New Jersey. We hereby commit ourselves to offer graduate medical education programs in which physicians in training develop personal, clinical and professional competence under the guidance and careful supervision of our faculty and staff. The programs will assure the safe, appropriate and humane care of patients and the progression of resident physician responsibility consistent with each trainee’s demonstrated clinical experience, knowledge and skill. As faculty of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, we engage in scholarly activity, including research, and will make available to resident physicians opportunities to participate in the scholarship of our medical community. Graduate medical education programs at RWJMS will emphasize coordinated delivery of care with community orientation and will take advantage of cooperative opportunities to work with other educational institutions to fulfill mutual education roles. Marie C. Trontell, M.D. Associate Dean for Academic Affairs Chair, GME Committee Harold L. Paz, M.D. Dean, UMDNJ-RWJMS, School of Medicine Stuart D. Cook, M.D. President, UMDNJ section-one-selectionpromotion-process780.doc 2 2/9/2006
  6. 6. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL SECTION ONE – SELECTION/PROMOTION PROCESS POLICY I.1: SELECTION OF INTERVENTIONAL CARDIOLOGY RESIDENT SECTION: SELECTION PROCESS I. PURPOSE To establish guidelines for eligibility, selection, evaluation, promotion and dismissal of residents in the interventional cardiology fellowship training program. II. SCOPE This policy will apply to the postgraduate training program in Interventional Cardiology at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School. III. DEFINITIONS Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. IV. RESPONSIBILITIES/REQUIREMENTS A. Policy: 1. Eligibility for Admission to UMDNJ Fellowship Training in Interventional Cardiology Educational Requirements: a. In order to be admitted to graduate medical education programs, a candidate must have satisfied the educational requirements for registration as a resident in the State of New Jersey under the regulations promulgated by the New Jersey Board of Medical Examiners. Every medical school attended must be accredited by the Liaison Committee on Medical Education (LCME), or the American Osteopathic Association (AOA) or recognized and listed in the World Health Organization Directory of Medical Schools. (1.) For admission to the graduate medical education program as subspecialty resident (fellow) in Interventional Cardiology, the applicant must have completed an ACGME accredited cardiovascular diseases residency. The applicant is board eligible in cardiovascular diseases, as outlined by the ABIM. section-one-selectionpromotion-process780.doc 3 2/9/2006
  7. 7. Interventional Cardiology Policies (2.) For the admission to the Interventional Cardiology Fellowship (postgraduate year (PGY7), the applicant must qualify for registration/permit with the Board of Medical Examiners as defined in Board of Medical Examiners Regulation. (3.) For admission to any postgraduate year after the applicant has used up his or her five years of eligibility for registration/permit in the State of New Jersey, the applicant must have a New Jersey license. b. International Medical Graduates (IMGs) must be U.S. citizens, U.S. permanent residents or holders of J-1 Exchange Visit or visas issued by the Educational Commission on Foreign Medical Graduates (ECFMG) in order to be eligible for admission to a position in any of the University's graduate medical education programs. An eligible IMG must hold a currently valid ECFMG certificate. B. Procedure: 1. The following credentials will be collected for each candidate for an interventional cardiology resident position. a. Application blank, completed and signed b. Two letters of reference from faculty familiar with the individual's performance. One letter must be from the candidate's former Chief of Cardiology Service or Program Director. c. An ECFMG Certificate or ECFMG letter which must be verified in writing by the Program Director. All candidates should interview with the Program Director or a designee. Contracts are prepared by the Program Director and forwarded to the Office of Graduate Medical Education with a credential checklist (See Attachment 1) signed by the Chair, Program Director and accompanied by all credentials and documentation of the interview. If any of the required credentials are missing, contracts should be amended clause that states, "This contract should be amended with a cover memo". The Office of Graduate Medical Education and staff will review the contracts and supporting documents for completion and compliance and then forwards them to the Associate Dean for Academic Affairs for approval. Contracts for mailing and all original credentials will be returned to the Program Director through the Office of Graduate Medical Education. C. Interventional Cardiology Resident Selection The Interventional cardiology fellowship program selects from among eligible applicants on the basis of their preparedness, aptitude, academic credentials, personal characteristics and ability to communicate. section-one-selectionpromotion-process780.doc 4 2/9/2006
  8. 8. Interventional Cardiology Policies D. Interventional Cardiology Resident Contracts The contract for each interventional cardiology resident in a graduate medical program shall: 1. Specify the specialty and sub-specialty, where applicable, and the level or Postgraduate Year (PGY), e.g., Internal Medicine-Cardiology PGY 7, etc., and the term of the contract. 2. Have an attachment describing assigned duties including patient care and teaching, and the program's overall work schedules. 3. Specify that registration/permit/licensure requirements of the New Jersey Board of Medical Examiners must have been met as a precondition of the contract. 4. Contain an attachment defining scope of practice of registration or permit holders as per regulations of the New Jersey Board of Medical Examiners. 5. Describe benefits including vacations, professional and/or sick leave, family leave, liability insurance, health insurance and other insurance for residents and their families, and meals and laundry or their equivalent, consistent with hospital or University policies or the collective bargaining agreement between the Committee of Interns and Residents (CIR) and the University, where applicable; 6. Specify whether or not extramural employment (moonlighting) is permissible; and, where moonlighting is permissible, specify that malpractice coverage is not provided by the University for moonlighting and additionally specify that the cardiology resident must (a) have approval of the Program Director and (b) must give assurance that this activity will not interfere with the responsibilities to the residency program. 7. Have as attachments required copies of University policies. 8. Specify that compliance with the University's Cardiology Resident Immunizations and Health policy is required as a condition of the contract. section-one-selectionpromotion-process780.doc 5 2/9/2006
  9. 9. Interventional Cardiology Policies ATTACHMENT 1 APPLICANT: _______________________________________________________________ LAST FIRST M.I. CREDENTIALS CHECKLIST FOR INTERVENTIONAL CARDIOLOGY FELLOWSHIP APPOINTMENT (This form is to be attached to the front of each applicant’s folder. It shall accompany the credentials and contract being submitted for signature). U.S. Graduates Received Foreign Medical Graduates * Received Application _______ Application _______ Letters of Recommend. (2) _______ Letters of Recommend (2) _______ USMLE Scores _______ USMLE Scores _______ (Step 1 and 2 or equivalent) (Step 1 and 2 or equivalent) ECFMG Certificate or _______ ECFMG Letter Interview _______ Interview _______ * If documents are not in English, they need to be accompanied by English translation. Credentials Complete: _________________________________ Chief/Program Director Date _________________________________ Administrative Director of Date Medical Education _______________________________________________________________________________ Before hire: 1. All recent graduates need to provide a certified copy of their diploma. 2. All non-US citizens must provide proof of legal visa status. section-one-selectionpromotion-process780.doc 6 2/9/2006
  10. 10. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY I.2: PERFORMANCE EVALUATION SECTION: SELECTION/PROMOTION PROCESS I. PURPOSE To establish a general guideline within which each program can provide an interventional cardiology resident with periodic evaluations as required by the ACGME, University, CIR or RRC specific to each Program. II. SCOPE This applies to all Interventional Cardiology trainees. III. DEFINITIONS Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. IV. RESPONSIBILITIES/REQUIREMENTS A. The Interventional Cardiology Fellowship Program has in place a system of evaluation used to assess the academic performance of interventional cardiology residents on a continuing basis; this system is followed uniformly for all interventional cardiology residents in the program. This serves to enhance the education process and keep trainees apprised of their progress. Evaluations must be given bi-annually and there shall be timely feedback to interventional cardiology residents, particularly with regard to any deficiencies noted. B. The Program Director will assume responsibility for establishing the mechanism and frequency of performance evaluations in compliance with the ACGME essentials for the specific program. This is monitored through the GME internal review process. C. The Program Director will inform the interventional cardiology residents annually of the departmental procedure and schedule for performance evaluations. D. Documentation of periodic performance evaluations shall be maintained in the interventional cardiology resident’s academic record. E. In order to continue in a residency program, an interventional cardiology resident must make satisfactory academic progress as determined in accordance with the residency program’s evaluation system. F. All academic matters, including in-training exams should be considered in determining whether a cardiology resident is making satisfactory academic progress. Academic matters include acquisition of knowledge related to the discipline as well as all aspects of the development of clinical and professional skills necessary for effective functioning as a health care professional. Of particular importance as academic issues are such areas of professional development, professional ethics and maintaining professional relationships with patients and with other health care professionals, including subordinates, colleagues and superiors. G. The Program has a policy to evaluate the Interventional Cardiology Fellow each month, the faculty attendings of the Program and the Program itself. This provides a mechanism for monitoring Interventional Fellow performance, level of stress, and effective feedback from the fellow to the attendings, and will lead to incremental improvements in the Program. Examples of evaluation forms are attached to this policy. UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL section-one-selectionpromotion-process780.doc 7 2/9/2006
  11. 11. Interventional Cardiology Policies NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY I.3: ACADEMIC EVALUATION OF INTERVENTIONAL CARDIOLOGY RESIDENTS SECTION: SELECTION/PROMOTION PROCESS I. PURPOSE To establish procedures for evaluation of the academic performance of interventional cardiology residents at the University of Medicine and Dentistry of New Jersey as well as procedures for appeals of actions, including dismissal, based on such academic evaluations. II. SCOPE This policy is directed to all interventional cardiology residents. These procedures are not intended to be applicable to non-academic matters; procedures for dealing with non-academic discipline are specified in the University's contract with the Committee of Interns and Residents (CIR). However, please note that all matters that are academic in nature shall be addressed via this process even if such matters have both academic and non-academic implications. III. DEFINITIONS Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. Academic matters include acquisition of knowledge related to the discipline as well as all aspects of the development of clinical and professional skills necessary for effective functioning as a health care professional. Of particular importance as academic issues are such areas of professional development as professional ethics and maintaining professional relationships with patients, with staff members, with students and with other health care professionals including subordinates, colleagues and superiors. It should also be noted that when particular issues are of concern as both academic and employment-related, they should ordinarily be treated as academic issues. Since the academic development of residents is the paramount reason for the existence of residency programs at UMDNJ, it is incumbent upon residency program administrators and faculty to give the highest priority to and to place the strongest emphasis upon the academic significance of difficulties that interventional cardiology residents may be experiencing. IV. RESPONSIBILITY/REQUIREMENTS A. Each interventional cardiology resident (fellow) shall be continuously evaluated for his/her academic performance as follows: 1. All attending staff members who interact to a significant extent with the interventional cardiology fellow shall prepare periodical evaluations of knowledge and of clinical and professional development. Evaluation forms for this purpose are appended. Standard forms developed by the appropriate specialty board or college may be utilized for this purpose. The evaluation interval shall be established by the program and shall, at a minimum, meet accreditation standards. 2. Evaluations are to be completed at the conclusion of each rotation by the interventional cardiology fellow supervising attending, utilizing the school/department/program evaluation forms. The section-one-selectionpromotion-process780.doc 8 2/9/2006
  12. 12. Interventional Cardiology Policies evaluation will be based on: i) Appropriateness of procedure indication ii) Number of procedures performed iii) Procedural skill – including complication rates iv) Post-procedure care v) Research and scholarly activity 3. Other measures of performance to be considered in assessing academic growth include but are not limited to the following: a. Standardized examinations b. Required certifications, such as ACLS c. In-service examinations d. Quality of research, presentations, publications, etc. e. Success in achieving assigned goals, including remediation goals. 4. Personal communications between program director and faculty or other persons in a supervisory role. (In order for such communications to be used meaningfully in evaluation, oral communications must be documented, with a copy placed in the fellow's file and another copy provided to the fellow. However, documentation of such communication may occur for the first time when an evaluation form is completed.) 5. Periodic review of each fellows progress in the program by the program director in which all of the above performance measures will be discussed. B. Remediation of Academic Deficiencies. In the event that academic deficiencies are identified: 1. The program director or designee shall counsel the fellow. If a designee conducts counseling, the program director shall be informed in writing. 2. When a interventional cardiology resident is asked to attend a personal interview for the purpose of investigating his/her performance or conduct and such interview may reasonably be expected to lead to actions that could be characterized as disciplinary in nature (such as a formal letter of reprimand, a suspension or a dismissal), written or oral notice of the interview shall be given to the associate or assistant dean responsible for graduate medical education and to the CIR. A CIR representative may accompany the interventional cardiology resident to hear the matter being discussed, but may not interfere with the interview or speak. Upon determining in good faith that the matter is academic in nature, the CIR representative should leave. 3. The program director shall outline corrective measures and shall establish criteria and time frames for the correction of the deficiencies. 4. The program director shall document the above interactions with the fellow in writing, with a copy placed in the cardiology resident’s file. 5. The program director shall re-evaluate compliance with corrective actions as established earlier. 6. If performance is restored to a satisfactory level, the program director will indicate this orally to the fellow as soon as it has occurred. A written notation of this interaction will also be placed in the fellow's file, with a copy to the interventional cardiology resident. 7. If the interventional cardiology resident fails to correct the identified academic deficiencies to the satisfaction of the program director within the specified time frame, the program director may either extend the remediation period, using the same section-one-selectionpromotion-process780.doc 9 2/9/2006
  13. 13. Interventional Cardiology Policies procedures as for an initial remediation effort, or proceed with termination in accordance with the process described in the following subsection of this document. 8. For severe deficiencies warranting immediate termination, the program director may proceed in accordance with the steps outlined below. 9. Copies of all documentation regarding academic deficiencies of the interventional cardiology resident should be provided to the associate or assistant dean responsible for graduate medical education. C. Termination 1. In the event of severe academic deficiencies or failure to remedy lesser deficiencies, the program director may make the determination that the fellow should be terminated from the program. The program director should consult with a representative group from among the faculty who interact to a significant extent with the interventional cardiology resident. 2. Once the program director has made the decision to terminate the interventional cardiology resident from the program, the director shall notify the interventional cardiology resident in writing of the termination. Copies of this notice shall be provided to the associate or assistant dean responsible for graduate medical education and to the CIR. Termination shall ordinarily become effective not less than two weeks after receipt of the written notice. The notification period may be waived at the discretion of the program director if, in the judgment of the program director, continuance of the interventional cardiology resident in the program during the notice period would result in a risk of danger to patients or in a risk of other harm or damage either to the program itself or to other University personnel. The notification shall include the following: a. Reasons for dismissal b. Effective date of dismissal c. Process for appealing the dismissal D. Appeals Process 1. The interventional cardiology resident may appeal the program director's adverse academic decision to an Ad Hoc Appeal Committee, established as indicated below, or to the residency program's standing Committee on Interventional Cardiology Resident Evaluation (or its equivalent). This appeal must be made in writing to the program director within five working days of having received the notification of termination or an adverse action. 2. If the interventional cardiology resident submits a timely notice of appeal, the director shall schedule a meeting of the Residency Program Committee on the interventional cardiology resident’s evaluation or convene the Ad Hoc Appeals Committee. The Ad Hoc Appeals Committee, if created, should consist of [not fewer than five] faculty members of the division, department or group of departments responsible for the program. The faculty members selected for this purpose shall be experienced faculty in the area of graduate medical education. The number of members of the Ad Hoc Committee shall be large enough to be representative of the faculty of the division or responsible for the program. The committee considering the interventional cardiology resident's appeal should include at least one cardiology resident. 3. The interventional cardiology resident may request to meet with the Committee in person and be accompanied at the hearing by a faculty member or fellow cardiology resident who may act as an advisor. If a CIR representative has not previously determined that the matter at issue is academic, a representative of the CIR who shall not participate in the section-one-selectionpromotion-process780.doc 10 2/9/2006
  14. 14. Interventional Cardiology Policies proceedings may also accompany the interventional cardiology resident. (The CIR representative's only role in the hearing is to make a determination whether the matter under discussion is a bona fide issue of academic performance.) The program director will also be present at the hearing at which time he or she shall set forth the circumstances leading to the planned adverse action or the reasons for which the interventional cardiology resident has been dismissed. Following the presentation, the interventional cardiology resident and/or their advisor shall be permitted to set forth whatever information the interventional cardiology resident wishes the Committee to consider as reasons to vacate the decision to endorse the adverse action or to dismiss the interventional cardiology resident. 4. Following the hearing before the Committee, the Committee will immediately confer and, following deliberations, advise the Department Chair in writing of its recommendation and the reasons for that recommendation. The Department Chair shall render a decision, and the decision of the Chair shall be final. If the Department Chair is the Program Director, the decision of the Committee shall be final. This decision shall be conveyed to the interventional cardiology resident in writing. The Chair shall provide copies of the notice of adverse action or dismissal to the associate or assistant dean responsible for graduate medical education. section-one-selectionpromotion-process780.doc 11 2/9/2006
  15. 15. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY I.4: TERMINATION OF APPOINTMENT SECTION: SELECTION/PROMOTION PROCESS I. PURPOSE To provide guidelines and procedure for the voluntary and non-voluntary termination of an appointment prior to the established expiration date of the interventional cardiology resident's contract. II. SCOPE This policy is applicable to all trainees in the interventional cardiology training program. III. DEFINITIONS Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. IV. RESPONSIBILITY/REQUIREMENTS Termination of an interventional cardiology resident's appointment prior to the established expiration date may be accomplished only for good reason. A. Voluntary Termination 1. If an interventional cardiology resident desires such a termination due to personal hardship, he or she should write a letter to the Program Director and the Chair of the Department stating the reason for the request. 2. An interview may be requested. 3. Termination may be granted with the concurrence of the Chair and/or Program Director. B. Non-voluntary Termination (Dismissal) 1. Reasons for a non-voluntary termination of a interventional cardiology resident prior to the established expiration date of contract may include but is not limited to: a. Unsatisfactory performance b. Excessive absenteeism which effectively disrupts training. c. Personal conduct. 2. In accordance with both University policy and the CIR, dismissals for academic cause are not grievable. section-one-selectionpromotion-process780.doc 12 2/9/2006
  16. 16. Interventional Cardiology Policies C. The Medical School's procedure for due process regarding decisions on academic issues concerning residents is: 1. All complaints by an interventional cardiology resident regarding academic issues are to be referred to the Program Director for initial discussion. 2. If resolution of the problem cannot be achieved at this level, the issue is to be directed to the Chair of the Department within 6 working days. 3. Complaints that are not resolved by the Chair should be referred promptly to the Associate Dean for Academic Affairs as the Director of GME for final consideration. 4. In accordance with both University policy and the CIR, dismissals for academic cause are not grievable. 5. Academic decisions may be appealed by the process described in Policy I.4 of this manual (Academic Evaluation of Interventional Cardiology Resident and Procedures for Appeals of Academic Decisions.) D. An interventional cardiology resident may be disciplined or discharged for cause, however, these actions shall be grievable, and in the event the involved interventional cardiology resident files a grievance, the burden of proving just cause shall be upon the University. The University shall give five (5) working days advance notice, in writing, of any intended disciplinary action to the affected interventional cardiology resident and the CIR. The notice shall state the nature and extent of discipline, the specific charges against the interventional cardiology resident and describe the circumstance(s) upon which each charge is based. section-one-selectionpromotion-process780.doc 13 2/9/2006
  17. 17. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL SECTION THREE – WORK SCHEDULES POLICY III.1: MOONLIGHTING SECTION: WORK SCHEDULES I. PURPOSE To establish guidelines as set forth in the University Policy # 00-01-30-10:00 for outside employment while a trainee in the interventional cardiology training program. II. SCOPE This policy is directed to residents (fellows) in the interventional cardiology training program. III. DEFINITION Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. IV. RESPONSIBILITY/REQUIREMENTS A. The primary work obligation of a full-time interventional cardiology resident of the University is to the University. B. Full-time interventional cardiology residents may engage in outside employment only if the outside employment does not: 1. Constitute a conflict of interest (see University policy 00-01-10-05:00, Code of Ethics: General Conduct). 2. Occur at a time when the interventional cardiology resident is expected to perform his or her University duty; or 3. Diminish the interventional cardiology resident's efficiency in performing his or her primary work obligation at the University. C. Notice of regular or continuing outside employment of full-time interventional cardiology residents is required during the regular work year. (Such individuals will complete a Notice of Outside Employment and will follow the submission process as indicated below.) If the cardiology resident plans to engage in outside employment, they are required to receive approval of outside employment from their Program Director, Department Chair and forward the forms for final signature to the Associate Dean for Academic Affairs. D. This policy shall not apply to outside employment undertaken by an interventional cardiology resident during his or her annual leave or vacation periods, except that no such interventional cardiology resident may engage at any time in outside employment that constitutes a conflict of interest. section-one-selectionpromotion-process780.doc 14 2/9/2006
  18. 18. Interventional Cardiology Policies E. OUTSIDE EMPLOYMENT MUST BE REPORTED AS FOLLOWS: Each interventional cardiology resident must complete an Outside Employment Declaration Form whether or not he/she plans to engage in outside employment. All outside employment must be approved prior to commencing such activity. The Outside Employment Declaration Form must be forwarded to the Office of Graduate Medical Education and signed by the Program Director, Department Chair and Associate Dean for Academic Affairs. The Program Director and Department Chair shall keep copies of cardiology residents declaration forms on file. The Program Director shall forward the original form to the Office of Graduate Medical Education. F. Failure of the interventional cardiology resident’s compliance with this policy shall result in disciplinary action up to and including termination. G. Outside Employment Declaration Form (Procedure should be followed for newly hired interventional cardiology residents) 1. Newly hired/appointed interventional cardiology residents shall receive an Outside Employment Declaration form from his/her Medical Education Office during personnel processing/upon appointment. 1.The Program Director is responsible for indicating whether or not outside employment has been approved by signing the Outside Employment Declaration Forms and submitting the original forms to the appropriate Department Chair. Copies shall also be retained by the Program Director. 2.The Department Chair is responsible for signing the Outside Employment Declaration forms as an indication that he/she agrees with the Program Director and submitting the originals to the Associate Dean for Academic Affairs. 3.The Associate Dean for Academic Affairs is responsible for signing the forms as an indication that there is agreement with the Program Director and Chair and forwarding the forms to the GME office for submission to the Senior Vice President for Academic Affairs. section-one-selectionpromotion-process780.doc 15 2/9/2006
  19. 19. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY III.2: DUTY SCHEDULES SECTION: WORK SCHEDULES I. PURPOSE To provide Interventional Cardiology Fellows with a policy on the scheduling of fellows hours. II. SCOPE This policy is directed to trainees in the Interventional cardiology training program. III. DEFINITION Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. IV. RESPONSIBILITY/REQUIREMENTS A.The Program Director is responsible for duty schedules and, of necessity, must make the ultimate decisions regarding night duty scheduling. B. On-call rooms are provided by the hospital for residents with on-call responsibility. C. The on-call schedule is tailored to meet the residency requirements set by the Accreditation Council on Graduate Medical Education for each training program. It is recognized by the sponsoring institution that in-house call is an integral part of the house staff education and is to be scheduled so as to maximally enhance that educational pursuit. D. Duty Hours a. Duty hours are defined as all clinical and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. b. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities. c. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities. d. Adequate time for rest and personal activities must be provided. This will consist of a 10-hour time period provided between all daily duty periods and after in-house call. section-one-selectionpromotion-process780.doc 16 2/9/2006
  20. 20. Interventional Cardiology Policies E. On-Call Activities The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution. a. In-house call must occur no more frequently than every third night, averaged over a four-week period. b. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in Specialty and Subspecialty Program Requirements. c. No new patients, as defined in Specialty and Subspecialty Program Requirements, may be accepted after 24 hours of continuous duty. d. At-home call (pager call) is defined as call taken from outside the assigned institution. 1). The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. 2). When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit. 3). The program director and the faculty monitor the demands of at-home call in interventional cardiology and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue. F. The GME Office is sent individual departmental rotation schedules to review for compliance and to formulate monthly house staff billings. Additionally, the GMEC as part of the review process reviews Program hourly work and on-call schedules for compliance. Scheduled call that is not in compliance with this policy will be returned by the GME Office to the program director to be revised. section-one-selectionpromotion-process780.doc 17 2/9/2006
  21. 21. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY III.3: BACK UP SECTION: RESPONSIBILITIES & SUPERVISION I. PURPOSE To provide a guideline that covers the responsibility of interventional fellow in his/her absence. In case of unexpected absence II. SCOPE This policy is directed to all trainees and attendings in the Interventional Cardiology training program. III. DEFINITION Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. IV. RESPONSIBILITY/REQUIREMENTS In case a trainee is unable to report to work, the attending interventional physician or the Cardiovascular Disease fellow (Cath Lab fellow) assigned to the Cath Lab rotation will fulfill his/ her responsibilities for clinical tasks related to the invasive laboratories. The attending physician or the Cath Lab fellow will also cover inpatient and outpatient consultations related to interventional cases. section-one-selectionpromotion-process780.doc 18 2/9/2006
  22. 22. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL SECTION FOUR – TIME OFF POLICY IV.1: MEDICAL LEAVE AND FAMILY LEAVE SECTION: TIME OFF I. PURPOSE To provide guidelines for use of medical leave and family leave. II. SCOPE This policy is directed to all trainees in the Interventional Cardiology training program. III. DEFINITION Interventional Cardiology Resident - refers to all interventional cardiology residents (fellows) enrolled in a University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School postgraduate training program. IV. RESPONSIBILITY/REQUIREMENTS A. The University policies regarding medical leave and family leave, as they apply to interventional cardiology residents, shall be fairly and uniformly applied. B. Interventional Cardiology Residents must notify their Program Director if they are unable to work. Interventional Cardiology Residents are responsible for keeping their Program Director aware of their status. C. The Cardiology Division is responsible for maintaining a record of interventional cardiology resident usage of medical leave and family leave for each year. D. Sick Leave Days. Interventional Cardiology Residents will be credited with twelve (12) sick leave days at the beginning of each academic year. First year interventional cardiology residents in their initial year of appointment are not eligible to use sick time until six full months have been completed. Interventional cardiology residents can accumulate up to forty-eight (48) sick leave days. Medical leave shall be used when a interventional cardiology resident is unable to work due to illness or personal injury. Approval for use of this time shall not be unreasonably denied by the Program Director. E. Medical Leave Each Interventional cardiology resident is eligible for up to twelve weeks of medical leave (they are eligible after six months of service). An interventional cardiology resident can use any remaining allotment of his/her sick leave prior to being in an unpaid status. Once sick leave days have expired and before the interventional cardiology resident chooses to be in "leave without pay" status and apply for disability, the interventional cardiology resident shall have the option to use any remaining portion of his/her vacation days. Once paid leave days have expired, the section-one-selectionpromotion-process780.doc 19 2/9/2006
  23. 23. Interventional Cardiology Policies interventional cardiology resident would be in "leave without pay status" and eligible to apply for temporary disability. The interventional cardiology resident must provide appropriate medical documentation to his/her Program Director. Upon submission of the appropriate medical documentation, such leave shall be approved. F. Family leave 1. For Birth or Adoption of a Child All interventional cardiology residents are eligible for unpaid family leave upon the birth or adoption of a child after one year of service. This leave, in accordance with the Family Medical Leave Act and New Jersey State Law, can be up to twelve (12) weeks. An interventional cardiology resident can use paid vacation leave to cover a portion of this twelve-week period. Upon submission of appropriate documentation to the Program Director, such leave shall be approved. 2. For Serious Illness in the Family All interventional cardiology residents are eligible for unpaid family leave to take care of a seriously ill family member after one year of service in accordance with the Family Medical Leave Act and New Jersey State Law. This leave can be up to twelve (12) weeks. An interventional cardiology resident can use paid vacation leave to cover a portion of this twelve-week period. Appropriate documentation must be provided to the Program Director. Upon submission of appropriate medical documentation, such leave shall be approved. G. Impact of leave on completion of training program. If cumulative absences negatively impact the number of months of training of a cardiology resident with respect to the number of months required or number of procedures needed to satisfy the criteria for completion of the fellowship program, (see exceprt on next page) the Program Director shall assess the cardiology resident's ability to fulfill his/her residency educational obligations and may require additional training in lieu of termination. If additional training is required it may or may not be paid sepending on the current C.I.R. agreement. Excerpt from Program Requirements for Fellowship Education in Interventional Cardiology (effective 7/1/2005): XI. Educational Program B. The interventional cardiology program must be 1 year in length. C. The interventional cardiology program is accredited for 12 continuous months of clinical training. XIV. Specific Program Content B. Technical and Other Skills 1. Fellows must have formal instruction, clinical experience, and must demonstrate competence in the performance of the following: f) coronary interventions (Each fellow must perform a minimum of 250 coronary interventions, a single coronary intervention being defined as all coronary interventions performed during one hospitalization.); section-one-selectionpromotion-process780.doc 20 2/9/2006
  24. 24. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY IV.2: BEREAVEMENT SECTION: TIME OFF I. PURPOSE To establish a policy and procedure for an interventional cardiology resident's absence in the event of a death of a member of his/her immediate family. II. SCOPE This policy is directed to all trainees in the Interventional Cardiology training program. III. DEFINITION Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. Immediate Family Member is defined as a spouse, child, parent, legal guardian, sibling or parent of a spouse, or unmarried domestic partner. For unmarried domestic partners to be included, prior notice of the relationship must have been provided to the University's Office of Labor Relations. IV. RESPONSIBILITY/REQUIREMENTS A. If there is a death in the immediate family, an interventional cardiology resident may utilize sick leave for up to three (3) consecutive days of bereavement leave. The University may require reasonable and appropriate documentation of the relationship or of cohabitation, such as leases or drivers license, etc. Additional leave may be granted as may be necessary without pay upon request to the Program Director. B. The interventional cardiology resident will inform the Program Director or his/her designee of the need for his/her immediate absence. section-one-selectionpromotion-process780.doc 21 2/9/2006
  25. 25. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY IV.3: HOLIDAY TIME SECTION: TIME OFF I. PURPOSE To establish a policy and procedure for the scheduling of holiday time-off for interventional cardiology residents. II. SCOPE This policy is directed to all trainees in the Interventional Cardiology training program. III. DEFINITION Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. IV. RESPONSIBILITY/REQUIREMENTS A. Interventional Cardiology Residents are entitled to the following holidays: New Year's Day, Martin Luther King, Jr's Birthday, Good Friday, Memorial Day Observance, Independence Day Observance, Labor Day, Thanksgiving Day, Day After Thanksgiving, Christmas Day and three (3) float holidays, one of which shall be taken within (30) days of the cardiology resident's birthday, except as mutually agreed upon between the Program and the cardiology resident. B. Interventional Cardiology Residents who work (including beeper calls) on a scheduled holiday shall be granted an alternate day off during the rotation in which the holiday occurs or shall receive an additional day's pay in lieu of the holiday. (This provision does not apply to the float holidays.) Scheduling of an alternate day off shall be with the approval of the Program Director or designee as appropriate. Pay in lieu of a holiday shall be at the rate of one tenth (1/10) of a bi-weekly pay. C. Holidays falling on Saturday shall be observed the preceding Friday. Holidays falling on Sunday shall be observed the following Monday. D. The University shall inform all Program Directors and the CIR of the procedure to be followed to obtain an additional day's pay in cases where an alternate day off is not granted. Each Program Director must complete a request for Holiday pay form and submit to the Office of Graduate Medical Education for processing and payment. section-one-selectionpromotion-process780.doc 22 2/9/2006
  26. 26. Interventional Cardiology Policies section-one-selectionpromotion-process780.doc 23 2/9/2006
  27. 27. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL SECTION FIVE – RESPONSIBILITIES & SUPERVISION SUBJECT: SUPERVISION OF HOUSESTAFF I. PURPOSE To establish an institutional supervision policy to ensure all residency/fellowship training programs provide increasing amounts of responsibility with appropriate supervision for all housestaff. II. SCOPE This policy is applicable to all postgraduate training programs. III. DEFINITIONS Housestaff - refers to all interns, residents and subspecialty residents (fellows) enrolled in a UMDNJ-Robert Wood Johnson Medical School postgraduate training program. A member of the housestaff may be referred to as a house officer. IV. RESPONSIBILITY/REQUIREMENTS A. Policy: Every house officer is assigned to a designated service. On-call schedules and rotation schedules are developed on a monthly basis to provide housestaff with a variety of service and patient experiences. Back up is available at all times through more senior house officers and faculty and attending physicians. 1. It is the responsibility of the directors to establish detailed written policy describing housestaff supervision at each level for their individual residency programs on file in GME office. 2. The requirements for on-site supervision are established for and by each department in accordance with ACGME guidelines monitored through departmental reviews. 3. In all resident care cases, the ultimate responsibility rests with the attending physicians, who supervises all resident activities. The Medical School provides professional liability insurance coverage for faculty attendings engaged in teaching and supervision. Approved by GMEC 2/23/99 section-one-selectionpromotion-process780.doc 24 2/9/2006
  28. 28. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL SECTION FIVE – RESPONSIBILITIES & SUPERVISION POLICY V.1: DELINEATING INTERVENTIONAL CARDIOLOGY FELLOWS RESPONSIBILITIES SECTION: RESPONSIBILITIES & SUPERVISION I. PURPOSE To describe the division of duties and responsibilities for the Interventional Cardiology Residents as they relate to the Cardiovascular Disease Residents and the Internal Medicine house staff. II. SCOPE This policy is applicable to all Interventional Cardiology trainees. III. DEFINITIONS Interventional Cardiology Resident - refers to all interventional cardiology residents (fellows) enrolled in a University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School postgraduate training program. IV. RESPONSIBILITY/REQUIREMENTS Interventional Cardiology Fellows have primary responsibility for all interventional procedures. He or she can assign teaching cases to the medical house staff and Cardiovascular Disease Fellows. The Interventional Cardiology Fellow will work with the Cardiovascular Disease Fellow assigned to the CCU/in-patient rotation of RWJUH and will act as consultant for all necessary cardiac interventions. He or she is responsible for consultation to the medical house staff regarding procedure management problems and for the performance of therapeutic interventional procedures (e.g. angioplasty, IABP, etc.). He or she makes patient rounds and participates in teaching rounds. The Interventional Cardiology fellow gives Cardiology fellows on the invasive cardiology rotation clinical literature and review assignments. Cardiology fellows will gain arterial access and perform the diagnostic catheterization and then the Interventional Cardiology fellow will proceed with the therapeutic intervention where indicated. They make patient rounds with the Interventional Cardiology fellow before they present the patients to the faculty. They interpret the results of invasive and interventional procedures together. Interventional Cardiology Fellows actively participate in the teaching and supervision of medical students, medical house staff and Cardiovascular Disease Fellows. The Interventional Cardiology Fellow will work with the Cardiovascular Disease Fellow assigned to the CCU/in-patient rotation of RWJUH for any emergent invasive cardiac procedure. He/she is section-one-selectionpromotion-process780.doc 25 2/9/2006
  29. 29. Interventional Cardiology Policies responsible for discussing with the medical house staff regarding the intervention performed (with alternatives) and its pre- and post-interventional procedure management problems. He/she makes patient rounds and participates in teaching rounds. The Interventional Cardiology Fellow reviews cases with the Cardiovascular Disease Fellow taking the invasive cardiology rotation (Cath Lab fellow). They interpret electrocardiograms, angiograms and clinical laboratory test results of invasive and interventional cases together. For patients covered by both Internal Medicine and Cardiology services, under the supervision of a faculty member, the Cardiology fellow (floor of CCU) is responsible for the daily progress notes and physical examination of the patient. He/she makes diagnostic, therapeutic disposition and educational plans, and discusses these plans with the Medicine residents who are responsible for implementation. Plans for interventional procedures and alternatives are discussed with the Interventional Cardiology Fellow Although the Medicine residents write orders for the patients and are primarily responsible for their management, the Interventional Cardiology Fellow assumes overall responsibility for the interventional procedure-related management and for solving problems that may arise pre- and post-procedures. The Interventional Cardiology Fellow should be available for immediate consultation when the situation changes on any patient requiring a cardiac interventional procedure. section-one-selectionpromotion-process780.doc 26 2/9/2006
  30. 30. Interventional Cardiology Policies UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY V.2: FACULTY ATTENDING SUPERVISION SECTION: RESPONSIBILITIES & SUPERVISION I. PURPOSE To identify/define the responsibilities of the attending faculty. II. SCOPE This policy is applicable to all Interventional Cardiology attendings. III. DEFINITIONS Interventional Cardiology Resident - refers to all interventional cardiology residents (fellows) enrolled in a University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School postgraduate training program. IV. RESPONSIBILITY/REQUIREMENTS The Interventional Cardiology Fellow will perform the required procedure under the direct supervision of a faculty interventional cardiologist who is always present in the room and scrubbed. Reports are written by fellows and reviewed by faculty. Name of the patient, type of procedure, procedure number and date are recorded in the logbook. The name of the trainee is included in the final procedure report. The Interventional Cardiology Fellow discusses patients seen in the hospital or outpatient clinics with the full-time interventional faculty. Management decisions are reviewed and interesting problems are discussed in depth. Some may be presented by the Interventional Cardiology Fellow in conferences for discussion of their management. Interventional cardiology faculty and trainees work together as described above. In addition, there is one faculty member for invasive and interventional cardiology on call 24 hours, available for emergencies. Three additional cardiology faculty members are on call 24 hours, available for emergencies.  Faculty #1: clinical cardiology;  Faculty #2: echocardiography;  Faculty #3: electro physiology. The Interventional Cardiology Fellow consults the interventional cardiology attending for any emergency cardiac intervention and can consult with other above mentioned faculty members when needed. In all cases, the ultimate responsibility rests with the attending physicians, who supervise all interventional fellow activities. The Medical School provides professional liability insurance coverage for faculty attendings engaged in teaching and supervision. section-one-selectionpromotion-process780.doc 27 2/9/2006
  31. 31. UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY V.3: MEDICAL ORDERS WRITING SECTION: RESPONSIBILITIES & SUPERVISION I. PURPOSE To provide guidelines to Interventional Cardiology Fellows on medical orders writing. II. SCOPE This policy is directed to all trainees in the Interventional Cardiology training program. III. DEFINITION Order writing pertains to the Interventional Cardiology Fellow’s involvement in patient care. Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. IV. RESPONSIBILITY/REQUIREMENTS Although Medical Residents must write all orders for patients in the teaching service under their care the Interventional fellow assumes primary responsibility in writing the post-procedure orders. Interventional Cardiology Fellows are involved in in-patient care, admissions, and discharges, in particular managing all elective admissions for interventional cardiology procedures during their hospital stay and discharge. Orders are either written or entered into the computer system for in-patients under interventional cardiology service and consultation. If the fellow is not on the premises, telephone orders are given for emergency situations and the fellows sign these within the next 24 hours. All fellows not in possession of a valid New Jersey license must have orders countersigned by a cardiology attending.
  32. 32. UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY V.4: NON-TEACHING PATIENTS SECTION: RESPONSIBILITIES & SUPERVISION I. PURPOSE To provide guidelines that directs the Interventional Cardiology Fellow’s responsibility regarding non- teaching patients. II. SCOPE This policy is directed to all trainees in the Interventional Cardiology training program. III. DEFINITION Non-teaching patients are all patients admitted to Robert Wood Johnson University Hospital without an assigned resident. All patients admitted to the Interventional Cardiology Faculty Service are teaching patients. Interventional Cardiology Fellows may act as consultant for non-teaching patients when so required by the primary attending in emergency situations. In this case fellows may assume temporary care of the patient.
  33. 33. UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL SECTION SIX – GRIEVANCE PROCEDURE POLICY VI.1: RESOLUTION OF PROBLEMS SECTION: GRIEVANCE PROCEDURE I. PURPOSE To identify/define the due process for interventional cardiology residents seeking resolution to an individual problem. II. SCOPE This policy is applicable to all Interventional Cardiology trainees. III. DEFINITIONS Interventional Cardiology Fellow - refers to all residents (fellows) enrolled in the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School interventional cardiology training program. IV. RESPONSIBILITY/REQUIREMENTS A. Policy: Every interventional cardiology resident is a member of the bargaining unit of the Committee of Interns and Residents Union (CIR) and is required to follow the Grievance Procedure as outlined in the agreement between the University and the CIR. The purpose of this procedure is to assure prompt, fair and equitable resolution of disputes concerning terms and conditions of employment arising from the administration of this Agreement by providing the sole and exclusive vehicle set forth for adjusting and settling grievances related to non academic issues. B. Definition: A grievance is an allegation by a interventional cardiology resident that there has been: 1. A breach, misinterpretation or improper application of the terms of the CIR agreement; or 2. An improper or discriminatory application of, or failure to act pursuant to, the written rules, policies or regulations of the University or statutes to the extent that any of the above established terms and conditions of employment which are matters which intimately and directly affect the work and welfare of interventional cardiology residents and which do not significantly interfere with inherent management prerogatives pertaining to the determination of public
  34. 34. policy. C. Preliminary Informal Procedure The parties agree that all problems should be resolved, whenever possible, before filing a grievance. Interventional Cardiology Residents may orally present and discuss a grievance with his or her Program Director, or with the University's approval, an appropriate designee. The grievant may, at his or her option, request the presence of a CIR representative. D. Formal Steps 1. Step One: A grievant shall initiate his or her grievance in writing and present it formally to his or her Program Director or designee and to the University's Office of Employee Relations no later than (30) calendar days after the date on which the act which is subject of the grievance occurred or thirty (30) calendar days from the date on which the individual interventional cardiology resident should reasonably have know of its occurrence. The Program Director or designee shall meet with the grievant and a representative of the CIR for the purpose of discussing the grievance. The Program Director or designee shall issue a written decision, stating the reasons therefore, within fifteen (15) calendar days following the conclusion of the meeting. 2. Step Two: If the grievance is not satisfactorily resolved at Step One, the grievant may file a written request for review with the appropriate Dean or designee within (14) days following the decision of the Step One decision. The Dean or designee shall review the grievance and where he or she deems it appropriate, witnesses may be heard and pertinent records received. The hearing shall be held within (14) days, and a decision shall be rendered in writing within 14 days following the conclusion of the review. 3. Step Three: If the grievant is not satisfied with the disposition of the grievance at Step Two, he may appeal to the President. 4. Step Four: If the grievance involves a contractual violation of the Agreement, the CIR upon request of the grievant and as a representative of the grievant may, upon written notification of intent to arbitrate to the President or his designee, appeal the President's decision to arbitration. E. Time Limits A grievance must be filed at Step One within thirty (30) days from the date on which the act which is the subject of the grievance occurred or thirty (30) calendar days from the date on which the individual interventional cardiology resident should reasonably have known of its occurrence.
  35. 35. UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL SECTION EIGHT – HUMAN RESOURCES/ADMINISTRATION POLICIES POLICY VIII.1: EMPLOYEE ASSISTANCE PROGRAM SECTION: HUMAN RESOURCES I. PURPOSE To offer professional counseling assistance to all UMDNJ staff members and their family members who may experience personal or emotional difficulties which may affect job performance. UMDNJ has contracted with University Behavioral Health Care to provide this free and confidential service. II. ACCOUNTABILITY Under the direction of the President, the Vice President and Chief Executive Officer for University Behavioral Health Care shall ensure compliance with this policy. The Deans, Vice Presidents and Associate Vice Presidents shall implement this policy. III. APPLICABILITY The Employee Assistance Program is offered to all regular full and part-time UMDNJ staff members and their family members. IV. POLICY Through this program, the University of Medicine and Dentistry of New Jersey expresses a social and caring attitude about its staff member and recognizes that most human problems such as marital or family distress, substance abuse, legal problems or other concerns can be treated successfully, particularly when identified early. Early identification, treatment and resolution serve to minimize human costs and the potential of difficulty with job performance. While UMDNJ has no intention of becoming involved in a staff member's private life, it is our policy to provide help when a staff member requests help for personal problems or offer help when deteriorating job performance and reduced productivity suggest problems outside of the work environment may be contributing to work problems. A. Requirements: 1. UMDNJ encourages staff members and their family members to utilize the professional counseling services available through the Employee Assistance Program. In addition, supervisory staff members should utilize the resources of the Employee Assistance Program as an integral part of an intervention program to deal with poor job performance. 2. The University acknowledges that use of the Employee Assistance Program does not in any way alter management's responsibility or authority as an employer. 3. Participation in the Employee Assistance Program will not in any way jeopardize future employment or career advancement; participation will not, however, protect the staff member from disciplinary action for continued substandard job performance or rule infractions. B. Confidentiality:
  36. 36. 1. All information shared with the Employee Assistance counselor is strictly confidential. 2. No records of staff member participation or the content of their discussion with the Employee Assistance Program and its staff member are kept in the medical or personnel records. 3. No release of information is made to anyone without specific written consent of the staff member concerned, except where required by law. 4. All information regarding a staff member or family member's participation in the Employee Assistance Program is part of the clinical record maintained by University Behavioral HealthCare-Managed Care Resources and is subject to state and federal confidentiality laws governing such medical records. C. Sessions: 1. Appointments with the Employee Assistance Program should be scheduled during non work hours. 2. Each staff member and his/her family member is entitled up to three (3) free, confidential consultation sessions, per problem, with the Employee Assistance Program. The Employee Assistance Program is staffed by experienced professionals who are prepared to help with any type of behavioral health problem. If the concern is outside the Employee Assistance Program counselor's area of expertise, or if there is a need for longer term treatment, the Employee Assistance Program counselor will (with the Employee Assistance Program client's consent) make a referral for appropriate services. D. Referral Procedures: 1. Self Referrals a. The staff member or family member may request an assessment/evaluation by contacting University Behavioral HealthCare-Managed Care Resources (EXHIBIT I). b. An appointment will be scheduled within three days, where mutual schedules permit. Emergencies will be seen immediately. c. Following the initial assessment, referral for treatment or service will be made to appropriate providers in the community if this is deemed appropriate. Referrals will be based on clinical need, geographical convenience and health plan considerations. d. At no time will the names of staff members or their family members be revealed or acknowledged to the University without written consent. 2. Supervisor Referrals a. Supervisors and management personnel are responsible for observing job performance and, when appropriate, referring the staff member to the program based upon decline or difficulties in job performance. A referral form can be obtained from the Employee Assistance Program. b. The decision to seek and/or accept help is entirely the responsibility of the staff member. No attempt will be made to force or require staff members to use the Employee Assistance Program. Whether help is sought or not, each staff member will continue to be judged on the basis of his/her job performance. No special advantages or disadvantages will accrue because a staff member
  37. 37. participated in this program. This policy does not constitute a waiver of management responsibility to maintain appropriate performance standards or to take disciplinary action when necessary. Nor does this policy constitute a waiver of any staff member rights under law or the Collective Bargaining Agreements. c. The supervisor will be requested to provide the Employee Assistance Program with written documentation specifying the staff member's job difficulties; action taken thus far; and consequences of failure to correct performance problems. d. All information shared with the Employee Assistance counselor is strictly confidential. e. The content of all sessions is confidential and will not be released to management or other individuals without the specific written consent of the staff member. f. With the staff member's consent, the referring supervisor will receive feedback from the Employee Assistance Program reporting whether the staff member has followed through with the referral by attending an Employee Assistance Program consultation session. No other personal or diagnostic information will be supplied unless specifically authorized in writing by the staff member and a release of information has been signed listing the specific information to be released. This information will not be included in the staff member's Human Resources file or any files maintained by the staff member's department. V. EXHIBIT I Contact Numbers for Employee Assistance Program Campus Phone Number Hours Newark (973) 972-5459 8:30 a.m. - 5:00 p.m. Piscataway/New Brunswick (732) 235-5930 8:30 a.m. - 5:00 p.m. Stratford/Camden (609) 770-5750 9:00 a.m. - 5:00 p.m.
  38. 38. UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL NEW BRUNSWICK, NEW JERSEY INTERVENTIONAL CARDIOLOGY TRAINING PROGRAM POLICY MANUAL POLICY VIII.2: PHYSICIAN IMPAIRMENT/SUBSTANCE ABUSE POLICY SECTION: HUMAN RESOURCES I. PURPOSE To establish an institutional policy regarding Counseling and Support Services to assist program directors and residents on finding resources for dealing with physician impairment and substance abuse. II. SCOPE This policy is directed to all trainees in the Interventional Cardiology training program. III. DEFINITION Interventional Cardiology Resident - refers to all interventional cardiology residents (fellows) enrolled in a University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School postgraduate training program. An impaired interventional cardiology resident is one who is unable to participate in the residency program with reasonable skill and safety. This impairment may be due to drug and/or alcohol dependency, mental disorder, or other medical disorders. The signs and symptoms of such impairment could include but are not limited to a persistent pattern of the following: A. Patient injury and/or formal complaints B. Unusual or inappropriate behavior C. Adverse changes in clinical and/or academic performance D. Repeated or unexplained absences and/or tardiness from hospital or academic responsibilities E. Repeated or unexplained illnesses or accidents F. Repeated interpersonal conflicts G. Legal problems, including DWIs H. Significant inability to contend with routine difficulties and act to overcome them IV. Responsibility/Requirements A. Policy The abuse of alcohol, legal and/or illicit drugs, and most mental disorders are treatable diseases which can adversely affect a cardiology resident in his/her academic responsibilities and seriously impair patient care if not recognized and managed appropriately. UMDNJ is committed to the rehabilitation of all impaired individuals who have academic and patient care responsibilities, whenever possible. When attempts at treatment or rehabilitation fail or are inappropriate, impairment associated with interference in the ability to safeguard the public health and/or the ability to perform assigned duties is sufficient grounds for action, including dismissal from a residency program.

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