ACCOMMODATIONS FOR DISABILITIES POLICY
It is the policy of East Tennessee State University, James H. Quillen College of Medicine to provide reasonable accommodations as necessary for qualified individuals with disabilities who are accepted in to our post graduate training programs. We will adhere to all applicable federal and state laws, regulations and guidelines with respect to providing reasonable accommodations as required in accordance with the policies and procedures of the University.
University Policies and Procedures link:http://www.etsu.edu/humanres/relations/procedures.aspx
The Graduate Medical Education Office will work with the University Office of Disability Services in determining if a resident has a disability and what accommodations may be reasonable and necessary for the College of Medicine to provide. Residents will still be required to meet all program educational requirements with or without accommodations as they must be able to demonstrate proficiency in all of the ACGME defined competencies and programs must certify that they are able to practice the specialty in which they have been trained competently and independently upon completion of training. This includes the ability to perform the required technical and procedural skills of the specialty. Patient safety must be assured as a top priority in these determinations.
Residents must request accommodations in writing to the Program Director. At that time the resident will be required to provide medical verification of a medical condition that he or she believes is a disability. The resident is responsible for the costs of obtaining verification. The Program Director must notify, within five (5) working days of the request, the Designated Institutional Official and the Executive Associate Dean for Graduate Medical Education.
The College of Medicine Graduate Medical Education Program recognizes the need and benefits of graduate medical education and sponsors training programs which emphasize personal, clinical and professional development. The College of Medicine residency programs are conducted in substantial institutional and program requirements of the ACGME and its individual Residency Review Committees.
In the event the College of Medicine has to reduce the number of positions in or closes a residency training program or to close a program, the College of Medicine will notify the GMEC, DIO, and residents in training as soon as possible. If possible, reductions will be made over a period of time to allow all residents to complete training. In the event that an ACGME action or decreased financial or educational resources force the closure of a training program, the College of Medicine will allow the residents already in the program to complete their education or assist them in locating another ACGME accredited program in which they can continue their education.
CRIMINAL BACKGROUND CHECK (Reviewed & Endorsed 11/15/2012 by GMEC)
Quillen College of Medicine is committed to educating well-trained physicians who possess the traits of high moral character and standards. All prospective employees and students of Quillen who will have direct contact with patients must undergo a Criminal Background Check (CBC) as a condition for hire or matriculation. All conditionally accepted medical students must undergo a CBC prior to matriculation, according to the policy outlined in the College of Medicine Catalog. Prospective faculty or staff employees who have direct patient contact must undergo a CBC as a condition of employment, according to the Faculty and Staff Criminal Background Check Policy.
Review and approval of a completed CBC is a precondition to employment for new resident and fellow physicians. Based on requirements mandated by the State of Tennessee (T.C.A. § 63-1-149), Quillen College of Medicine will not employee any resident or fellow who appears on any state's sexual offender registry, the national sex offender public registry website coordinated by the United States Department of Justice, any state adult abuse registry, or the Tennessee Department of Health's elder abuse registry. The CBC may also reveal information not contained in the above registries that could disqualify one from being considered for employment.
Quillen College of Medicine uses Truescreen, Inc., an outside vendor contracted with the Tennessee Board of Regents, for the CBCs of employee hires. The CBC will include a record of all arrests and convictions, including those that would lead to inclusion in the registry listings above. A list of the information checked and evaluated in the CBC may change from time to time.
After hiring, all residents and fellows are required to disclose within five (5) working days of their occurrence, any criminal charges or events. Failure of a resident or fellow to notify his/her program director of such events may result disciplinary action up to and including termination.
If the CBC evaluation identifies any issue that may preclude participation in activities where direct patient contact occurs, the case will be referred immediately to the Criminal Background Administrative Committee (CBAC) for evaluation. All post-hire employee reported events will also be referred to the CBAC. The CBAC is comprised of the Executive Associate Dean for Academic Affairs, Associate Dean for Graduate Medical Education, and the Associate Dean for Student Affairs. This committee is responsible for making recommendations to the Dean who retains the authority to make the decision in all such matters about hiring or employee disciplinary action.
The College reserves the right, at its sole discretion, to amend, replace, and/or terminate this policy at any time.
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DELINQUENT MEDICAL RECORDS
Residents are expected to maintain all appropriate and reasonable medical records in a timely fashion. A resident who is identified as having delinquent medical records (any record considered delinquent by hospital bylaws) will be notified and given five (5) days to report to the hospital to complete the records. Any records not available to the resident at that time will become the responsibility of the attending physician of record. If the resident does not report within the five (5) day period, he/she will be subject to suspension. Each day of suspension will be counted as one day of annual leave; if there is no available annual leave, the resident will be placed on leave without pay. Extended lengths of suspension may require make-up duty, as outlined by the ACGME/RRC.
The James H. Quillen College of Medicine, East Tennessee State University, acknowledges its ongoing support of graduate medical education in the face of any disaster (natural or otherwise) that interrupts the hospital/clinic based educational process. This ongoing support consists of the following commitments:
The Dean and College of Medicine administration, working with the graduate medical education affiliated hospitals, will strive to ensure financial and logistical support of residents until normal educational site(s) resume clinical activity.
The Office of Graduate Medical Education will maintain contact with all residents during any times of disruption, and provide assistance toward resuming the educational experience as soon as possible. To fulfill this commitment, resident demographic data will be collected and electronically secured off-site from the College of Medicine/University campus.
The Office of Graduate Medical Education, working with the various departments and training programs, will coordinate efforts to provide an alternate educational venue that is convenient and provides appropriate educational experience.
Specifically, programs will focus on strategies to utilize the existing Mountain States Health Alliance, Wellmont Health System, and Veterans’ Affairs Health System to provide temporary clinical settings for the displaced residents. If these regional clinical sites are not available, the Program Director and Chair, along with the Graduate Medical Education Office, will strive to place residents in an educationally rewarding environment as close to this region as possible. The various programs will coordinate their efforts with the appropriate Residency Review Committee and the ACGME to ensure an approved experience for the displaced residents. In the aftermath of the disruption of graduate medical education, the College of Medicine will work to restore the clinical teaching environment as soon as possible so that residents may return to their pre-disaster hospital/clinic setting.
DISCRIMINATION & HARASSMENT - COMPLAINT & INVESTIGATION PROCEDURE
(Reviewed & Endorsed 11/15/2012 GMEC)
Important: Other Available Complaint
An aggrieved individual may also have the ability to file complaints with external agencies such as the Equal Employment Opportunity (EEOC), the Tennessee Human Rights Commission (THRC), the Office of Civil rights (OCR), and the courts. Please note that the deadlines for filing with external agencies or courts may be shorter than the deadline established for filing a complaint under this Guideline. Examples of shorter deadlines include, but are not limited to 180 days to file a complaint under Title VI & Title IX, as well as 300 days to file a complaint under Title VII.
It is the intent of the Tennessee Board of Regents that the Board and all of the institutions within the Tennessee Board of Regents System (including East Tennessee State University) shall fully comply with the applicable provisions of federal and state civil rights laws, including but not limited to, Executive Order 11246, as amended; the Rehabilitation Act of 1973, as amended; the Americans with Disabilities Act of 1990, as amended; the Vietnam Era Veterans Readjustment Act of 1974, as amended; the Equal Pay Act of 1963, as amended; titles VI and VII of the Civil Rights Act of 1964, as amended: Title IX of the Educational Amendments of 1972, as amended; the Age Discrimination in Employment Act of 1967; the Age Discrimination Act of 1975; the Pregnancy Discrimination Act; the Genetic Information Nondiscrimination Act of 2008; and regulations promulgated pursuant thereto. The Board of Regents and ETSU will promote equal opportunity for all persons without regard to race, color, religion, creed, ethnic or national origin, sex, sexual orientation, gender identity/expression, disability, age (as applicable), status as a covered veteran, genetic information, and any other category protected by federal or state civil rights law.
Campuses and the Central Office affirm that they will not tolerate discrimination against any employee or applicant for employment because of race, color, religion, creed, ethnic or national origin, sex, sexual orientation, gender identity/expression, disability, age (as applicable), status as a covered veteran, or genetic information, nor will they tolerate harassment on the basis of these protected categories or any other category protected by federal or state civil rights law.
Similarly, the campuses shall not subject any student to discrimination or harassment under any educational program and no student shall be discriminatorily excluded from participation nor denied the benefits of any educational program on the basis of race, color, religion, creed, ethnic or national origin, ex, sexual orientation, gender identify/expression, disability, age (as applicable), status as a covered veteran, genetic information, or any other category protected by federal or state civil rights law.
Please see the full TBR policy at: http://www.tbr.edu/policies/default.aspx?id=7907
Affirmative Action Officer for ETSU – Office of the President, 206 Dossett Hall. (423) 439-4211.
DRESS CODE (Approved 7/12/2007 and Revised & Approved 11/15/2012 by GMEC)
In order to address one aspect of the ACGME Professionalism Core competency, residents are expected to maintain professional appearance and demeanor at all times. Lab coats with QCOM departmental patches will be supplied for residents by their program with the expectation that residents wear a clean white lab coat when appropriate and always display an appropriate identification badge during rotation assignments.
In accordance with departmental policy, training program directors shall ensure that all residents are properly attired and appropriately groomed for their patient care roles. Access to, usage and proper maintenance of scrubs, lab coats and similar attire shall follow hospital and/or departmental regulations. In order to comply with participating hospitals' patient safety and OSHA requirements, open toed shoes and artificial nails are not permitted.
Special accommodations may be made for residents whose cultural and/or religious beliefs require certain types of attire.
DUE PROCESS (Approved 7/12/2007 and Revised & Approved 3/28/2013)
This outline of Due Process is applicable to any resident who wishes to appeal an adverse decision by his/her program. Adverse actions include: non-renewal of contract; suspension from residency program; termination from residency program; imposition of formal disciplinary action (probation); or actions taken resulting from violation of residency policy or procedure which may delay promotion and/or extend the period of residency/fellowship training.
Residents/fellows shall abide by the rules and regulations set by the program directors, the hospitals and the Office of Graduate Medical Education. Failure of a resident/fellow to perform his/her duties or to abide by the College of Medicine's and the affiliated hospitals' rules and regulations shall be reported to his/her program director and/or departmental chair. The program shall then institute appropriate disciplinary action based upon its own discipline policy.
A resident/fellow who wishes to appeal an adverse decision by his/her program director or department chair may appeal the decision of the department and request a due process hearing before an ad hoc committee. The resident must provide a written request to the GME office for a due process hearing within 4 weeks of the adverse action taken. This committee shall consist of not less than five (5) faculty members and two (2) residents to be appointed by the Dean. The five faculty members will be from programs other than the resident/fellow's program and will have little or no personal involvement with the resident's instruction or evaluation. One of the two resident representatives will be selected by the Associate Dean for Graduate Medical Education from a list supplied by the resident making the appeal and the other selected by the Associate Dean for Graduate Medical Education from the Chief Residents' Committee, but this resident shall not be from the appellant's program. The Associate Dean for Graduate Medical Education will appoint a member of the GME faculty outside of the resident/fellow's discipline to be chair of the committee. In the event that the actions of the Associate Dean for Graduate Medical Education are a factor in the hearing, the Dean will appoint the chair. The committee shall convene a hearing at a date agreeable to all parties, but in no case more than four (4) weeks after receiving the written request for the appeal.
Committee witnesses will include those on a list provided by the resident/fellow to speak on his/her behalf. The committee will also request testimony from those in the program responsible for evaluations and decisions which led to an adverse action. The ad hoccommittee may request from the department copies of all evaluations and documents leading to an adverse action. The resident making the appeal has the right to have an advocate present. The advocate cannot be an attorney. The resident has the right to hear all witnesses and to ask any questions under the direction of the chair of the ad hoc committee. An electronic recording of the proceedings may be made, but only for the purpose of producing a written transcript,; at which time all recordings will be destroyed. This transcript and all other records related to the appeal will be available to the appellant upon request. The chair of the committee will not have a vote in the committee's decision, but will create and submit his/her recommendation along with the recommendations of the committeethe committee's recommendation in a written report to the Dean. The report must include a numerical statement describing the result of a vote taken on whether to recommend upholding (i.e., the appellant received adequate due process) or overturning the adverse action taken against the resident/fellow, and it may include a narrative of considerations the committee used in reaching that conclusion. In addition to the committee report, the Dean has access to the transcript of the hearing. The decision of the Dean is final.
ETHICAL GUIDELINES GOVERNING GRADUATE MEDICAL EDUCATION
Policy and Guidelines for Interactions between the James H. Quillen College of Medicine, East Tennessee State University, and commercial interests ( i.e., any entity producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients). (Adopted 4/1/2009 by GMEC, Endorsed 3/27/2014 by GMEC).
The purpose of this policy is to establish guidelines for interactions with commercial interests for medical staff, faculty, staff, students, and trainees of the James H. Quillen College of Medicine, East Tennessee State University. The intent of this policy to recognize the potentially positive and important value of many of the interactions with commercial interests while providing a framework for an ethical relationship that avoids conflicts of interest that could influence patient care, research objectivity, the integrity of our education and training programs, or the reputation of individual faculty members or the institution.
It is the policy of the James H. Quillen College of Medicine that interactions with commercial interests should be conducted so as to avoid or minimize conflicts of interest. When conflicts of interest do arise they must be managed appropriately, as described herein.
Principles for Interaction
As the James H. Quillen College of Medicine and commercial interests both share the goal of improving the health of our population, the following principles should be used in guiding interactions:
1. The interactions should serve to enhance the health of the public.
2. The interactions should be transparent.
3. All of the interactions must reflect high standards of medical professionalism that reach beyond applicable laws and regulations.
4. The interactions should involve reciprocal communications, with knowledgeable parties on both sides of the interactions.
5. The interactions should support and enable the free exchange of information in appropriate settings, assuring such exchanges are evidence-based and free of bias to the maximum possible extent.
Scope of Policy and Guidelines for Interaction
This policy addresses many types of interactions with commercial interests, e.g. pharmaceutical and device marketing, training, educational support of students and trainees, and continuing medical education. Its scope includes interactions with commercial interests both on-site and off-site.
1. Gifts to Individuals
a. Personal gifts from commercial interests may not be accepted anywhere at the Quillen College of Medicine, college clinical offices, or training sites. It is strongly advised that no form of personal gift from commercial interests be accepted under any circumstance.
b. Examples of prohibited transactions include but are not limited to the following:
i. Individuals may not accept gifts or compensation for listening to a sales talk by an industry representative.
ii. Individuals may not accept gifts or compensation for prescribing or changing a patient's prescription.
iii. Individuals must consciously and actively divorce clinical care decisions from any perceived or actual benefits expected from any company. It is unacceptable for patient care decisions to be influenced by the possibility of personal financial gain.
iv. Food supplied by a commercial interest is considered a personal gift and is not permitted at the Quillen College of Medicine, college clinical sites, or functions. This does not apply when food is provided in connection with ACCME accredited programming or through unrestricted grants to departments or divisions that follow ACCME guidelines.
v. Individuals may not accept compensation from commercial interests, including the defraying of costs, for simply attending a CME or other activity or conference unless the individual is speaking or otherwise actively participating or presenting at the event.
2. Pharmaceutical Samples
a. Sample medications are centrally managed at all ETSU facilities, in accordance with guidelines outlined by MEAC, ETSU Family Medicine and Associates, and individual departments.
b. Sample medications may only be dispensed to patients.
3. Site Access by Industry Representatives
a. Access of the representatives of commercial interests to individuals is limited to non-patient areas ( e.g., private physician offices at a practice location or conference rooms) and must take place by appointment or the invitation of a faculty member, with the following exceptions:
i. Access by device manufacturer representatives to patient care areas is permitted by appointment or invitation by faculty members or clinic supervisors.
ii. Device manufacturer representatives may not be present during patient interactions unless there has been prior disclosure and consent by the patient. Such interactions must be limited to in-service training or assistance on devices and equipment.
b. Medical students and trainees may be included for educational purposes. These interactions must occur under the supervision of a faculty member.
4. Support for Educational and other Professional Activities
a. The Office of Continuing Medical Education administers all accredited CME activities to ensure compliance with ACCME standards ( www.accme.org).
b. All educational events sponsored by the James H. Quillen College of Medicine and its departments or divisions must be compliant with ACCME Standards for Commercial Support ( www.accme.org) whether or not CME credits are awarded, and whether or not they are held on or off campus.
5. Participation in Programs Sponsored by Commercial Interests
a. Faculty, staff, students, and trainees are strongly encouraged to avoid attending or speaking at meetings and conferences that are exclusively or primarily organized, underwritten, or presented by commercial interests because of the high potential for perceived or real conflict of interest. This provision does not apply to meetings of professional societies that may receive partial support from commercial interests or to meetings supported by commercial interests governed by ACCME Standards. It also does not apply to special and specific training on the use of new patient care medical devices for which alternate sources of education and training are not available.
b. Individuals who participate ( e.g., by giving a lecture, organizing the meeting) in meetings and conferences supported in part or in whole by commercial interests and not governed by ACCME Standards should follow these guidelines:
i. Financial support by commercial interests is fully disclosed by the meeting sponsor.
ii. The meeting or lecture content is determined by the speaker and not the commercial interest.
iii. Participants, including the ETSU participant, are being expected to provide a fair and balanced assessment of therapeutic options and to promote objective scientific and educational activities and discourse.
iv. The ETSU participant is not required by a commercial interest to accept advice or services concerning speakers, content, etc., as a condition of the sponsor's contribution of funds or services.
v. The ETSU participant makes clear that content reflects individual views and not the views of ETSU.
vi. The use of the ETSU name in non-ETSU events is limited to the identification of the individual by his or her title and affiliation.
6. Sponsorship of Scholarships and Other Educational Funds for Trainees by Commercial Interests
a. Educational grants that are compliant with the ACCME standards ( www.accme.org) may be received from commercial interests but must be administered by the Office of Continuing Medical Education, departments or divisions and not by individual faculty.
b. No quid pro quo may be involved for donated scholarship or educational funds.
c. The evaluation and selection of recipients of scholarships or grants is the sole responsibility of ETSU or of a nonprofit-granting industry, with no involvement by the donor commercial interest.
7. Professional Travel
a. Direct payments by commercial interests to ETSU faculty, staff, students, and trainees is not allowed other than for reimbursement of direct travel when the faculty, staff, student, or trainee is providing a legitimate service for which the travel is necessary and is reasonable in relation to the services provided.
a. ETSU faculty, staff, students, and trainees are prohibited from having publications or professional presentations of any kind, oral or written, ghostwritten by any party, industry or otherwise.
b. This does not apply to transparent writing collaboration with attribution between academic and industry investigators, medical writers, and/or technical experts.
9. Boards of Directors, Advisory Boards, and Consulting
a. ETSU faculty, staff, students, and trainees are allowed to interact as members of boards and/or as consultants via professional service agreements, as long as such activities are conducted in full compliance with the ETSU Conflict of Interest Policy ( http://www.etsu.edu/research/ConflictofInterest.htm) and ETSU training program policies ( http://www.etsu.edu/com/gme/reshandbook.aspx and Handbook2009.pdf)
a. In scholarly publications, individuals must disclose their related financial interests in accordance with the International Committee on Medical Journal Editors ( http://www.icmje.org)
a. Individuals having a direct role in making institutional decisions on equipment or drug procurement must disclose any financial interest they or their immediate family have in companies that might substantially benefit from the decision. They must also disclose any research or educational interest they or their department have that might substantially benefit from the decision. This provision does not include indirect ownership such as stock held through mutual funds.
HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACTS OF 1996 (HIPAA)
All Graduate Medical Education activities will be conducted in strict compliance with University policies pertaining to HIPAA. For further information and requirements, please refer to the ETSU Notice of Privacy Practices on the College of Medicine webpage: http://com.etsu.edu/default.asp?V_DOC_ID=1619.
HOSPITAL SUSPENSION OF A RESIDENT (Approved 7/12/2007and Reviewed & Endorsed 4/25/2013 by GMEC)
The affiliated hospital administration may find cause to suspend a resident from clinical activities. When such a suspension occurs, the hospital administration will immediately notify the appropriate departmental chair and program director. Within five (5) working days the program director will convene a committee of two departmental faculty selected by the program director and two representatives from the involved hospital selected by the hospital administration. This committee, chaired by the program director, will investigate the incident and recommend appropriate action to the departmental chair. Such action will also be communicated to the hospital administration representative in charge of graduate medical education. If the hospital administration is not agreeable with the committee’s recommendation to the chair, the issue will be submitted to the Executive Associate Dean for Graduate Medical Education. If agreement can still not be reached with the hospital administration, the issue will be referred to the Dean of the College of Medicine and the CEO of the appropriate hospital. The ultimate decision regarding resident clinical privileges shall be made by the Hospital.
If the resident disagrees with the final recommended action, the resident has access to the grievance process outlined in the grievance policy.
MECHANISM TO RESOLVE RESIDENT INITIATED GRIEVANCES
It is desirable for resident’s concerns to be resolved within the departmental structure. When resolution is not obtained the resident’s grievance regarding the residency program should be expressed to his/her preceptor, program director, department chair, or any other faculty member or administrative officer of the College of Medicine who will help to resolve the issue or agree on further action.If not resolved, the problem then will be brought by the involved resident and appropriate faculty member to the attention of the resident’s program director and the Executive Associate Dean for Graduate Medical Education.If there is still no resolution of the problem, the Executive Associate Dean for Graduate Medical Education will convene an ad-hoc committee and proceed with the due process.If the resident’s grievance is against the Executive Associate Dean for Graduate Medical Education, program director, department chair of any clinical department or any other person who might otherwise take part in the process of resolving the problem, the above steps will be structured to exclude the involvement of that person from the judging process.
NON-RENEWAL OF RESIDENT CONTRACT (TIMELY) (Approved 7/12/2007and Revised & Approved 4/25/2013 by GMEC)
Appointments are made on a year-to-year basis. Reappointment for subsequent years is dependent on the resident's satisfactory progress as monitored according to evaluation and promotion policies, the availability of training positions at the University, and funding. Should the University decide not to renew the appointment, the Physician will be notified no later than four months prior to the end of the current agreement. However, if the primary reason(s) for the non-renewal occur(s) within the last four months of the agreement, the University will provide the Physician with as much written notice as circumstances will reasonably allow, prior to the end of the agreement.
OBSERVERSHIPS (Created & Approved 11/15/2012 by GMEC)
The Quillen College of Medicine does not offer or provide the opportunity for externships or observerships to individuals holding the MD/DO degree (or its equivalent) who are not training in an ACGME or AOA approved residency. This policy does not apply to visiting faculty.
Medical students enrolled in an LCME or AOA accredited school may apply for M4 electives at the following link: http://www.etsu.edu/com/acadaffairs/visiting/default.aspx
OUTSIDE EMPLOYMENT (MOONLIGHTING) (Rev. 5/23/2002, Approved 6/18/2002 and Revised & Approved 11/15/2012 by GMEC)
Moonlighting refers to voluntary, compensated medically related work undertaken by a resident outside the context of the residency program. Residents/fellows may not engage in moonlighting activities that interfere with the responsibilities to their program, especially in the context of work hour limitations. Program Directors may establish a "no moonlighting" policy based on academic, workload, and/or work hours considerations. PGY I residents and residents holding a J1 visa are not permitted to moonlight.
Residents may not engage in any outside employment or professional medical activity without first completing the QCOM Institutional Moonlighting Acknowledgement form (http://www.etsu.edu/com/gme/formslinks.aspx) and obtaining written approval of the program director. The Program Director is responsible for assuring there are no conflicts between their moonlighting schedule and requirements of the program. The program director is responsible for monitoring the health and program performance of the moonlighting resident and must take corrective action if these are adversely affected by the moonlighting activity. Additionally, the resident/fellow must enter moonlighting hours (both internal* and external) as part of his/her duty hour log in New Innovations. Time spent moonlighting must be counted towards the 80-hour maximum weekly hour limit.
Program Directors reserve the right to deny moonlighting activity. Any resident/fellow failing to comply with moonlighting guidelines is subject to departmental disciplinary action.
Any resident/fellow engaged in moonlighting must be licensed for unsupervised medical practice in the state where the moonlighting occurs. It is the responsibility of the institution where moonlighting occurs to determine whether medical licensure is in place, whether adequate liability coverage is provided, and whether the resident has the appropriate training and skills to carry out assigned duties.
Professional liability insurance coverage provided by the QCOM DOES NOT extend to any medical practice or activities outside the medical education program of the University.
The QCOM does not encourage its residents/fellows to engage in outside employment. QCOM accepts no responsibility for the financial consequences to residents who engage in moonlighting if permission for that employment is withdrawn as a consequence of poor performance in the training program, conflict with work hour limitations, or for other cause.
PERIODIC REVIEW OF GME POLICIES (Created & Approved 3/28/2013 by GMEC)
The GMEC will review and revise its policies on an as-needed basis in response to changing circumstances, accreditation standards, etc., but the GMEC will review for educational appropriateness (and where indicated revise) all GME policies every 5 years.
POLICY ON A DRUG-FREE CAMPUS
It is the policy of this university that the unlawful manufacture, distribution, possession, use of alcohol and illicit drugs on the ETSU campus in the workplace (on or off campus), on property owned or controlled by ETSU, or as part of any activity of ETSU is strictly prohibited. All employees and students are subject to applicable federal, state and local laws related to this matter. Additionally, any violation of this policy will result in disciplinary action.
II. Legal Sanctions
Various federal, state and local statutes make it unlawful to manufacture, distribute, dispense, deliver, sell or possess with intent to manufacture, distribute, dispense, deliver or sell, controlled substances. The penalty imposed depends upon many factors which include the type and amount of controlled substance involved, the number of prior offenses, if any, whether death or serious bodily injury resulted from the use of such substance, and whether any other crimes were committed in connection with the use of the controlled substance. Possible maximum penalties for a first-time violation include imprisonment for any period of time up to a term of life imprisonment; a fine of up to $4,000,000 if an individual; supervised release; any combination of the above; or all three. These sanctions are doubled when the offense involves either: 1.) distribution or possession at or near a school or college campus or, 2.) distribution to persons under 21 years of age. Repeat offenders may be punished to a greater extent as provided by statute. Further, a civil penalty of up to $10,000 may be assessed for simple possession of “personal use amounts” of certain specified substances under federal law. Under state law, the offense of possession or casual exchange is punishable as a Class A misdemeanor; if there is an exchange between a minor and an adult at least two years the minors senior, and the adult knew that the person was a minor, the offense is classified a felony as provided in T.C.A. Section 39-17-417. ( 21 U.S.C. Section 801, et. seq.; T.C.A. Section 39-17-417)
It is unlawful for any person under the age of twenty-one (21) to buy, possess, transport (unless in the course of his employment), or consume alcoholic beverages, wine, or beer. Such offenses are classified as Class A misdemeanors punishable by imprisonment for not more than 11 months, 29 days, or a fine of not more than $2,500, or both. (T.C.A. Sections 1-3-113, 57-5-301) It is further an offense to provide alcoholic beverages to any person under the age of twenty-one (21), such offense being classified as a Class A misdemeanor (T.C.A. Section 39-15-404). The offense of public intoxication is a Class C misdemeanor punishable by imprisonment of not more than 30 days or a fine of not more than $50, or both (T.C.A. Section 39-17-310).III. Institutional/School SanctionsEast Tennessee State University will impose the appropriate sanction(s) on any employee or student who fails to comply with the terms of this policy.
As a condition of employment, each employee, including student employees, must abide by the terms of this policy, and must notify the Office of Human Resources of any criminal drug statute conviction for a violation occurring in the workplace (on or off campus) no later than five days after such conviction. A conviction includes a finding of guilt, a plea of nolo contendere, or imposition of a sentence by any state or federal judicial body. Possible disciplinary sanctions for failure to comply with this policy, including failure to notify of conviction, may include one or more of the following depending on the severity of the offense:
mandatory participation in and satisfactory completion of drug/alcohol abuse program, or rehabilitation program;
recommendation for professional counseling;
referral for prosecution;
letter of warning;
Moreover, the following certification and notification requirements apply (responsibility of Research and Sponsored Programs in coordination with Human Resources):
Possible disciplinary sanctions for failure to comply with the terms of this policy may include one or more of the following depending on the severity of the offense:
IV. Health Risks Associated With the Use of Illicit Drugs and the Abuse of Alcohol
There are many health risks associated with the use of illicit drugs and the abuse of alcohol including organic damage; impairment of brain activity, digestion, and blood circulation; impairment of physiological processes and mental functioning; and, physical and psychological dependence. Such use during pregnancy may cause spontaneous abortion, various birth defects or fetal alcohol syndrome. Additionally, the illicit use of drugs increases the risk of contracting hepatitis, AIDS and other infections. If used excessively, the use of alcohol or drugs singularly or in certain combinations may cause death.
V. Available Drug and Alcohol Counseling, Treatment, Rehabilitation Programs, and Employee Assistance Programs
The university and local community provide a variety of educational programs and services to respond to the problems associated with alcohol and drug abuse. The Campus Alcohol and Other Drug (AOD) Program at East Tennessee State University is designed to serve university students by providing information related to alcohol awareness and chemical dependency. The Office of the Vice President for Student Affairs offers several educational programs which seek to involve university student organizations.
Below is a list of campus and community agencies which also provide referral, information, and/or counseling to students and/or employees:
|ETSU Counseling Center (students only)||439-4841|
|ETSU Department of Public Safety||439-4480|
|ETSU Employee Assistance Program||439-5825|
|State of Tennessee Employee Assistance Program||1 (877) 237-8574|
Comprehensive Community Services
(Alcohol & Drug Counseling & Prevention Center)
|Watauga Mental Health Center||232-6200|
POLICY ON SEXUAL HARASSMENT
East Tennessee State University desires to maintain an environment which is safe and supportive for students and employees and to reward performance solely on the basis of relevant criteria. Accordingly, the University will not tolerate sexual harassment of students or employees.
Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitute sexual harassment when: (1) Submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment or academic standing; (2) Submission to or rejection of such conduct by an individual is used as a basis for employment or academic decisions affecting an individual; or; (3) Such conduct has the purpose or effect of unreasonably interfering individual’s work or academic performance or creating an intimidating, hostile or offensive working or academic environment.
Recommended actions to be taken by anyone who believes he or she is being sexually harassed:
In circumstances where you think you will not be jeopardizing your personal safety, your job, or your academic status, communicate clearly to the offender that the behavior is not humorous or welcome and should cease immediately.
Keep a record of what happened and when it took place. Should there be any Witnesses, ask for their names to include in your documentation of the incident.
If the harassment continues, or if you choose not to confront the offender directly, you many report the situation to the Affirmative Action Officer, Office of the President. You may also report the situation to any of the other persons listed below who will assist you in preparing charges to be reported to the Affirmative Action Officer:
Associate Vice President of Student Affairs
Box 70725, (423) 439-4210
Affirmative Action Officer for ETSU
Office of the President, 206 Dossett Hall (423) 439-4211
Source: Tennessee Board of Regents (TBR) Personnel Policy No: 5:01:02:00; TBR Personnel Guide No. P-080.
PROFESSIONALISM AND PERSONAL RESPONSIBILITY (Approved 3/27/2014 by GMEC)
The physician in training must:
ETSU GME programs must model and residents must demonstrate adherence to these principles of professionalism and personal responsibility.
PROMOTION OF RESIDENTS (Approved 7/12/2007 and Revised & Approved 2/24/2013 by GMEC)
Residents are promoted from one year to the next based upon meeting the academic standards and curricular requirements of the program as determined by the Program Director and the Resident Evaluation/Clinical Competency Committee. Evaluation of resident performance includes review ofprogram specific milestones as determined by evaluations and performance measures.
RESIDENT DUTY HOURS (Reviewed & Approved 11/15/2012 by GMEC)
1. Duty hours must be limited to 80 hours per week, averaged over a 4-week period, inclusive of all in-house call activities and all moonlighting.
2. Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). At-home call cannot be assigned on these free days.
3. Duty periods of PGY-1 residents must not exceed 16 hours in duration.
4. Duty periods of PGY-2 and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. It is essential for patient safety and resident education that effective transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours.
5. Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
6. In unusual circumstances, residents, on their own initiative, may remain beyond the scheduled period of duty to care for a single patient. These circumstances include caring for an acutely ill or unstable patient, academic importance of the event transpiring, or humanistic attention to the patient or their family. Under those circumstances the resident must: 1) appropriately hand over the care of all other patients to the team responsible for their continuing care, and, 2) document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director. The documentation will occur in New Innovations.
7. PGY-1 residents should have 10 hours and must have eight hours free of duty between scheduled
8. Intermediate-level residents (as defined by the Review Committee) should have 10 hours free of duty, and must have 8 hours between scheduled duty hours. They must have at least 14 hours free of duty after 24 hours of in-house duty.
9. Residents in the final years of education (as defined by the Review Committee) must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods (within the context of the 80 hour, maximum duty length and 1 day off in 7 standards).
10. Residents must not be scheduled for more than six consecutive nights of night float. PGY-2 residents and above must be scheduled for in-house call no more frequently than every third night (when averaged over a four week period).
11. Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum hour limit. The frequency of at-home call is not subject to the every-third-night limitation, but it must satisfy the requirements for one-day-in-seven free of duty, when averaged over 4 weeks. At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.
12. Duty hours are monitored by each residency/fellowship program and by the GME office. Corrective actions are developed for confirmed work hour violations.
1. Time spent by residents in external and internal moonlighting (as defined by ACGME) must be counted towards the 80-hour maximum weekly hour limit.
2. PGY-1 residents are not permitted to moonlight.
3. Residents on J-I visas are not permitted to moonlight.
RESIDENT ELIGIBILITY AND SELECTION (Approved 7/12/2007 and Revised & Approved 1/24/2013 by GMEC)
Residents and Fellows are selected on a fair and equal basis without regard to sex, race, age, religion, color, national origin, disability, veteran status, or any other applicable legally protected status.
The GME office will monitor programs for compliance with this policy on recruitment and appointment.
Applicants with one of the following qualifications are eligible for appointment to programs, subject to additional qualifications as may be specified in specialty/subspecialty programs:
Individuals applying for Fellowship programs must document completion of an appropriate residency program, including an ACGME-accredited residency, or meet requirements as outlined in ACGME program requirements.
A resident/fellow in our program must be a U.S. citizen, lawful permanent resident, or possess the appropriate documentation to legally train in the U.S.
Resident applicants should apply through ERAS. All residency programs participate in the NRMP for entry level residents and will select residents according to NRMP policies and procedures. Each program will develop specialty specific criteria according to its own program's needs and those of the institution. These criteria may encompass preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity or other relevant personal, professional and educational characteristics of the candidate.
Applicants who are invited for an interview must be informed, in writing or by electronic means, of the terms, conditions, and benefits of appointment, either in effect at the time of the interview or that will be in effect at the time of their eventual appointment.
Beginning with the 2013 NRMP Main Residency Match, any program that participates in the NRMP Match must register and attempt to fill all of its positions through The Match or another national matching plan. This includes International Medical Graduates. Refer to the "All-In" Policy of the NRMP for the relatively limited situations in which exceptions can be made (Rural Scholars Program; Family Medicine Accelerated Programs; post-SOAP positions). One exception that may occur is that of off-cycle appointments. If training would begin prior to February 1 in the year of The Match, the position can be offered outside The Match; if training would begin after February 1, the position must be filled through The Match.
If a position can be offered outside The Match within the foregoing rules and guidelines of the NRMP, the following conditions should be met before an "out-of-Match" position is offered and accepted:
Residents are evaluated in writing at the end of each clinical rotation by their attending faculty. In addition, at least twice per year, formal meetings will be held with each resident to review rotational evaluations and other evaluative data relating to individual residents.
Each residency program will have stated goals for the entire residency which are compatible with the ACGME special requirements and the appropriate specialty board.
Specific objective and performance standards will be defined for each rotation or curriculum segment of each residency program.
Each residency program will have a defined curriculum.
The residency program director for each program will be responsible for developing and implementing an on-going evaluation process of the program and of the individual residents in the program.The evaluation process will ensure that each resident is evaluated on a regular basis. This should include monthly rotation evaluations or periodic evaluations at a suitable interval of specific curriculum segments. Evaluations will be performed in writing and retain on file by the program director.
All faculty members will be expected to review their evaluations of a resident’s performance with that resident and to provide appropriate feedback and comments to the residents.
Periodically, formal meetings will be held with each resident to review rotational evaluations and other evaluative data relating to individual residents, such as results of in-training examinations. These feedback sessions should occur at a minimum of twice per year. These meetings will be conducted by the program director or by another faculty member designated by the program director and will be documented in writing. Such documentation will be signed by both the resident and the program director/designated faculty.
Evaluations will include cognitive, psychomotor and affective (or professional) domains of the resident’s experience.
The evaluation process will solicit residents to provide evaluations of their rotations, services, faculty and the institution, as well as other appropriate educational processes as deemed relevant by the program director.
RESIDENT SUPERVISION (Approved 7/12/2007 and Revised & Approved 4/25/2013 by GMEC)
The common program requirements for resident/fellow supervision shall be met. This includes but is not limited to:
In the clinical learning environment, each patient must have an identifiable, appropriately credentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient's care. This information should be available to residents, faculty members, and patients; and the patients should be informed of these roles in their care.
The program must use the following classification of supervision:
- Direct Supervision — the supervising physician is physically present with the resident and patient.
- Indirect Supervision with direct supervision immediately available — the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.
- Indirect Supervision with direct supervision available — the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision.
- Oversight — the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members. The program director must evaluate each resident's abilities based on specific criteria. When available, evaluation should be guided by specific national standards-based criteria. Faculty members functioning as supervising physicians should delegate portions of care to residents, based on the needs of the patient and the skills of the residents. Senior residents or fellows should serve in a supervisory role of junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow. Programs must set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members, such as the transfer of a patient to an intensive care unit, or end-of-life decisions.
Each resident must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence.
PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. [Every discipline's Review Committee will describe the achieved competencies under which PGY-1 residents' progress to be supervised indirectly, with direct supervision available.]
Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility.
RESTRICTIVE COVENANTS/ “NO COMPETE” CLAUSE
(Approved 7/12/2007 and Revised & Approved 11/15/2012 by GMEC)
In accordance with ACGME accreditation standards, no house staff member enrolled in an accreditated training program sponsored by Quillen College of Medicine shall be required by ETSU or its teaching affiliates to sign any type of non-compete agreement or restrictive covenant.
The Graduate Medical Education Committee recommends that residents and fellows exercise caution in using social networking sites such as Facebook or MySpace. Items that represent unprofessional behavior posted by residents on such networking sites are not in the best interest of the University and may result in disciplinary action up to and including termination.
Residents and Fellows are expected to exhibit a high degree of professionalism and personal integrity consistent with the pursuit of excellence in the conduct of his or her responsibilities. They must avoid identifying their connection to the University if their online activities are inconsistent with the values or could negatively impact the University's reputation.
If using social networking sites, residents and fellows should use a personal e-mail address as their primary means of identification. Their University e-mail address should never be used for personal views. Residents who use these websites must be aware of the critical importance of privatizing their websites so that only trustworthy friends have access to the websites/applications.
In posting information on personal social networking sites, residents may not present themselves as an official representative or spokesperson for a residency/fellowship program, hospital, or the University. Patient privacy must be maintained and confidential or proprietary information about the University or hospitals must not be shared online. Patient information is protected under the Health Insurance Portability and Accountability Act (HIPAA). Residents have an ethical and legal obligation to safeguard protected health information and posting or e-mailing patient photographs is a violation of the HIPAA statute.
TERMINATION OF A RESIDENT (Approved 7/12/2007 and Reviewed & Endorsed 3/28/2013 by GMEC)
Termination of a resident may occur based on either of two situations: 1) Unacceptable personal behavior serious enough to call for immediate temporary or permanent suspension. This action may be taken when the resident’s performance endangers the health or safety of others, or, for any other reason is deemed unacceptable by the Program Director and/or the Dean; or; 2) Failure to meet academic standards despite a carefully planned remediation program.
Effective August 11, 2008, ETSU is a Tobacco-Free Campus, with smoking and all other tobacco usage permitted only in private vehicles. This policy applies to all university buildings/grounds; ETSU-affiliated off-campus locations and clinics; any buildings owned, leased or rented by ETSU in all other areas; and ETSU facilities located on the campus of the James H. Quillen Veterans Affairs Medical Center at Mountain Home. Tobacco use is also prohibited in all state vehicles. This tobacco-free policy is in effect 24 hours a day year-round.
The university promotes a healthy, sanitary environment free from tobacco smoke and tobacco-related debris. The ETSU community acknowledges that long-term health hazards may accrue to people who use tobacco products or who are subjected to second-hand smoke. The failure to address the use of tobacco products on campus would constitute a violation of the Americans with Disabilities Act, the Vocational Rehabilitation Act and Tennessee law.Support
Understanding the addictive nature of tobacco products, ETSU will make every effort to assist those who may wish to stop using tobacco.
The university offers current information about available resources via http://www.etsu.edu/humanres/relations/SmokingResources.aspx
It is the responsibility of all members of the ETSU community to comply with this Tobacco-Free Campus Policy. Violations of the policy will be dealt with in a manner that is consistent with university procedures. There shall be no reprisals against anyone reporting violations of this policy.
TRANSFER OF RESIDENT POLICY (Reviewed & Approved 9/25/2013)
Before accepting a resident who is transferring from another program, the program director must obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the transferring resident.
In the event that a program director wishes to rank a resident candidate in the NRMP who has previously started but not completed another program, the program director must obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation prior to finalizing a rank order list.
A program director must provide timely verification of residency education and summative performance evaluations for residents who leave the program prior to completion.
UNSATISFACTORY PERFORMANCE BY A RESIDENT/FELLOW (Approved 7/12/2007 & Revised & Approved 1/24/2013 by
Residents/fellows who experience a deviation from expected performance will be identified in a timely manner by the program director. Any instance of a resident/fellow being removed from his/her clinical duties requires the office of the Associate Dean for Graduate Medical Education to be notified as soon as possible.
A resident/fellow deemed to be deficient in any aspect of his/her performance will be given verbal or, depending on the severity of the deficiency, written notification and may be placed on departmental remediation. If the problem involves serious academic or behavioral issues, the program director may require a fitness for duty evaluation after consulting the Associate Dean for Graduate Medical Education. Departmental remediation is utilized when it is anticipated that there will be a successful outcome on the part of the resident/fellow. The remediation period will be left to the discretion of the program director, but generally will be 3 to 6 months. When remediation action occurs, the program director will inform the resident/fellow in writing by giving him/her a letter of deficiency which should include the following elements:
When necessary this approach will include the appointment of one or more faculty to work with the resident/fellow on a regular basis using a planned, individualized format.
If the resident/fellow satisfactorily remediates deficiencies outlined in a letter of deficiency, no further action is necessary. If the resident/fellow does not satisfactorily remediate deficiencies during the remediation period and/or if, in the Program Director's opinion, the resident/fellow's original deficiency may result in termination, the resident/fellow will be placed on probation, generally not to exceed three (3) months. Again, the resident/fellow must be given written notification with the elements outlined above included in a letter of probation and the additional element:
A copy of the signed letter of probation should be sent to the GME office. Probation is an official action taken against a resident/fellow, and it is entered into the record of the resident/fellow for subsequent reporting/credentialing purposes.
At the end of the probationary period the resident/fellow's performance will be reassessed and the resident/fellow will be notified in writing as to his/her status. The resident/fellow may be removed from probation if the stated deficiencies have been remediated, or the probation may be continued if the resident/fellow's performance has improved but deficiencies remain or new deficiencies are uncovered, or the resident/fellow may be terminated. The program director must obtain approval of the Associate Dean for Graduate Medical Education prior to terminating a resident/fellow. The resident/fellow is given written notification of termination and the reasons for this action. The written notification must also inform the resident/fellow of his/her due process rights.
VISAS AND FOREIGN MEDICAL GRADUATES (Approved 7/12/2007 & Revised & Approved 7/25/2013 by by GMEC)
The clinical departments of the Quillen College of Medicine each maintain policies for selecting and accepting candidates into graduate medical education (GME) residency and fellowship training programs. These policies must be followed for graduates of foreign medical school as for all other eligible candidates.
Graduates of foreign medical schools who are not permanent U.S. residents or U.S. citizens must be willing to obtain a J-1 exchange visitor visa sponsored by the Education Commission to Foreign Medical Graduates (ECFMG) if they are chosen according to the rules of the NRMP Match. They are also expected to be willing to obtain a J-1 for placement in the unusual circumstance of being accepted outside of the NRMP Match.
The Quillen College of Medicine does not sponsor H1-B visas for the purpose of residency or fellowship training in its GME programs.