Policy & Training Manual

131

Program Policy & Procedure ManualDivision of Metabolism, Endocrinology and Genetics

University of Kansas School of Medicine

Kansas City, Kansas

Covering Policies and Procedures for Fellows-In-Training

As a supplement to the

House Staff Policy and Procedure Manual of the University of Kansas School of Medicine, Office of Graduate Medical Education

And

Program Manual for Residents in the Department of Medicine

University of Kansas School of Medicine, Kansas City, Kansas

Revised June 2019

Leland Graves, III, MD, Program Director

Division of Metabolism, Endocrinology and Genetics

Department of Internal Medicine

TABLE OF CONTENTS:

I. INTRODUCTION3

II. CONTACT INFORMATION 4

III. INSTITUTIONAL SUPERVISING FACULTY5

IV. Academic6

A. Program Overview6

B. Mission Statement6

C. Overall Goals and Objectives6

D. Performance Expectations7

E. Conferences, Lectures and Other Educational Opportunities11

F. Professional and Ethical Behavior11

G. Evaluation of Fellows12

H. Advancement to succeeding training year12

I. Evaluation of Faculty and Program13

J. Documentation of Training13

V. POLICIES AND PROCEDURES14

A. Prerequisites14

B. Fellowship Selection Process 14

C. Duration of Program15

D. Duties15

E. Duty Hour Policies and Fatigue16

F. Call Schedule 18

G. Lines of Communication and Responsibilities - Supervision18

H. Meeting Attendance20

I. Vacation and Leave Time Policies20

J. Benefits26

K. Moonlighting 28

L. Ethics26

M. Utilization Management29

N. Quality Improvement29

O. Risk Management30

P. Professionalism31

Q. Impairment32

R. Disciplinary Actions, Probation, Suspension and Termination32

S. Grievance Resolution37

VI. REFERENCES

A. Conference Schedule 40

B. Common Program Requirements Worksheet41

C. Resident Supervision Template43

D. Goals and Objectives47

E. Core Competency Matrix and Vanderbilt Matrix126

F. ACGME Program Requirements128

G. GMEC Fatigue (Transportation/Swing Room) Guidelines130

H. Online Training131

APPENDIX

1.Endocrinology Curriculum

2.Evaluation Forms

3.Rotation Schedule

I. Introduction

Welcome to the Endocrinology, Diabetes and Metabolism Division at the University of Kansas School of Medicine. We are pleased that you have chosen this Program to continue your training. We believe that you will find the KU Endocrinology Division to be an excellent program with a talented and dedicated faculty eager to provide instruction and guidance to you as you complete your training. Within this program, you will encounter a broad array of Endocrine diseases that will allow you to become an excellent consultant in the discipline. Additionally, we believe that professionalism, ethical standards and humanistic qualities are paramount to the successful practice of medicine and are fostered within our program. Our faculty subscribes to the “lead by example” philosophy. When you complete your training, our goal and expectations are that you will be a competent, compassionate, ethical Endocrinologist who will be a life-long learner and a dedicated teacher for the next generation, ready to solve new problems and disseminate information for others to study and emulate.

The KU Endocrinology faculty and I consider it a privilege to work with you, the physicians of the future, and we take our contributions to your education seriously. My expectations are the same for you as well as for our faculty: a commitment to excellence in clinical care, education, and research, coupled with a zest for life-long learning.

We look forward to working with you and have every confidence that you will graduate as a competent, confident, compassionate physician. You have many exciting opportunities ahead, and we welcome the opportunity to share them with you.

Leland Graves, III, MD

Professor of MedicineChief of Staff

Fellowship Program Director

Director, Division of Metabolism, Endocrinology and Genetics

II. Contact Information

Division of Metabolism, Endocrinology and Genetics - KUMC

Leland Graves, III, MD Professor of MedicineDirector, Metabolism, Endocrinology and Genetics

Program Director, Endocrinology Fellowship Program

David Robbins, MD. Professor of MedicineDirector, Cray Diabetes Center, Diabetes Institute

John Miles, MDProfessor of Medicine

Raj Bhattacharya, MDProfessor of Medicine

Leigh Eck, MDAssociate Professor of MedicineProgram Director, Internal Medicine Residency Program

Rudruidee Karnchanasorn, MD Associate Professor of Medicine

Candice Rose, MDAssistant Professor of Medicine

Ioannis Papagiannis, MD Assistant Professor of Medicine

Abeer Anabtawi, MDAssistant Professor or Medicine

Kristin Gridnovac, MDAssistant Professor of Medicine

Eric Rush, MDAssistant Professor, Volunteer Faculty Member

Barbara Lukert, MDProfessor Emeritus

Joseph Kyner, MDProfessor Emeritus

Division of Endocrinology, Diabetes and Metabolism - VAMC

Maria Gomes, MDSite Director, KC Veteran’s Administration

Assistant Professor of Medicine

Mariana Garcia-Touza, MDAssistant Professor of Medicine

Associated Faculty-KUMC

Pratibha Rana, MDPediatric Endocrinology, KUMCJames Casey, MDPediatrics, KUMC

Patrick Moriarty, MDDirector, Lipid Clinic, KUMC

Division of Pharmacology

Courtney Marsh, MDReproductive Endocrinology and Infertility

Department of Gynecology, KUMC

Ajay Nangia, MDDirector of Male Infertility,

Department of Urology, KUMC

III. Institutional Supervising Faculty

KU Hospital and KUMC: Sponsoring Institution

Director & Site Director: Leland Graves, III, MD (20 hrs each week)

Supervisor of fellow on consultation service: Attending assigned to consult service

Supervisor of fellow on clinic rotation: Attending assigned to clinic on same day

Supervisor of fellow on research rotation: Leland Graves, III, MD or assigned mentor for the research project.

KCVA

Site Director: Maria Gomes, MD

Supervisor of fellow on consultation service: Maria Gomes, MD

Supervisor of fellow on clinic rotation: Maria Gomes, MD

IV. Academic

A. Program Overview

The Endocrinology Fellowship Training Program at the University of Kansas is a two-year program designed to train outstanding clinicians in Endocrine diseases who will have the skills and knowledge to succeed in either the academic or private health care sectors.

The training program utilizes two training sites: The University of Kansas and the Kansas City VA Hospital. The educational rationale for presence at each training site is carefully considered. Clinical experience at the University of Kansas Hospital provides opportunities for fellows to learn under the mentorship of both clinical investigators and medical educators, while caring for a patient population which includes tertiary care referrals from physicians throughout the region, as well as the local, culturally diverse populations. Our educational affiliation with the Kansas City VA Hospital is designed specifically to expose fellows to a practice setting with increased autonomy, yet adequate faculty supervision, and a patient population with a different spectrum of disease than our university hospital.

B. Mission Statement

The mission of the Division of Metabolism, Endocrinology and Genetics at the University of Kansas School of Medicine is to train physicians who are clinically competent in the field of Endocrinology and who are capable of practicing in a variety of clinical and academic settings. They will possess habits of life-long learning to build upon their knowledge, skills, and professionalism.

C. Overall Goals and Objectives

Goals

The goal of the fellowship in Endocrinology is for the fellow to acquire a comprehensive understanding of endocrine diseases, with emphasis on providing excellence in diagnosis and management. In addition, fellows will participate in scholarly activities during their fellowship. Our curriculum meets the ACGME program requirements graduate medical education in endocrinology curriculum guidelines (see appendix attached).

Objectives

Detailed objectives for each rotation are provided in the appendix of this document.

In general, fellows will be expected to develop competence in pathophysiology, epidemiology, clinical manifestations, diagnostic tools, and therapeutic options of Endocrine disease. Fellows will also be expected to further their knowledge through participation in scholarly activities, including literature reviews, research endeavors, attendance of conferences, publication of manuscripts, and local/national presentations.

All aspects of the fellowship program operate within the framework of the common objectives of the six core competencies identified by the ACGME including practice-based learning, professionalism; systems based practice, interpersonal communication skills, medical knowledge, and patient care. During their fellowship training, all fellows must be able to demonstrate proficiency in performing procedures related to the care of Endocrine diseases. At the completion of training, all fellows are expected to take and pass the ABIM subspecialty exam in Endocrinology.

D. Performance Expectations (See page 48 -- Goals and Objectives)

All details of performance expectations are guided by the ACGME six core competencies and are detailed in the appendix of this document and as noted below.

1. Patient Care

a. Goal: Fellows in Endocrinology are expected to provide patient care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness, and treatment of Endocrine diseases.

b. Objectives: The fellow will be able to:

i. Gather accurate, essential information from all sources, including medical interviews, physical examination. must demonstrate competence in the practice of health promotion, disease prevention, diagnosis, care and treatment of patients of each gender, from adolescence to old age, during health and all stages of illness

ii. management of hormonal problems including diseases, infections, neoplasms and other causes of dysfunction of, the following endocrine organs:.

iii. Make informed recommendations about preventative, diagnostic, and therapeutic options and interventions that are based on clinical judgment, scientific evidence, and patient preference.

iv. Develop, negotiate, and implement effective patient management plans and integration of patient care both as a provider of endocrine care and consultant to others.

v. Perform competently the diagnostic and therapeutic procedures considered essential to the practice of Endocrinology outlined by the Accreditation Council for Graduate Medical Education (ACGME).

Educational Activities: Exposure to a variety of endocrine diseases on our

Inpatient consultative service, outpatient clinical settings, and didactic lectures.

Evaluation Methods: Attending Evaluation, Self-Evaluation, Direct Observation,

360 Evaluation

2. Medical Knowledge

a. Goal: Fellows are expected to demonstrate knowledge of established and evolving biomedical, clinical, and social sciences as they apply to the rheumatic diseases, and to apply their knowledge to patient care and the education of others.

b. Objectives: The fellow will demonstrate knowledge of scientific method of problem solving, and evidence-based decision making and must demonstrate knowledge of indications, contraindications, techniques, and interpretation of results of those diagnostic and therapeutic procedures integral to the discipline, including the appropriate indications for and use of screening tests/procedures. They must demonstrate knowledge of:

i. Basic laboratory techniques, including quality control, quality assurance, and proficiency standards.

ii. Biochemistry and physiology, including cell and molecular biology, as they relate to endocrinology, diabetes and metabolism.

iii. Developmental endocrinology, including growth and development, sexual differentiation, and pubertal maturity.

iv. Apply this knowledge to clinical problem solving, clinical decision-making, and critical thinking.

vi. Use their knowledge of endocrinology to design, implement, and analyze data from independent clinical or basic research.

Educational Activities: Direct patient care in both inpatient and outpatient care.

Didactic conferences: core conferences, case conferences, journal clubs, and

research conferences. Continuous learning through provided educational

resources.

Evaluation Methods: Attending Evaluation, Self-Evaluation, Direct Observation

3. Interpersonal and Communication Skills

a. Goals: Fellows are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams.

b. Objectives: The fellow will learn to:

i. Communicate effectively with patients, families and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds.

ii. Communicate effectively with physicians, other health professionals, and health related agencies

iii. Work effectively as a member or leader of a health care team or other professional group.

iv. Act in a consultant role to other physicians and health professionals.

v. Maintain comprehensive, timely, and legible medical records.

Educational Activities: Practical communication skills are built throughout each day in the interactions of the fellows with patients, families, ancillary staff, peers, and faculty members. It is demonstrated in conferences provided by the fellow.

Evaluation Methods: Attending Evaluation, Self-Evaluation, Direct Observation, 360 Evaluation, Conference Evaluation

4. Professionalism

a. Goals: Endocrine fellows are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, and understanding and sensitivity to diversity, and a responsible attitude toward their patients, their profession and society.

b. Objectives: By completion of this program, rheumatology fellows will be able to:

i. Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues.

ii. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors, and disabilities of patients and professional colleagues.

iii. Adhere to principles of confidentiality, scientific and academic integrity, and informed consent.

iv. Recognize and identify deficiencies in peer performance.

Educational Activities: Professional characteristics such as honesty, integrity, and empathy are modeled by faculty and demonstrated by fellows throughout each day in the interaction with patients, families, ancillary staff, peers, and faculty members.

Evaluation Methods: Attending Evaluation, Self-Evaluation, Direct Observation, 360 Evaluation

5. Practice-Based Learning Improvement

a. Goals: All endocrinology fellows are expected to demonstrate the ability of investigate and evaluate their care of patient, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.

b. Objectives: Endocrinology fellows will build upon their previous learning and refine their skills. They will be able to:

i. Identify strengths, deficiencies, and limits in one’s knowledge and expertise, set learning and improvement goal and identify and perform appropriate learning activities.

ii. Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice.

iii. Develop and maintain a willingness to learn from errors to improve the system or processes of care. And participate in the education of patients, families, students, fellows and other health professionals.

iv. Use information technology or other available methodologies to access and manage information, support patient care decisions, and enhance both patient and physician education.

v. Demonstrate the ability to organize learning opportunities including the selection of conference topics, coordinating speakers, and scheduling conferences.

Educational Activities: Direct patient care in both inpatient and outpatient care.

Didactic conferences: core conferences, case conferences, journal clubs, and

research conferences. Educational resources are provided to further

practice-based learning. Departmental Patient Safety Conferences (previously

Morbidity and Mortality) are held to enhance the patient care experience by using

the Vanderbilt Patient Healthcare Matrix to demonstrate use of all core

competencies.

Evaluation Methods: Attending Evaluation, Self-Evaluation, Direct Observation

6. Systems-Based Practice

a. Goals: Endocrinology fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care as well as the ability to call effectively on other resources in the system to provide optimal health care.

b. Objectives: Endocrine fellows will be able to:

i. work effectively in various health care delivery settings and systems relevant to their clinical specialty,

ii. coordinate patient care within the health care system relevant to their clinical specialty.

iii. incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population based care as appropriate.

iv. Advocate for quality patient care and optimal patient care systems

v. work in inter professional teams to enhance patient safety and improve patient care quality

vi. participate in identifying system errors and implementing potential systems solutions.

.

Educational Activities: Direct patient care in both inpatient and outpatient care.

Didactic conferences: core conferences, case conferences, journal clubs, and

research conferences. Departmental Patient Safety Conferences (previously

Morbidity and Mortality) are held to enhance the patient care experience by using

the Vanderbilt Patient Healthcare Matrix to demonstrate use of all core

competencies.

Evaluation Methods: Attending Evaluation, Self-Evaluation, Direct Observation

E. Conferences and Lectures

Department of Medicine Grand Rounds, Patient Safety, and Clinicopathological Conference

Fellows attend Departmental conferences, which each meet weekly to monthly, as often as possible.

Internal Medicine Ground Rounds are held weekly and cover an array of topics including general and sub-specialty internal medicine, ethics, and professional development.

The Patient Safety Conference (Morbidity and Mortality) is a monthly designed to critically review patient management, including creating a “culture of safety”, learning from defects in patient care, and incorporating human and environmental factors to reduce error. These conferences use the Vanderbilt as a key tool to evaluating each case (see appendix) and empower clinicians to effectively implement change, using the. Attendees include physicians from all specialties within the medical center, risk management employees, attorneys, administration, nursing, and quality control.

The Clinicopathological Conference is a multidisciplinary conference presented as case-based teaching followed by correlation of clinical and pathological findings. This conference provides a venue for fellows to review biopsy or autopsy results of cases and discuss the impact these findings have on disease management. In addition, the conference serves to convey an understanding of problem-solving skills and to provide an in-depth review of complex or unusual cases.

F. Professional and Ethical Behavior

The mentors in the training program strive to role model a culture that values professionalism and ethical behavior. Qualities emphasized include commitment to scholarship, excellence in clinical patient care, humanistic qualities of respect and compassion, and professionalism. Opportunity is taken in conferences, bedside rounds and in one-on-one evaluation sessions with the program director and faculty to discuss and educate the fellows on biomedical ethics and to allow the fellows to participate in ethical decisions arising from the management of their patients.

Fellows and faculty are instructed to recognize and intervene if colleagues suffer physical or psychological impairment, including substance abuse, alcoholism, sleep deprivation, or excessive stress. If there are concerns, these matters are addressed accordingly.

G. Evaluation of Fellows

Fellows are evaluated using a variety of assessments (see appendices). Faculty members evaluate fellows on inpatient, outpatient and VA rotations. On the clinical services, fellows are assessed after each rotation by a faculty member who had direct supervision during the rotation. The evaluation is conducted with an electronic form subdivided into the six core competencies of patient care, medical knowledge, practice-based learning, interpersonal skill and communication, professionalism and systems-based practice. Evaluators are asked to choose a rating scale that measures the strength of agreement with a clear statement about the how well the fellow succeeded in each category. The evaluation is presented to the fellow, who reviews it at the completion of the rotation (for the clinic rotations, this may be verbal and/or at the 6 month evaluation meeting with the Division Director). Should differences in opinion arise, the fellow, faculty member and Program Director meet for discussion. In addition, inpatient charts are audited daily by the attending physician, and daily case-based feedback is provided to the fellow. Concerns of the faculty or fellows are addressed immediately by the Program Director.

Fellows also receive 360 degree evaluations from clinic staff, peers, self, and periodic patient evaluations with assessments of communication, interpersonal, and professionalism skills.

The Program Director meets with each fellow at least twice per year for a review of his or her performance with a written report filed in the trainee’s evaluation folder. At the end of the two-year training, a written summary of the trainee’s performance is reviewed with the fellow and placed in his or her folder for a permanent record for future reference.

H. Advancement to Succeeding Training Year

The KU Endocrinology Division Director meets with each first year fellow annually to review each fellow’s performance and make recommendations for advancing to the next year. Additional meetings may be called at the discretion of the Endocrinology Fellowship Program Director. Criteria used to base recommendations for promotion include: rotation evaluations with specific emphasis on the fellows’ performance in the core ACGME competencies; participation in academic conferences; annual in-training examination performance; compliance with all hospital, departmental and fellowship record keeping, policy and documentation requirements.

Disciplinary and remedial action may be initiated when the Program Director, after consulting with key clinical faculty, determine that such action is warranted.

I. Evaluation of Faculty and Program

Fellows evaluate faculty at least twice annually for the clinic rotations. These evaluations are submitted anonymously. They are summarized for individual faculty and for the Program Director and are used to counsel faculty and to assign faculty to specific teaching rotations. Fellows evaluate the program on an annual basis and these evaluations are used to develop programmatic changes.

J. Documentation of Training

The program will keep a file on each fellow, which will include copies of their evaluations, copies of their summaries, letters of recommendation, and any other document pertinent to their training and performance. The fellow may view this folder at any time. These files are maintained indefinitely to document the length and content of their training as well as their performance. The program is responsible for completion of forms documenting training as residents apply for hospital credentials, state medical licenses, etc. Fellows should ensure that the program has updated contact information, including business address, e-mail, and phone numbers so that future communication can be maintained.

V. POLICIES AND PROCEDURES

The Endocrinology Program uses its best efforts, within the limits of available resources, to provide an educational training program that meets the ACGME's accreditation standards. In addition, the Program will provide the fellow with adequate and appropriate support staff and facilities in accordance with federal, state, local, and ACGME requirements. The policy and procedures in this manual are in addition to the policies and procedures manuals in place at the departmental and institutional level. Fellows should refer to the GME office Housestaff Policy and Procedure Manual and the Program Manual Department of Internal Medicine for a comprehensive review of Housestaff Policy for full details. These manuals are reviewed at general housestaff orientation. Copies of these materials are available from the program director, department administration, or the dean's office. They are also available on the KUMC websites: http://www.kumc.edu/school-of-medicine/gme/policies-and-procedures.html and http://www.kumc.edu/Documents/internalmed/HousestaffManual%202018-07-25%20Final.pdf

A. Prerequisites/Selection/Eligibility

Fellows must hold an MD or DO degree from an accredited medical school meeting one of the following criteria: 1) graduation from a medical school in the United States or Canada accredited by the Liaison Committee on Medical Education (LCME), 2) graduation from a college of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA), 3) graduation from an acceptable medical school outside the United States or Canada with one of the following: i) successful completion of a Fifth Pathway program provided by an LCME accredited medical school, ii) a current, valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) prior to appointment iii). All Canadian citizens and eligible Canadian Landed Immigrants who are NOT graduates of a foreign medical school must hold a status, which allows employment as a medical resident, and maintain an appropriate status throughout the length of the graduate medical training program. Possession of valid immigration documents which verify the status must be presented iv) A full, unrestricted license to practice medicine in the State of Kansas and Missouri, depending on the training program. Definition of acceptable medical school outside the United States is further defined in the GME office Housestaff Policy and Procedure Manual (Section 4.1)

Fellows must have satisfactorily completed an ACGME accredited US residency program in Internal Medicine. On rare occasion, fellows are accepted as transfer from another accredited Endocrinology Training program. Transferring fellows must meet requirements and regulations as outlined in the GME office Housestaff Policy and Procedure Manual (Section 4.2)

B. Fellowship Selection Process

The Endocrinology division participates in the Electronic Residency Application Service (ERAS). We also participate in the National Residency Match Program for Internal Medicine Subspecialty Programs. Potential fellow applicants must submit an application consisting of ERAS forms, an updated curriculum vitae, 3 letters of recommendation, and a personal statement prior to consideration for a personal interview. After review of the submitted materials, selected applicants are asked to personally visit the program and interview with members of the faculty. Every attempt is made for applicants to meet the majority of the full-time KUMC-based key clinical faculty. After the personal interview with the program director and faculty, candidate evaluation forms are submitted. After completion of the interview of candidates, a fellowship selection committee consisting of the Program Director and Endocrinology faculty meet to rank the candidates according to interview evaluation ratings. Once the NRMP releases the match results, the applicants matched to our institution receive a contingent offer of appointment. The fellow then must complete the appropriate documentation and requirements as detailed in the GME office Housestaff Policy and Procedure Manual (Section 4.5). Official notification from the University of Kansas School of Medicine is by contract that is mailed in the spring prior to beginning the fellowship.

C. Duration of Program

The program is two years (24 months) with an emphasis on training in clinical endocrine diseases.

D. Duties

The fellowship includes both clinical and research responsibilities. It is the duty of the fellow to carry out the clinical responsibilities of the services to which the fellow has been assigned. This includes not only clinically evaluating patients, following their progress and implementing therapy but also teaching of medical students and residents. Fellows should be aware of the fellow and attending on-call schedule as posted on the Divisional calendar. Electronic email reminders of call schedule will be sent at the start of the academic year and revisions as necessary. Fellows are expected to utilize the proper checkout procedure when rotating to a new service. This provides an opportunity for the fellow to learn to work in teams and effectively transmit necessary clinical information to ensure safe and proper care of patients.

Specific duties for each rotation are outlined and reviewed prior to the beginning of each rotation. Educational expectations and guidelines should be reviewed by the fellow and discussed by the attending staff at the beginning of the rotation. The guidelines are provided to each fellow at the beginning of the fellowship and remain available throughout their training for review. These are also provided at the beginning of each rotation to fellows and faculty by email through MedHub.

In the area of research, the fellow is expected to carry out a scholarly activity under the guidance of a faculty mentor. This project should culminate in both publications in a journal and scientific presentation at a regional or national meeting (examples of these meetings include the Kansas ACP or the ACR annual meetings). Laboratory research training and experience may be acquired in conjunction with Endocrinology, Internal Medicine faculty or through another department approved by the Program Director. Experience with endocrinology clinical trials is available with endocrinology faculty.

In addition to training in the discipline of endocrinology, fellows are expected to participate in the education of Internal Medicine residents and medical students during Faculty/Fellow-Student interactions and in physical diagnosis.

It is the philosophy of the program that fellows should follow the principles of adult learning including self-motivation, utilizing the medical literature to solve clinical problems, and broadening their knowledge base on rare disorders that may not be seen as frequently. Thus, it is expected that rare disorders will be discussed in core curriculum conferences, case conferences, and that the fellows will identify such areas and obtain articles from the medical literature so that they have a conceptual understanding of these disorders. The faculty are expected to be readily available for guidance and suggestions.

E. Duty Hours Policy and Fatigue

The fellowship program strictly adheres to the ACGME requirement concerning work hours as reflected in the KU GME Policy and Procedure Manual (Section 15). To this end, fellows will not work more than 80 hours per week averaged over a four week period, inclusive of all in-house call activities during any rotation. Moonlighting hours will be included in this calculation. Fellows will be provided 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 1 continuous 24-hour period free from all clinical, educational, and administrative duties. Adequate time for rest and personal activities must be provided. The program director continuously monitors work hours at the semi-annual evaluation conducted with each fellow. The GME office conducts annual surveys of all trainees at KUMC.

The usual time for fellows to begin the workday varies by hospital, rotation, and day of the week. In general fellows are expected to begin clinical service work by 8 am. Fellows are expected to attend a 7am conference as often as once weekly. The conclusion of the day is when all clinical responsibilities are met including evaluating patients, completing appropriate documentation and coordinating a care plan for the following day with the attending. It is expected that all fellows have 10 hours free of duty between scheduled duty periods. Specific duty hour and work expectations will be unique to the individual site the fellow is assigned. Expectations are at the discretion of the attending and will be reviewed at the beginning of each clinical rotation.

All clinical faculty and fellows have been instructed on the work hour policies and the detection of fatigue in trainees and updated on institutional policies annually. Both faculty and fellows are required to successfully complete the ANGEL Fatigue module. Signs and symptoms of fellow fatigue and/or stress may include but are not limited to the following: inattentiveness to details, forgetfulness, emotional lability, mood swings, increased conflicts with others, lack or attention to proper attire or hygiene, difficulty with novel tasks and multitasking, awareness is impaired (fall back on rote memory), and lack of insight into impairment. Supervising faculty monitor fellows for signs of fatigue and report these findings to the program director as soon as possible. The program encourages fellows to use alertness management strategies such as strategic napping, in the context of patient care responsibilities. Fellows have access to sleeping quarters (KUH IM on call rooms 4461-4464) to be used at their discretion.

If adequate rest facilities are not available, then you may use the voucher fatigue transportation service. The program leadership and administration will receive 2 vouchers for every 10 residents. The PC should keep this in a place well known to the residents for easy access afterhours.

· For each event 2 vouchers will be needed (one for home and then one for back to work the following morning)

· The Vouchers will need to be filled in by the resident/fellow and the transportation service driver (designated as KUMC Resident Program Transportation voucher). Please print your name, Department and home address on the voucher.

· When you are ready to leave, please call 10/10 Taxi Service (913-647-0010) and tell them you are using the KUMC Resident Program Transportation voucher and your destination. They will pick you up at the Main Entrance of the hospital.

· The transportation service will collect each voucher white copy and submit to the GME Office. It is important that you return the YELLOW copy of the voucher to your program director.

· The transportation service is allowed to pick you up from the KUH Hospital Main Entrance and drop you off at your home address, without any interval stops. This also applies for the return trip from your home to back to the hospital main entrance the next morning. You need to use the second voucher for the return trip.

· The resident is responsible for discussing the event and fatigue issue with their Program Leadership the following day. This must be documented by the program leadership in the “Fatigue/Transportation Incident Report” This is available in MedHub – Fatigue/Transportation Incident Report (example 111 below). Again, please return the yellow voucher copies to your program director at this time as well. The purpose of this file is to track both individual and program-wide episodes of fatigue and additional duty in order to mitigate future recurrences.

· The GME Office will manage the cab vouchers and bill back the departments as they are being used as well as replenish the voucher supply

Appropriate action including relief of duties for rest, modification of duties to insure adequate rest, cancellation of moonlighting privileges will be instituted by the program director after discussion with the fellow and faculty if such need arises. An overview of the GMEC Fatigue (Transportation/Swing Room) Guidelines are provided in References.

F. Call Schedule

Fellows will be on call at home in the evenings and on weekends during their inpatient consultation service rotation. At TUKHS, a rotating call schedule among fellows is made by the administration team and/or senior fellow(s). The call schedule and schedule of duty assignments is published and made available for review by the fellows on a monthly basis. At-home call, will not be so frequent as to preclude rest and reasonable personal time for each resident. Fellows taking at-home call are provided with an average of 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. There is a rotating back-up call schedule to assure this occurs. They will be expected to see any new emergency inpatient consultations in a timely manner and will take all clinic associated patient calls. On average, the at-home call fellow receives 3 telephone calls at night or on weekends. In general fellows are required to return to the hospital to participate in patient care no more frequently than once weekly, usually on weekends. Attending physicians are expected to see and discuss these cases with the fellow on call in a timely manner. When fellows are called into the hospital from home, the hours the fellow spends in-house are counted toward the 80-hour limit. The Program Director, faculty, and the GME office will monitor the demands of at-home call in their programs, and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.

G. Lines of Communication and Responsibility - Supervision

Communication

Communication between faculty and fellows is essential regarding patient care as well as others areas. Fellows are encouraged to use text paging, voice mail, EMR and MS Outlook secure e-mail to update faculty of any interactions with patients. Telephone calls between patients and fellows should be recorded as a telephone encounter in the electronic medical recorded and copied to the faculty attending physician in a timely manner when appropriate. When complex decisions are addressed, fellows are required to contact faculty in-person or by phone. Faculty supervision occurs continuously.

During the first year of training, fellows review all changes in therapy or recommendations for invasive procedures with the faculty attending prior to making the recommendation to another physician. As the first year of training progresses the faculty may allow the first year fellow to proceed with certain types of therapeutic recommendations before reviewing them with faculty. During the second year, if the trainee has made satisfactory progress, they are given more autonomy in making recommendations if he/she is comfortable and confident in the recommendation and then review with the Endocrinology attending following the communication. All trainee recommendations must be reviewed within 24-hours by the appropriate faculty member.

During a consultant service rotation, fellows may work directly with medical students and Internal Medicine residents assigned to the service. Students and IM residents report to the Endocrinology fellow according to the service they are assigned. Any of the trainees may directly contact the Endocrinology consultation attending at any time for problems, advice, or direction. When communicating with other services, students and residents must be clear that their recommendations are suggestions and must be reviewed with the Endocrinology attending prior to making a formal recommendation.

Endocrine Supervision Template found on Page 43.

Service Sign-out or Hand-off Policy

Fellows are instructed to follow a standard sign-off process when rotating from the inpatient consultative service. On the final day of consult rotation, the fellow is asked to communicate a checkout list of the patients they are actively following to the fellow taking over their service in a face-to-face manner or by phone if a face-to-face meeting cannot occur such as on a weekend. Active patient lists in the electronic record are to be kept updated with service designation and provider name in order to give other providers information on the assigned Endocrinology patient and contact information for the consulting team.

Non-teaching patients

At all sites where Endocrinology follows, there are no private service patients seen by fellows except under urgent/emergent circumstances such as a rapid response or Code Blue. Fellows are not required to provide routine intravenous, phlebotomy, or messenger/transporter services. Fellows’ service responsibilities are limited to patients for whom the consultation teaching service has diagnostic and therapeutic responsibility regardless of the inpatient admitting service. Fellows are expected to evaluate new consults on these services and follow them daily. 

Order writing

Endocrinology fellows write orders on patients seen in consultation only if the admitting team has approved. It is the responsibility of the Endocrinology fellow or attending who is writing the order to notify the primary service that the order was written. The electronic medical record provides guidelines for order protocols.

Lines of responsibility

The Endocrinology fellows are responsible to the Endocrinology attending assigned to oversee clinical responsibilities for patient related educational matters. Fellows and faculty are to report to the Division/Program Director. The Endocrinology Division Director reports directly to the Chair of the Department of Internal Medicine who is responsible to the Dean of the Medical School. The Endocrinology Division Fellowship Director reports to the Department of Medicine Residency and Fellowship Committee and Director. The Internal Medicine Residency and Fellowship Director reports to the Designated Institutional Officer.

H. Meeting Attendance

Fellows are required to attend weekly and monthly Endocrine conferences, inter disciplinary conferences and other Internal Medicine conferences.

· Endocrine Journal Club Conference. 3rd Tuesday of the month 12:00 PM

· Endocrine Core Conference: Every Tuesday at 12:15 PM

· Endocrine Case Series: Every Tuesday at 11:30 AM

· Endocrine Case Conference: 4th Tuesday of the month at 12:15 PM

· Thyroid/Parathyroid Tumor Board: 3rd Wed of the month. 7 AM

· Endocrine Division Research Conference: Monthly (date varies)

· Multidisciplinary Pituitary Conference: First Thursday of the month 7:30 AM

· Endocrine Imaging Conference: once monthly, dates TBD

All conferences are conducted at KUMC. When a fellow is assigned to a rotation at the KCVA, they are expected to travel to KUMC for these conferences but return promptly to their training site to complete rotation assignments in a timely manner. Fellows and faculty are expected to attend all conferences unless illness or vacation precludes. Under certain circumstances, fellows may be able to attend conferences virtually while on rotation at KCVA.

The Division regards several institutional conferences as an integral part of fellowship education. Fellows are expected to participate in the following meetings at each educational site (KUMC and KCVA):

· Patient Safety Conferences (Morbidity and Mortallity)-once monthly

· Clinical Pathologic Conference- once monthly

· Internal Medicine Grand Rounds-weekly Wed at 12:00 PM

· Internal Medicine Core Conferences given by Endocrinology faculty.

These conferences are conducted at KUMC. Grand Rounds and Internal Medicine Core Conferences are broadcast to the KCVA.

I. Vacation and Leave Time

Scheduled leave (maternity leave, paternity leave, personal and interview time) must be requested at least 60 days in advance by submitting a request through Qgenda and is approved by the Division Director. This is done to avoid negatively affecting the continuity clinic schedule for providing patient care.

The Program Coordinator will maintain all time off requests and provide notification that leave time has been approved. The fellow requesting leave must inform the appropriate clinic attending.

Vacation Leave

· Fellows will be granted vacation days off in accordance with the most current KU School of Medicine GME Policy and Procedure Manual.

“The University will provide up to a maximum of three weeks (15 workdays) of vacation, per contract year, which is covered by the resident stipend. Vacation must be requested from and approved by the Program Director or a designee in advance in the manner prescribed by the program. Denial of a specific request for vacation is a management decision on the part of the officers of the program and is not a grievable matter. (5.5.11 v.2 4.21.15)”

· Fellows scheduling and vacation preferences will be accepted prior to the start of the academic year. Fellows are encouraged to prioritize, rank, and provide context for the requests. The program leadership will attempt to accommodate fellow requests, but cannot promise that all requests are granted.

· Vacations requests are should be taken in one week blocks. Consideration will be given for one of the three weeks to be split into individual days. Any vacation day that is taken outside of a one week block that involves clinical time needs to be approved by the program director and the faculty member in charge of that rotation. Vacations will run from Monday through Sunday unless there is specific program director approval. Fellows cannot be assured that they will be free from call duties on both the weekend before and after the requested vacation week.

· Fellows should try to take only one week off from each rotation. An extended vacation of 2 consecutive weeks is possible with prior approval from the program director. Every effort should be made to overlap this extended vacation between two rotations to avoid an extended absence from one rotation. An extended absence from one rotation should be taken from the research rotation.

· Fellows should make request for vacation time at least 60 days prior to planned vacation. Remember do not make travel plans such as airline reservations prior to approval.

Vacation time scheduled when on the VA rotations must be split as equally as possible between all fellows. The VA allows the same amount of vacation and professional time as KU (based upon a 1.0 FTE position). Vacation time cannot be accumulated from year to year.

The KU Endocrinology and Internal Medicine programs require leave without pay for a fellow that does not return on time from vacation, including persons unable to return on time due to immigration process reasons.  This program also advises fellows that the program is not responsible for problems that impede a scheduled international return. Should any fellow wish advice on this matter, they may seek counsel from the KUMC office that specializes in immigration matters and immigration law.

Holidays/Days Off

· The KU Endocrinology Fellowship positions are financially funded by University of Kansas Hospital, and the Kansas City Veterans Hospital. These different organizations observe different holiday schedules and clinical service coverage may vary for institutionally observed holidays. It is the responsibility of the fellow to be in communication with their site director as to the clinical duties expected around institutionally observed holidays.

· Fellows are not guaranteed holidays off beyond what is granted through vacation requests.

· Before the start of the year fellows may also submit a single request for their preference of a “holiday no-call day” to the program director. (i.e. Thanksgiving day, Christmas day, New Year’s day, or other). Efforts will be made to distribute holiday call in accordance with these requests but is not guaranteed. Even if the fellow is off call duty on that holiday, some sites may consider the day after the holiday a regular work day (i.e. Friday after Thanksgiving). Hence, fellows wishing for time away on the holidays, particularly for traveling out of town, should submit a vacation request instead. Fellows are typically scheduled on-call for either Thanksgiving OR Christmas but not both.

· In accordance with ACGME policy Fellows 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.

Professional Leave

· Fellows have 5 professional days per year with approval of the Program director. Any additional days are at the discretion of the Program Director.

· Fellows may attend one of the national meetings associated with the field of endocrinology. Fellows who attend will be allotted a stipend for travel expenses. Additional travel costs exceeding the stipend are the fellow’s responsibility. Fellows need to receive approval for absence from the faculty in charge of the rotation and the program director before planning absence to attend a professional meeting.

· Fellows should have request for professional time along with the needed approval at least 60 days prior to the planned dates.

· Fellows may take professional leave for medical board examinations. Fellows should communicate their board exam schedule to the program director once the date is confirmed.

· Fellows may take professional leave to interview for permanent jobs after fellowship. This absence must be approved by the program director and needs to be approved 60 days in advance.

· The professional day is counted as the actual day of the interview, board exam, conference, or presentation. Additional days off such as to travel, may be counted as the scheduled 1 day off in 7. Thereby, call schedules may be adjusted as need to account for absences.

· Endocrine University attendance by second year fellows will not be included in the professional days of the second year.

Sick Leave

The University will provide up to 10 workdays of sick leave per year to cover personal illness or illness in the fellow’s immediate family (spouse or children). Sick leave cannot be accumulated from year to year.

· Fellows requiring sick leave must page and speak directly with the program director. Text pages and emails are not acceptable.

· Fellows are also required to contact and speak with their staff physician for the rotation as well as their clinic attending if applicable that day.

· A request in Qgenda for the sick day is required; this can be entered after feeling better.

· Program directors may require documentation of illness, particularly if multiple days are missed. Fellows may present to their PCP, minute clinic, make a rapid return appointment at KU or be seen in the ER for this documentation. For chronic conditions, please discuss with the program director.

· A fellow calling in sick on a call day may have their call/required days off rescheduled.

· If all 10 days of sick leave are used, vacations days may be required to be used for sick leave. If neither sick days nor vacation days remain, the fellow may have to take unpaid leave. Fellows are not eligible for FMLA until they have been employed for at least 12 months. For details on KUMC’s complete FMLA policy, please refer to http://www.kumc.edu/human-resources/policies-and-procedures/family-and-medical-leave-act.html

Should a leave of absence exceed accrued time, stipend payments will be interrupted. However, family health insurance benefits will continue as long as the resident pays the individual premium.

The American Board of Internal Medicine allows up to one month, per year, as time away from the program. Time used beyond this one month will be required to be made up to meet the requirements for taking the board exam. The ABIM does not distinguish between vacation time and leave for illness, including pregnancy-related disabilities, and includes them as time away from the program. (See IM House Staff Program Manual, Section L)

Maternity Leave:

· Fellows expecting a baby are asked to notify the program director of the due date as soon as possible to plan/adjust schedules.

· Any unused sick leave/vacation time needs to be used to cover maternity leave.

· For leave beyond these 5 weeks (3 weeks vacation + 2 weeks sick), you may be able to schedule an elective rotation in order to facilitate additional flexibility in your schedule.

· If you choose to use an elective, you may still be expected to attend your continuity clinic as directed in order to remain in compliance with ACGME guidelines, the fellow should discuss with the fellowship director.

· Fellows will be expected to view missed core lectures, GME conferences via recorded review or live webstream where applicable. The fellow should discuss with the fellowship director specifics.

Paternity Leave

· Fellows expecting a baby are asked to notify the program director of the due date as soon as possible to plan/adjust schedules.

· Fellows can use Vacation Requests and Sick Days to accommodate their schedule.

Family Leave Policy

The Division of Endocrinology follows the family leave policy delineated in the KU School of Medicine Graduate Medical Education Policy Manual (Section 5). This document includes description of leave policy for each parent, and supersedes any policy of the Division. Should there be extenuating circumstances; the Division Director welcomes the fellow to bring any unforeseen problems to attention for consideration. It is important to inform the Program Director promptly upon knowledge of pregnancy. This permits necessary adjustments in the schedule.

A resident eligible for FMLA leave may request FMLA designation pursuant to the University’s FMLA policy for up to twelve weeks of leave per academic or contract year: (1) because of the resident’s own serious health condition, including because of the resident’s own pregnancy, or a qualifying work-related illness or injury; (2) to care for the resident’s immediate family member who has a serious health condition; (3) for the birth of a child or placement of a child with the resident for adoption or foster care; or (4) for any “qualifying exigency” arising out of the fact that the resident’s spouse, son or daughter (of any age) or parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves. A resident eligible for FMLA leave also may request up to 26 weeks of military caregiver leave to care for a spouse, son daughter, parent or next of kin who is a covered service member in the regular armed forces, the National Guard or Reserves and who is undergoing medical treatment, recuperation or therapy, or who is otherwise on the temporary disability retired list, for a serious injury or illness relating to that covered service member’s military service.

Refer to KUMC’s complete FMLA policy and/or contact KUMC’s Human Resources for additional details regarding FMLA leave. Residents must draw down all PAID leave while on FMLA. If the maximum number of vacation and sick leave days for the year has been used, the resident’s FMLA leave will be unpaid.

Stipend payments to the resident will be suspended during periods of leave without pay, but the resident will continue to receive all other non- healthcare benefits.

Residents will be responsible to pay out of pocket for continued health care benefits while on leave without pay. Residents should work with KUMC’s Human Resources on maintaining health care benefits while on leave.

When possible, the resident must give the School and program a 30 day notice of the intent to take leave for foreseeable covered events such as childbirth, adoption, or necessary medical treatment. However, if the need for leave arises without 30 days advance notice, the resident must provide notice of the need for leave as soon as is reasonably possible.

Residents requesting leave will work with their program director to address coverage of resident duties during leave, transition of resident duties both prior to and following leave, and the impact of leave on all ACGME and RRC training requirements for competency and Board certification requirements.

Note: The use of leave may require the resident to extend his/her training program to satisfy ACGME or the training board eligibility/certification requirements (see http://www.kumc.edu/Documents/gme/2015%20EligibilityforSpecialtyBoardExams. xlsx for information regarding specialty board exams). The length of the extension, if required, normally will be equal to the total time absent from the program, excluding vacation leave and sick leave, but is dependent on the specific training board requirements. A resident satisfying an obligatory training extension will receive a stipend and other benefits subject to the usual terms of the Agreement that covers the extended training period.

Residents returning from FMLA Leave must meet all certification and reinstatement requirements of KUMC’s FMLA policy prior to being returned to work. KUMC does not discriminate against residents who use FMLA leave or who exercise their rights under the FMLA. Additionally, KUMC does not consider the taking of FMLA 23 as a negative factor when making employment decisions.

In addition, residents are required to make up time at the end of residency should they exceed their accumulated time for leave. This is subject to approval from the Program Director as the Department of Medicine becomes financially responsible for a resident’s salary if training is completed “offcycle,” or after June 30 of the second year of training.

Funeral Leave:

· Fellows may take up to 6 days of Funeral Leave for the death of a close relative, pending approval of the Program Director. In order to take a Funeral Leave you must communicate with the program director. In addition fellows must send an email to the program coordinator.

Child Illness:

· If your child is sick, then you are allowed to take this as a sick day. The above policies re: sick leave apply.

· If you are having childcare issues, this is required to be taken as a vacation day and the above policies apply.

Late Start

The Endocrinology program cannot allow a late start (after July 1) to the usual training period due to financial restraints at the University. This means that an unscheduled and unforeseen ability to initiate or to continue training on time may result in the inability of the program to accept such a fellow.

J. Benefits

Compensation is set by the Department of Medicine. The first year fellow is considered at the PGY 4 and the second year at the PGY5 level. Additional benefits are those designated by the Department of Medicine for residents of the same level. These are provided by the Department of Medicine and are outlined in detail in the Department of Medicine Program Manual (Section 5). Benefit questions can be further directed to the Endocrinology Fellowship Program Coordinator (588-6841) or the Internal Medicine Business office (588-6000).

Pay

Fellows get paid every two weeks, starting two weeks after the fellow completes the first pay period. A resident can choose to have the pay check mailed to his/her home or have it deposited electronically into his/her account.

Medical insurance

Medical insurance is paid by the University but fellows do have a choice regarding particular plans. This is the same choice offered to University employees. Detailed information on the various coverage plans will be made available during the new fellows’ orientation.

Life insurance

The Department purchases a group term life insurance policy for all of its residents and fellows without the necessity of prior examination. This includes accidental death and dismemberment protection in the amount of $50,000. This policy is convertible to permanent life insurance within 31 days of leaving the group. This benefit should be kept firmly in mind as the training program finishes.

Malpractice insurance

While practicing medicine at the KU Medical Center and its affiliated hospital training sites, fellows are covered by a self-insurance plan administered by the State of Kansas. This policy provides standard coverage for all activities typical to internal medicine. There is tail coverage for any suits filed after a fellow has left the Department for a period of 3 years. This policy covers fellows only while practicing under approved circumstances in the KU Medical Center and its affiliated hospitals. In general, this is not confining. However, when considering issues related to moonlighting, there may not be coverage provided for non-affiliated hospitals. It is the fellows’ responsibility to know if they have coverage during moonlighting time.

Disability insurance

The Department insures fellows should they become disabled and cannot work. The policy pays $1000/month if benefits begin 181 days after the disability. This policy takes effect without the necessity of a qualifying physical examination. This policy may be converted to private use, again without requiring an examination, if one decides to do so within 31 days of the termination of with the Department. This is potentially a very valuable benefit, which should be considered, as one approaches the end of training. There are multiple supplemental policies, which are further defined in the orientation lectures.

Parking

Parking is provided by the Division in the P5 parking facility at the beginning of the academic year. Parking at the Kansas City and KCVA Hospitals is also provided.

White coats

The Division provides each resident with two embroidered white coats. Residents should be aware that it is official medical school policy that white coats with name and hospital ID be worn at all times. This same policy states that no other buttons, stickers, pictures, appliqués, statements, political comments etc. adorn the white coats.

Access to Medical Literature and Board Preparation Materials

The Archie Dykes Library for the Health Sciences is located across 39th Street, north of the hospital. The library stocks the vast majority of commonly desired books by the clinical and basic science staff. Access to the library’s electronic journals and databases are available online through the KUMC website, both on and off campus. All University and KCVA hospital computers have Up To Date and internet access to the Dykes library is available both on campus and from home. There are books, including board review resources available in the Endocrinology library located the fellows’ office and the outpatient clinics.

Work environment

The Endocrinology Program will provide a safe and adequate work environment as outlined in the GME office Housestaff Policy and Procedure Manual (Section 5.8.3).

The Program will provide access to food service and sleeping quarters to the fellow while on-call or otherwise engaged in clinical activities requiring the fellows to remain in the Medical Center overnight. However, the Endocrinology fellows are not scheduled for in house overnight call. Sleeping quarters and quiet rooms are also available for fellows should they experience fatigue that would mitigate alertness management strategies such as strategic napping.

In addition, personal protective equipment including gloves, face/mouth/eye protection in the form of masks and eye shields, and gowns will be available. The Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control (CDC) assume that all direct contacts with a patient’s blood or other body substances are infectious. Therefore, the use of protective equipment to prevent parenteral, mucous membrane and non-intact skin exposures to a healthcare provider is strongly recommended.

K. Moonlighting Policy

Professional activity outside of the scope of the fellowship program, which includes volunteer work or service in a clinical setting, or employment that is not required by the program (moonlighting) shall not jeopardize any training program of the University, compromise the value of the trainee's education experience or interfere in any way with the responsibilities, duties and assignments of the fellowship program. It is within the sole discretion of the Program Director to determine whether outside activities interfere with the responsibilities, duties and assignments of the fellowship program. Before engaging in activity outside the scope of the Fellowship Program, fellows must receive the written approval (using the form provided by GME) of the Division Director and/or Fellowship Program Director of the nature, duration and location of the outside activity. Furthermore, the frequency or duration of outside professional activities must not be such as to result in physical and mental fatigue leading to impairment of training. The Endocrinology fellow may not schedule time to exceed the 80 hours maximum duty time each week mandated by the Policy and Procedure Manual.

Fellows while engaged in professional activities outside the scope of the fellowship are not provided professional liability. A fellow providing services outside the scope of the fellowship program shall warrant to University that the fellow is and will remain insured during the term of any outside professional activities.

The regulations governing moonlighting activities and professional liability insurance requirements for these activities are discussed in the Department of Medicine Program Manual Policy and Procedures Section V.O and the KU GME Policy and Procedure Manual Section 16. The documents are made available to the fellow during the Department of Medicine orientation and are available online.

L. Ethics

With increasing medical sophistication, the ethical questions, which surround a patient’s care often, overwhelm the medical decisions. Medical and even more so ethical complexities are commonplace in the field of medicine. Even in the most complicated ethical situation, the first and most important step is to talk with the patient and, if permitted by the patient, the family. Only through full communication with the appropriate decision maker can the fellow address honestly, thoroughly and expediently the issues of concern.

The hospital ethics committee, available 24 hours a day by pager, consists of both medical and other personnel who are available to explore and advise on major ethical concerns. Physicians on the committee are available for discussion and for consultation at any time. In addition, there is a monthly Ethics conference held by the Ethics committee in conjunction with the General Medicine division. Ethical dilemmas arising on the inpatient medical services are discussed in an informal setting.

M. Utilization Management

It is the responsibility of the Endocrinology Fellow to assure that documentation in the record completely describes the patient's severity of illness, as well as the intensity of treatment services provided to the patient. Documentation of level of care, complexity of the case, records reviewed, diagnostic tests and radiographs personally reviewed, diagnoses, and recommended management are to be included on every note in the patient’s chart.

N. Quality Improvement

Continuous Quality Improvement (CQI) is an ongoing, flexible, integrated and coordinated healthcare program that stresses a commitment to continuously improve patient care and service and resolve identified problems by assessing and improving all aspects that most affect patient outcomes. It is the responsibility of all employees, including house staff, to actively participate in the CQI activities. The goal of the CQI program is to develop collection tools, analyze data, formulate data driven recommendations for improvement, and coordinate resolution of the identified opportunities for improvement. In identifying opportunities for improvement, the CQI program places emphasis on cost, quality, access, customer service, desired patient outcome. It pursues opportunity to improve care/service, allows for resolution of identified problems, assures a safe and healthy environment for patients, patient families and employees, and ensures appropriate and effective utilization of resources.

Continuous Quality Improvement Activities

Faculty and fellows will be expected to participate in the Patient Safety Conference of the Department of Medicine, which is presented monthly. In this conference the Vanderbilt Healthcare Matrix is utilized to review the case. This tool follows the six ACGME Clinical Competencies as well as the six IOM Aims (safe, timely, effective, efficient, equitable, patient centered. The tool provides a structured opportunity for the participants to look at an episode of care and determine how the quality of care was affected by the core competencies and identify potential areas of deficiencies and opportunities for improvement. The monthly Department of medicine CPC Conference also provides a structured environment to examine individual and system practices and opportunities for improvement.

Fellows are encouraged to participate in a variety of departmental Quality Improvement initiatives. Such projects are under the directorship of Endocrinology faculty and focus on topics such as optimal utilization of the electronic medical record.

Each fellow is evaluated using a 360-degree evaluation. This includes electronic anonymous evaluation by peers, nurses and clerks. An anonymous patient provided evaluation process has been implemented to include fellow evaluation in the clinic setting. Identified evaluations are completed by attending physicians.

In the same way, each faculty member is evaluated by a 360-degree evaluation. This includes anonymous evaluations by patients, and endocrinology fellows. The faculty evaluation includes the following: teaching abilities, commitment to educational program, clinical knowledge, professionalism and scholarly activities. An anonymous faculty program evaluation form is completed on a semi-annual basis.

Each faculty actively participates in yearly program assessment and contributes to recommendations for updating program policies, curriculum content and scheduling.

Lectures covering the topic of quality improvement are sponsored throughout the year by the Department of Medicine. Endocrinology Fellows are required to attend.

O. Risk Management

This section supplements the KU GME and Internal Medicine Policy and Procedure Manuals.

Risk Management involves both the Hospital and The University of Kansas. It also involves the prevention or handling of adverse events and the handling or legal issues.

Adverse Events

The State of Kansas requires reporting of all adverse events to a confidential reporting system. When a patient suffers an adverse event, the first priority is to assure the patient’s safety through intervention and follow-up, including ordering any additional monitoring or tests. An example might be an anaphylactic reaction to a known medication allergen. Priorities include stabilizing the patient and making sure staff report the adverse through the hospitals adverse event reporting system.

If an adverse event occurs that has the potential to leave a patient with severe, permanent disability or death, The Joint Commission requires a Root Cause Analysis (RCA) be conducted to determine contributing factors and an action plan to prevent recurrence of such an event. The Hospital’s[footnoteRef:1] Risk Manager will facilitate the RCA and its follow-up. [1: This could be the Veterans’ Administration Medical Center, the University of Kansas Hospital, or other facility where you perform resident activities.]

In addition, fellows should contact the University Risk Manager at 913-588-7283, and inform the University Risk Manager of the situation. Do not write any notes about the situation, other than objective charting in the patient’s record, or additional notes in the adverse reporting system for the Hospital or facility. If anyone asks you to write a summary of events, contact the University Risk Manager.

Other Reasons to Contact the University Risk Manager

In addition to serious or fatal adverse events involving patients, the University Risk Manager should be contacted whenever the following happens:

1) You receive a phone call from any attorney requesting to meet with you. These can be plaintiff’s attorneys in our or others malpractice cases or malpractice cases, defense attorneys in our or others malpractice cases, criminal defense attorneys, or criminal prosecuting attorneys, usually a District Attorney’s office.

2) You receive a subpoena from any source. A subpoena is a court document directing you to court to testify or to a deposition to provide sworn testimony prior to a case, either civil or criminal. A subpoena must be properly served before it is enforceable and the University Risk Manager will assist you in properly responding to the subpoena and assuring you do not miss any time deadlines that might put you at risk of being held in contempt.

3) You receive a summons from any source. This is a court document that “summons” you to court to defend yourself in a lawsuit. You have a limited time, 20 days, to respond to a summons so contact the University Risk Manager immediately. A defense attorney will be assigned to you to respond to the summons. In civil cases, the summons is accompanied by a petition or complaint. In a criminal case, the summons is accompanied by an arrest warrant.

4) You have any questions about medical-legal situations. It is far easier for everyone involved to answer questions and take preventative measures than to undo some situations. Examples include:

a. Questions around required reporting of abuse, victims of crimes, etc.

b. Questions around how to chart adverse events in the patient chart.

c. Questions around litigation process, contacting your defense attorney,

etc.

d. Wanting to review a case and evaluate potential risks issues.

P. Professionalism

It is imperative that the fellow learn appropriate behavior of a professional during their experience. It is recognized that health care is best delivered when physicians are collegial, yet frank with each other and respectful and caring of their patients. It is thus the responsibility of the fellow to be fit, ready for work and dressed appropriately. Faculty should be notified if the conduct of the fellows is ever considered less than professional. The Program Director will discuss such incidents with the fellow in question.

The use of illicit drugs will not be permitted at any time and alcohol shall not be consumed by anyone who is on call or on active duty. Anyone found in violation of these rules will be treated in accordance with departmental and school policy.

Sexual or gender harassment by fellows of anyone at the university will not be tolerated and will be grounds for referral to the department's administration. At the same time no fellow should ever be the subject of sexual, gender, religious, ethnic or other harassment. Any complaint of such behavior should be reported to the Division Director, the program director, or the department chairman.

Finally, the Division recognizes the advantages of diversity amongst its members and supports their rights to different religious, political, economic, and artistic beliefs. Thus, any discrimination or harassment of any fellow, or any other member of the Division, because of these differences should be reported.

These policies and procedures are a supplement to the policies and procedures outlined for the Department of Medicine and the KU SOM Graduate Medical Education Office (Section 7). These manuals are provided at the beginning of the fellowship and available on the web sites of Internal Medicine or the Graduate Medical Education Office.

Q. Impairment

Satisfactory performance includes the absence of significant impairment (impaired function of a resident to a degree that it is causing less than satisfactory performance, and/or the impaired function, if not corrected or is uncorrectable, is likely to lead to future unsatisfactory performance) due to physical, mental, or emotional illness, personality disorder, or substance abuse. Every effort will be made to reasonably accommodate those individuals with conditions or impairments that qualify as a disability under applicable law, provided that the accommodation does not present an undue hardship for the Department, the Medical School, or venues of training. Fellows will nevertheless be required to satisfactorily meet the Department’s performance criteria, requirements, and expectations of the Endocrinology Fellowship Program. If the Director has cause to suspect that a fellow’s behavior may be altered due to a physical or mental impairment, the use of drugs, narcotics, or alcohol, the Director will consult with the IM RRC office to follow the standard procedures of the University in this regard. Please refer to KU GME Policy and Procedure Manual (Section 7) for the details of institutional policy regarding identification of impairment, reintegration into training, and ongoing monitoring of affected residents or fellows.

R. Disciplinary Actions, Probation, Suspension and Termination

The Fellowship Director or the Associate Fellowship Director is responsible for the evaluation & discipline of each endocrinology fellow in this program. Fellows are monitored and evaluated based on the six core competencies and standards set forth by the Division and Institution and include the following:

1) Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

2) Medical knowledge including established and evolving biomedical, basic science and clinical, sciences and the application of these to patient care.

3) Practice-based learning and improvement that involves investigation and evaluation of the fellow’s own provisions of patient care, appraisal and assimilation of scientific evidence, followed by improvements in delivery of patient care.

4) Interpersonal and communication skills that result in effective information exchange making provision to team with patients, families, and other health professionals.

5) Professionalism as shown by a commitment to carrying out professional activities and responsibilities, adherence to ethical principles, and sensitivity to diverse patient types and backgrounds.

6) Systems-based practice shown by actions that demonstrate awareness of and responsiveness to the larger health care system, the ability to effectively use system resources to provide optimal care.

In addition, the fellow will comply with the rules and requirements of KU Hospital, the KUMC GME office, the Department of Medicine Internal Medicine Program Manual. While rotating at the KCVAMC or RMC, each fellow will comply with their specific rules, guidelines, and requirements as well as those promulgated by the Boards of Healing Arts of the States of Kansas or Missouri as required.

Other specific guidelines require that each fellow will:

1) Develop a personal program of learning for continued professional growth with guidance from the teaching staff.

2) Participate in the educational and scholarly activities of their program and teach or supervise other residents, students, or fellows.

3) Participate in appropriate institutional committees as appointed by the division director or the designee

4) Submit regularly an electronic anonymous confidential evaluation of the faculty and of the educational experience.

5) Continue in active scholarship. This may include publications, or presentations at local, regional, or national scientific society meetings and could involve cases, reports or clinical series, or translational research.

6) Be an active participant in clinical discussions, rounds, journal clubs, and research conferences in a manner that promotes collegiality, inquiry and scholarship.

REMEDIATION AND PROBATION

Definitions and Causes

Remediation is the process in which the faculty of a Program and a resident judged to be performing at a less than satisfactory level work together to identify, understand, and correct the cause(s) for the resident’s deficiencies. Certain RRCs and specialty boards provide that, among the actions that a department may take in the remediation process for “marginal” residents, is possibility of requiring the resident to repeat one or more rotations, or in more extreme cases up to 12 months of training in the attempt to address deficiencies in performance. Such provision is entirely at the discretion of the Officers of the Program and must be allowed by the RRC of the specialty in question. Placing a resident on probation is another of the actions that may be taken by a department in the “remediation” of a resident. Probation identifies a resident as requiring more intensive levels of supervision, counseling and/or direction than is required of other residents at the same training level in the same program. Placement of a resident on probation implies that the department will be responsible for documenting the necessary increase in staff supervision, counseling and evaluation that will allow the resident to remedy the deficiencies, if possible. Unlike other remedial actions which occur at the departmental level, placement on probation also serves to notify the School of Medicine that the resident is experiencing difficulty in the training program.

Probation Categories and Criteria

Criteria for placement on academic probation include but are not limited to: a) unsatisfactory performance based on in-service examinations, quizzes, and/or oral/written examinations and evaluations; b) failure to show expected rate of improvement in fund of knowledge; or 63 c) unsatisfactory participation and/or performance in conferences or educational programs.

Criteria for placement on clinical probation include but are not limited to: a) unsatisfactory acquisition of clinical or technical skills or competence, b) unsatisfactory performance in the clinical setting, c) deviation from the professional standard of care, or d) provision of care without appropriate staff supervision.

Criteria for placement on administrative probation include but are not limited to: a) misconduct; b) violations of institutional and/or program policies and procedures or those of an affiliate; or c) unsatisfactory completion of charts or other deficiencies or delinquencies of the medical record.

When placing a resident on probation, the program can cite multiple criteria within a single category and/or deficits in more than a single category.

Documentation of Probationary Status

The probationary status of a resident shall be well documented and copies of the documentation shall be maintained and become a permanent part of the resident file.

11.3.2 Prior to placing a resident on probation, the program must notify the Associate Dean for Graduate Medical Education or designee, in writing, of the action and receive approval.

11.3.3 Materials leading to the resident probationary period, including copies of all pertinent letters, evaluations, and actions discussed with the resident, shall be provided to the Graduate Medical Education Office.

Duration

The duration of a probationary period will be three months. No resident will be allowed more than two periods of probation. Residents who show a continued lack of improvement, or otherwise unsatisfactory performance, at the end of their second probationary period will be proposed for corrective action.

Notice and Response

Probationary status begins upon the resident’s receipt of written notice of probation.

The written notice shall clearly specify the reasons for probation and the steps that the program believes must be taken by the resident to correct the deficits and be returned to good standing.

The resident must countersign the notice indicating that he/she has reviewed the notice and been informed of his/her change in standing. The resident’s signature indicates receipt of the notice only, and does not necessarily constitute agreement with the contents of the document.

The probationary resident will be allowed seven (7) days after receipt of the written notice to respond in writing to the notice of probation. The resident can either: a) respond indicating that he/she understands the reasons for the change in standing and accepts the program’s terms for remediation; b) request a meeting with the Program Director and/or Department Chair. Such meeting will provide the resident an opportunity to further explore and understand the reason(s) for the change in standing. At the conclusion of such meeting, the resident and the Officers of the Program will attempt to arrive at a mutually agreed upon plan for remediation. Should an agreement be reached, the Program Director will prepare a written summary that is countersigned by all participants; or c) submit a written request seeking redress of the probationary status through the grievance process. In such a case, the resident must be prepared to show that imposition of the probationary status is not in accordance with the policies and procedures for Graduate Medical Education or that the program is inconsistent or otherwise unfair in the processes of resident evaluation, probation and/or remediation.

Failure of the resident to respond to the notice of probation, in writing, is equivalent to acceptance of the terms and conditions of probation as outlined in the written notice.

The original notice and the resident’s response along with any other relevant documents will become a part of the resident’s file, and the Associate Dean for Graduate Medical Education will receive copies.

Evaluation during the Probationary Period

The Program Director or Chair must obtain evaluations from the faculty members who are supervising the probationary resident on a monthly basis throughout the probationary period.

The Program Director or Chair must prepare a brief written summary of these monthly evaluations and discuss the evaluations with the resident, at the same time providing counseling and feedback regarding the resident’s performance along with suggestions for improvement.

Discussion with the resident will be verified by having the resident sign the written summary.

Resolution of Probationary Status

1. If, in the judgment of the Program Chair and Program Director, a probationary resident shows satisfactory improvement, resolves his/her de