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Should changes be made to the program policy or monitoring issues the LSU School of Medicine- New Orleans Office of Graduate Medical Education and the GMEC Committee will be notified.

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III.E.10 Staying Longer Than 24+4 House Officer Policy¹²

House Officers are not allowed to stay longer than 24 hours with 4 hours for transitions. In those rare and extenuating cases where a House Officer absolutely must remain after 24+4, the House Officer must contact the Program Director for a specific exemption. If the Program Director verbally agrees, the House Officer must email the Program Director the following:

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The Program Director will directly monitor each request, and it believed such requests will be rare. The Program Director will collect and review written requests on a regular basis for each individual case and all cases totals. The Sponsoring Institution will monitor numbers and types of exceptions during annual program reviews.

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III.E.11 Moonlighting¹³

• All moonlighting activities must be reported by each House Officers as work hours in New Innovations

• All moonlighting must be counted toward the 80-hour weekly work hour limit

• House Officers cannot be required to engage in moonlighting activities

• PGY-1 House Officers are not permitted to moonlight

• House Officers employed under a J-1 visa are prohibited from moonlighting by law

• House Officers may not moonlight at pain or weight loss clinics

• Individual ACGME-accredited Programs may prohibit their House Officers from moonlighting

• Each House Officer must submit to his/her Program Director a written request for approval of all moonlighting, which must be signed and approved by the Program Director and/or Department Head and maintained as part of the House Officers permanent training record. Each request for moonlighting must include the nature, duration and location of the moonlighting and must be accompanied by a completed Disclosure of Outside Employment Form¹⁵ in accordance with LSU System PM-11¹⁶.

• House Officers participating in moonlighting activities must be fully licensed to practice medicine in each state where he/she moonlights and must have their own Federal DEA number. Neither a training license nor a training DEA number is valid for moonlighting.

• House Officers, who are moonlighting, will not be covered for medical malpractice under the LSU Health Sciences Center’s Professional Liability Insurance Policy. House Officers must maintain adequate professional liability coverage or ensure that his/her outside employer provides adequate professional liability coverage. It is the responsibility of the House Officer and his/her outside employer to determine what constitutes adequate coverage. It is also the responsibility of the House Officer and his/her outside employer to determine if the House Officer is appropriately licensed and has the appropriate training and skills to carry out his/her assigned duties.

• Program Directors are responsible for ensuring that moonlighting does not interfere with the ability of the House Officer to meet the goals, objectives, assigned duties, and responsibilities of the educational Program. Each Program Director will monitor all moonlighting activities in his/her Program; if moonlighting activities are believed to adversely affect the House Officer’s performance in the Program, the Program Director may withdraw permission to moonlight.

• Permission for moonlighting may be withdrawn at any time by the Program Director, Department Head, and/or the Associate Dean for Academic Affairs - Graduate Medical Education.

• House Officers moonlighting without prior written approval will be subject to disciplinary action.

• Any House Officer violating any School of Medicine moonlighting rule, policy, or procedure will be subject to disciplinary action.

Special Considerations:

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Once a House Officer has treated someone, a doctor-patient relationship has been created and all legal and professional standards apply, including HIPAA laws that prevent discussing a patient or case with anyone not directly involved in that patient’s care.

Moonlighting - Foreign Medical Graduates

Moonlighting by J-1 visa holders is not allowed; the J-1 visa is for educational and cultural exchange and is not a work visa, so activities considered integral part of the educational program should be covered by a House Officer’s base salary. If the base salary does not cover an activity, then it is considered moonlighting. Any J-1 visa holder that is moonlighting is in violation of the LSU contract with the House Officers and the ACGME guidelines.

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III.F. Fatigue Mitigation Education and Services

Programs must educate all faculty members and House Officers regarding the signs of fatigue and sleep deprivation. In addition, Faculty and House Officers must receive education in alertness and fatigue mitigation. House Officers are encouraged to use fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning. In the event a House Officer may be unable to perform patient care duties due to fatigue, illness, or similar issues, the Program must have a clearly defined backup plan in place to ensure continuity of patient care. A House Officer too fatigued to return home safely may use available call rooms to sleep or obtain safe transportation via taxi or ride-sharing services.

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III.F.1 Adequate Rest for House Officers Policy

The following policies are in place to ensure House Officers have adequate rest between duty periods and after on-call duty:

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6. Faculty are expected to model behaviors that encourage fitness for duty as noted above; the Supervision Policy requires faculty to observe for signs of fatigue, especially during transitions.

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III

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.F.2 Alertness Management / Fatigue Mitigation Strategies¹⁷

Programs must educate faculty and House Officers about alertness management and fatigue mitigation strategies via online modules and at departmental conferences. Pocket cards distributed to all House Officers contain the following alertness management and fatigue mitigation strategies:

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Programs will employ backup call schedules as needed in the event a House Officer cannot complete an assigned clinical work period.

How Monitored:

The Sponsoring Institution and Program monitor successful completion of all AMA online modules, especially those regarding fatigue mitigation. House Officers are encouraged to discuss any issues related to fatigue and alertness with supervisory House Officers, Chief Residents, and the program administration. Supervisory House Officers will monitor lower-level House Officers during any in-house call periods for signs of fatigue. Adequate facilities for sleep during day and night periods are available at all rotation sights and House Officers are required to notify Chief Residents and program administration if those facilities are not available or not properly maintained. Supervisory House Officers and faculty will monitor lower-level House Officers at all transition periods for signs of fatigue. The institution will monitor clinical and educational work hours violations in New Innovations, the Annual Resident Survey (administered by the institution to all House Officers and as part of the annual review of programs) and the special review process to ensure compliance.

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III.G. Professionalism¹⁸

In keeping with the Common Program Requirements, Programs ensure that:

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1. Providing and monitoring a standard Transitions Policy

2. Providing and monitoring a standard Clinical and Educational Work Hours Policy

3. Providing and monitoring a standard Supervision Policy

4. Providing and monitoring a standard master schedule and process in New Innovations

5. Adopting an institution-wide policy that all House Officers and faculty must inform patients of their roles in that patient’s care

6. Providing and monitoring an Alertness Management and Fatigue Mitigation Policy that includes:

7. Online modules for faculty and House Officers regarding signs of fatigue

8. Fatigue mitigation and alertness management including pocket cards, back up call schedules, and promotion of strategic napping

9. Assurance of available and adequate sleeping quarters when needed

10. Requiring that programs define what situations or conditions require communication with the attending physician

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III.G.1. Process for implementing Professionalism Policy

The Sponsoring Institution and Programs will assure effective implementation of the Professionalism Policy through:

1. Program presentations of this and other policies at program and departmental meetings

2. Core Modules for faculty and House Officers on Professionalism, Clinical and Educational Work Hours, Fatigue Recognition and Mitigation, Alertness Management, Wellness, and Substance Abuse and Impairment

3. Institutional Fitness for Duty and Drug Free Workplace policies

4. Institutional Clinical and Educational Work Hours policy

5. Specific language added to the Policy and Procedure Manual, the House Officer Manual and the Contract regarding the Clinical and Educational Work Hours Policy and the responsibility for and consequences of not reporting work hours accurately

6. Comprehensive Moonlighting policy

7. Orientation presentations on Professionalism, Transitions, Fatigue Recognition and Mitigation, and Alertness Management

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III.G.2. Monitoring Implementation of the Policy on Professionalism

The program and institution will monitor implementation and effectiveness of the Professionalism Policy by evaluation of House Officers and faculty including:

1. Daily rounding and observation of House Officers in the patient care setting

2. Evaluation of the House Officers’ ability to communicate and interact with all other members of the health care team by faculty, nurses, patients (where applicable) and other team members

3. Rotation and semi-annual competency-based evaluation of the House Officer

4. Annual Program Evaluations and Special Program Reviews.

5. Successful completion of online modules for faculty and House Officers on Professionalism, Impairment, Clinical and Educational Work Hours, Fatigue Recognition and Mitigation, Alertness Management, and others

6. Program and Sponsoring Institution New Innovations monitoring of work hours and procedure logging, as well as violations

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III.H. Well-Being

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III.H.1. Self-Care

The School of Medicine is committed to providing House Officers with an academic and clinical education carefully planned and balanced with concerns for patient safety, House Officer and faculty wellbeing. The Sponsoring Institution, in addition to each training Program, has the same responsibility to address well-being as they do to evaluate other aspects of House Officer competence. Programs, in partnership with the Sponsoring Institution, must make specific efforts to enhance the meaning that each House Officer finds in the experience of being a physician, including protecting time with patients, minimizing non-physician obligations, providing administrative support, promoting progressive autonomy and flexibility, and enhancing professional relationships. This responsibility must include:

...

House Officers must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours. The Institution and Programs must direct attention to House Officers and faculty member burnout, depression, and substance abuse. The Program, in partnership with the Sponsoring Institution, must educate faculty members and House Officers in identification of the symptoms of burnout, depression, and substance abuse, including means to assist those who experience these conditions. House Officers and faculty members must also be educated to recognize those symptoms in themselves and how to seek appropriate care. The Program, in partnership with the Sponsoring Institution, must encourage House Officers and faculty members to alert the Program Director, the GME Office, and appropriate Departmental faculty when they are concerned that a House Officer or faculty member may be displaying signs of burnout, depression, substance abuse, suicidal tendencies, or potential for violence.

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III.H.2. Coverage of Patient Care

In circumstances in which a House Officer may be unable to work, including but not limited to fatigue, illness, and family emergencies, each Program must have policies and procedures in place that ensure continuity of patient care without fear of negative consequences for the House Officer.

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III.H.3. Counseling and Mental Health Resources – Campus Assistance Program (CAP)

In collaboration with Participating Sites, the Sponsoring Institution works to ensure a healthy and safe environment for House Officers inclusive of access to appropriate tools for self-screening and access to confidential and affordable mental health assessments, counseling and treatment.

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Program Directors can administratively referral a House Officer to the program. The DIO will receive confidential updates to confirm that House Officers are attending sessions as required in their referral plan.

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III.H.4. Fitness for Duty

The Louisiana State University Health Sciences Center (LSUHSC) promotes and protects the well-being of faculty, staff, House Officers, students, and patients.

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This policy applies to all faculty, staff, House Officers, students, contract and subcontract workers, medical staff, volunteers, laborers, or independent agents who are conducting business on behalf of, providing paid or gratis services for, or being trained at LSU Health Sciences Center.

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IV. Institutional GME Policies and Procedures

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IV.A. House Officer Recruitment, Eligibility, and Selection Policy

House Officer selection criteria conforms to ACGME Institutional and Program Requirements where applicable. House Officers are selected by Program Directors from an applicant pool in the National Residency Matching Program (NRMP) or from NRMP Specialty Matching Services Programs.

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All House Officer trainees must have a valid active license or permit to practice medicine in the State of Louisiana (or a DDS license for General Practice Dentistry residents and pre-MD Oral Surgery residents). The Louisiana State Board of Medical Examiners issues temporary training permits to qualified post-graduate year 1 level trainees. Temporary permits (Visiting Resident Permits) also may be issued for certain foreign medical graduates entering the U.S. on J-1 visas. Foreign citizen trainees must have standard Educational Commission for Foreign Medical Graduates (ECFMG) certification. Rules and regulations regarding trainees with visas frequently change. The GME Office refers all questions regarding visas to the LSUHSC Office of Governmental Relations to ensure compliance with all institutional, state, and Federal rules and regulations.

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IV.A.1 Match Policy

All programs that are eligible to participate in the Match must do so in accordance with all rules and regulations of the National Residency Matching Program (NRMP, also referred to as the Match). Programs are advised to be aware of rules regarding hiring of House Officers outside the Match.

Programs that receive the list of students that matched with the program before Match Day are not to share this information with the students either directly or indirectly prior to Match Day. Failure to comply with this policy is considered a Match violation by the program and institution and can result in serious consequences for both.

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IV.A.2 Appointment of House Officers

Program administration must secure, in writing, funding for all house officers that will be training in the program. If funding is not adequate, Match quotas (the number of house officers a program accepts per year) will be adjusted. Approval by the DIO is required prior to requesting an increase in Match quotas.

Programs requesting an increase in funding for positions at LCMC participating sites must complete the required LCMC Documentation Request for Increase in Resident Complement Form and receive approval by the GMEC. The DIO must sign the form before it can be submitted to the Chief Academic Officer for LCMC.

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IV.A.3 J-1 Visa House Officers

The institution policy states that International Medical Graduates on J-1 ECFMG sponsored visas should not be given gratis appointments for clinical training positions. In addition, fellows on J-1 visas cannot be appointed in part as instructors nor may they moonlight to generate income.

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IV.A.4 INP-55 Positions

LSU does not allow appointment of international medical graduates into INP-55 positions for training purposes.

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IV.A.5 Accepting House Officer from another Program

All programs are required to verify the adequate performance of an outside House Officer in writing before accepting a trainee 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 House Officer directly from his/her training program. All required documentation can be found in the GME Knowledge Base¹⁹. Programs cannot offer a position to an applicant until all required documentation is submitted to the LSU GME Office, reviewed by the Director of Accreditation, and approved by the DIO.

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IV.A.6 Advanced Standing for House Officers with Previous Post Graduate Training

The School of Medicine will not pay House Officers at a higher level of salary if House Officers have completed internships or residencies prior to entering the LSU residency programs as post-graduate year 1 level trainees. For pay purposes, House Officers will be paid at the lowest PGY rate at which they can enter a program. If they can enter as a PGY-1 they will be paid as a PGY-1. If they must have one year of training (e.g., preliminary year) before they can begin training, they will be classified as a PGY-2, regardless of past training. In cases where House Officers could enter after two training years (e.g., Plastic Surgery), the House Officers will be paid at either level as determined by the GME Office. Other cases will be considered individually.

A House Officer that transfers into a program from another training program will be appointed and paid at his/her current level of training if all previous training months are approved by the specialty board of the program into which the House Officer transferred. If the Board does not accept any of the House Officer’s previous training, the House Officer will begin at the HO 1 level.

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IV.A.7 Drug Screening and Background Check

All newly hired faculty, staff, House Officers and student workers of LSU Health Sciences Center-New Orleans will be required to undergo drug (including cannabinoid) testing as a condition of employment.

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Background Check email for New House Officers starting July 1 will be sent from LSU Human Resources approximately April 15 and should be completed by the New House Officer within 7 days of email receipt. Once the background check is completed and the House Officer is cleared for hire the Program Coordinator and the GME Office is notified.

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IV.B. Agreement of Appointment/Contract

All written agreements of appointment/contracts are for one year. Each House Officer must be reappointed for each subsequent year of training, contingent upon satisfactory completion of the current training year with the assurance that all requirements are met for promotion. Contract renewal is subject to mutual written consent of the Department Head and the House Officer. A contract must be renewed in a timely manner and in accordance with ACGME requirements as outlined in the School of Medicine Policy and Procedure Manual, with dates set by the GME Office.²⁰

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IV.B.1. Agreement of Appointment/Contract – Notice of Non-Renewal

The institution must ensure that programs provide the House Officers with a written notice of intent not to renew a House Officer’s Agreement of Appointment (contract) in accordance with prevailing ACGME requirements. The Programs will provide their House Officers with as much written notice of the intent not to renew as circumstances will reasonably allow, prior to the end of the agreement of appointment. House Officers must be allowed to file a grievance according to the Sponsoring Institution’s procedures (outlined in House Officer Manual) once they receive written notice of non-renewal. Conditions for reappointment and non-renewal of the contract are discussed in the House Officer Manual.

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IV.C. Promotion, Appointment Renewal and Dismissal

All new House Officers are provided a conditional offer of appointment. The offer is contingent upon the successful completion of a background check and drug screen, as well as upon primary source verification of credentials to confirm that the individual possesses the basic requisite education, training, skills, personal characteristics, and professionalism to train at LSUHSC. Failure to meet all conditions of appointment will result in revocation of the offer of appointment in accordance with NRMP requirements. This action cannot be appealed. All written agreements of appointment/contracts are for one year and each House Officer must be reappointed for each subsequent year of training; reappointment is contingent upon the satisfactory completion of the current post-graduate year. Terms and conditions of appointment to a Program are outlined in the House Officer Agreement of Appointment/Contract. The Sponsoring Institution will honor the full term of the contract except when a House Officer’s performance justifies termination. Recommendations for the appointment and reappointment of House Officers are initiated by Programs. Contract renewal is subject to mutual written consent of the Department Head and the House Officer. House Officers are expected provide sufficient advance notice to the Department if they do not intend to return the following year.

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IV.C.1. New Hire, Promotion, Non-Promotions and Termination Paperwork

All completed paperwork for all new hires, promotions, non-promotions, and terminations within a program must be submitted to the GME office prior to June 1st. Clearance for hire will be issued once an individual has passed the required pre-employment drug screening and background check. All new hire packets must be completed with proper signatures before House Officers can begin the training program. All paperwork, (including PER 3’s if needed), to promote, terminate, or transfer House Officers must be submitted by June 1st.

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1. Pays the new House Officers for the first pay period of July.

2. Pays the continuing House Officers at their promoted levels.

3. Pays the terminating House Officers their last check and makes them eligible to receive their deferred compensation contribution if they elect to deduct the funds.

4. Pays the transferring House Officers and transfers them to the correct program for July 1.

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IV.C.2. Request for Adverse Action and Notice - Required elements, format, and suggestions

1. Due Process is for non-promotion, non-reappointment and termination but NOT probation.

2. IMPORTANT - Due Process consists of 2 parts:

   1. The Request for Adverse Action (described below): The Request for Adverse Action is sent to the Department Head, not House Officer. Once the Department Head has reviewed the request and agrees, he/she creates a short letter called the Notice

   2. The Notice – a short letter from the department head stating he/she supports the proposed adverse action.
      
      The Notice is attached to the Request for Adverse Action, and BOTH are delivered to the House Officer by mail or hand-delivered AND sent by email with a read receipt notice.

3. LSU GME Due Process is complex, and the timing is concise and crucial. It is vital that you follow the Due Process exactly as outlined. Failure to follow the Due Process timeline often leads to cases being overturned and legal action occurs.
   

4. Follow the Request for Adverse Action template in Appendix A. It should be detailed and include specific examples, dates, and witnesses.

5. The required FOUR components of The Request for Adverse Action are:

   1. The proposed disciplinary action - if possible, the CCC should meet and recommend the proposed disciplinary action.

   2. A list of deficiencies/Reasons for Action: list the deficiencies by competency and ensure they are detailed

   3. List of all known documentary materials that you will use at a hearing – programs should try to avoid listing the residency binder, as they will have to allow the resident/fellow to review the entire binder.

      1. It is suggested that departments provide a list of deficiencies and list individually the documents that support those deficiencies: letters, test scores, evaluations, emails, incident reports and other documents that refer to each allegation.

   4. List of witnesses to be called and summary of their expected testimony. In cases where the documentary evidence is the House Officer record, the summary for the witness may be, “will attest to accuracy of information in the file or an incident in the file.” The Department may also list the deficiency, then list a witness that will attest to that deficiency or incident (ex. – Incident 4 - Dr. XXXXX was late for OR on XX/XX/XXXX. In the list of witnesses say, “Dr Jones will attest to his arriving late for OR as described in number 4 above.”).

6. Collect and list deficiencies by competency. Most will be for patient care, medical knowledge, professionalism, communication. For example:

   1. Patient Care

      1. List specific occurrences in OR/wards, etc. and dates

      2. Include House Officer’s statement about not being safe in OR

      3. Specific instances in the past – always put specifics including dates and even who will testify about it

      4. Inability to make decisions

      5. Lack of integrity

      6. Poor judgment

      7. Specific skills they should be able to perform, but can’t – start IV, induce anesthesia, etc.

   2. Professionalism – listing specific examples

      1. Unexcused absences

      2. Unprofessional behavior with staff or families or other docs

      3. Repeated tardiness

      4. Lying

      5. Email, Facebook, HIPAA violations, etc.

      6. Other unprofessional behavior

      7. Failure to keep CAP contract in effect

      8. Failure to meet terms of probation

      9. Failure to comply with rules, regulations, House Officer contract, House Officer manual

      10. Noncompliance with program or school policies – e.g., moonlighting

   3. Medical knowledge

      1. Failure to provide care equivalent to peers

      2. Milestone issues

      3. Evaluation issues – may include other competencies

      4. Failure to meet program requirement – certain score on in-service exams, failure to meet program timeline – e.g. pass USMLE by some specific date

      5. Not complying with terms of probation – e.g., reading certain things

7. A sample Request for Adverse Action has been included in Appendix A.

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IV.D. Medical Licensure, CDS-CME, Professional Liability Insurance, and DEA Numbers

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IV.D.1. Medical Licensure

House Officers must have a valid Louisiana Medical Permit, License or Graduate Education Temporary Permit (GETP) for training. It is the House Officer’s responsibility to contact the Louisiana State Board of Medical Examiners (LSBME) regarding licensure and to maintain a valid LA Medical License or permit during all training years. All questions regarding permits or licensure should be directed to LSBME staff. The House Officer is expected to be aware of LSBME licensure rules which periodically change.

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The Board shall issue a temporary permit to an applicant of an approved American or Canadian medical school or college (allopathic or osteopathic), for the purpose of participating in an accredited program of postgraduate medical training (residency training), beyond postgraduate year one, in a Louisiana medical school that is fully accredited by the ACMGE and approved by the board. All questions regarding renewing permits beyond postgraduate year one should be directed to LSBME staff.

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IV.D.2. Permits - Provisional Temporary

The LSBME may issue provisional temporary permits to individuals pending application for VISA or for those individuals awaiting the results of a criminal history background check.

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IV.D.3. Graduate Education Temporary Permit (GETP)

The LSBME may issue a GETP to an International Foreign Medical Graduate (FMG), for the purpose of enrolling and participating in an accredited program of postgraduate medical education (residency or fellowship). The FMG must pass USMLE Step 3 within the 24 months during which GETP is maintained; otherwise, the FMG is ineligible for further training. The FMG must also comply with other provisions of the LSBME.

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IV.D.4. Federation Credentials Verification Service - FCVS

As part of the licensure process, the LSBME uses a service of the Federation of State Medical Boards (FSMB) called the Federation Credentials Verification Service (FCVS). Once a House Officer has applied for permit/licensure, the Program will complete an updated FCVS form yearly for each House Officer so that FCVS has a complete training record for each physician that will facilitate credentialing in each House Officer’s professional career. At the start of residency, House Officers will sign a release for all years of training²².

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IV.D.5. Professional Liability Insurance

Medical Malpractice Verification Requests for House Officers

A Medical Malpractice Verification form requires that the person requesting the verification indicates the nature of his/her association with the practice sites or organizations requesting the verification. This information must be included when submitting the form for the Director of Medical Education’s signature; it is then forwarded to the Vice Chancellor for Administrative, Community and Security Affairs Office for the verification letter. Forms that submitted without the required information will be returned to the Department. Please provide complete addresses for all agencies not listed in the multiple-choice section.

LSUHSC will not provide coverage for work not done for or on behalf of LSUHSC (moonlighting). Contracts between LSUHSC and other institutions include malpractice coverage for work done for and on behalf of LSUHSC.

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IV.D.6. DEA Numbers

All temporary DEA Numbers issued at UMCNO are valid from the date issued through the house officer’s period of training. This temporary DEA number is restricted to prescriptions written for UMCNO patients only. Violators will be reported to the Medical Director and the DEA for appropriate disciplinary action.

Once the house officer receives their LSBME license, he/she is eligible to apply for his/her permanent DEA license. The application process takes 3-6 months to complete, so it is recommended that physicians begin this process before their temporary DEA Number expires.

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IV.E. Health and Disability Insurance

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IV.E.1. Health Insurance

House Officers are eligible to enroll in the state employees' health insurance or state managed health care options (HMO's etc.) through Employee Benefits (504-568-7780), or LSU Health Sciences Center student/resident health insurance Gallagher Benefit Services, Inc., 235 Highland Drive, Suite 200, Baton Rouge LA 70810, contact: Phone 225-292-3515 or Fax 225-296-3998. If desired, other health insurance may be chosen and must be paid for individually by the House Officer. A House Officer agrees to maintain one of these plans or another plan with equal or better benefits.

Additional information about health insurance plans is available in the Benefits Guide for House Officers. ²³

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IV.E.2. Disability Insurance

The Graduate Medical Education Office provides the opportunity for House Officers to participate in group Long-term basic disability coverage /insurance. LSU Health Sciences Center provides disability insurance for all residents. Additional personal policies may be purchased at the discretion of House Officers based on their perceived need. Counseling by third-party insurance brokers regarding additional coverage is offered to House Officers.

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IV.F. Vacation, Sick Leave, ACGME Special Leave and Leaves of Absence

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IV.F.1. Vacation, Sick Leave

House Officers are granted sick and vacation leave as described in the House Officer Manual. Each type of leave will be monitored and granted in accordance with LSUHSC policy, the needs of the Program, and the provisions of applicable law. Whether training time missed because of extended leave can be made up by the House Officer is determined by the Department Head and/or Program Director in accordance with the requirements of the particular Program, the American Board of Medical Subspecialties and the provisions of applicable law. In some instances, a House Officer may exceed the time off allowed by his/her respective board when taking all leave allowed by LSUHSC. For that reason, House Officers should familiarize themselves with the policies of their respective board regarding the effects of leave on board eligibility and discuss the potential impact of taking leave with the Program Director.

House Officers are permitted 14 days (two 7-day weeks) of non-cumulative paid sick leave per year for illness or injury of the resident or for an immediate family member. Extended sick leave without pay is allowable at the discretion of the Department and in accordance with applicable law.  

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IV.F.2. ACGME Special Leave

Extended Medical, Parental, Caregiver Leave

The ACGME passed an Institutional Requirement in 2022 allowing for up to six (6) weeks of approved paid leave for extended medical, parental and/or caregiver leave(s) of absence for qualifying reasons that are consistent with applicable laws during each ACGME-accredited program, starting the day the resident/fellow is required to report. It may be an aggregate of noncontinuous or continuous leave. Any available sick or vacation leave will be exhausted concurrently to this leave designation.

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All leave is administered at the program level. Leave should be approved by and coordinated with the program. Consult with the training program regarding questions or issues with this or any other leave policy. If this doesn’t resolve the matter, please contact the GME office at 504-568-4006.

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IV.F.3. Leave Of Absence (LOA) Account

The House Officer LOA account is used in the PS-Resident Scheduler System to schedule House Officers on LOA/LWOP from the program and is a non-paying account.  This account should be used if the House Officer has exhausted all vacation, sick, and other allowed paid leave. House Officers are also assigned to this account if:

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1. One ePAF Retro PER 3 (not a Paper PER 3) must be submitted to change the source of funds "From" or "To" the LOA combo code and "From" or "To" the paying project Number/Combo Code.

2. One Paper PER 3 must be submitted to Pay the House Officer correctly or Recoup the overpayment made to the House Officer.

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IV.G. Out-of-State and International Rotations

Necessary out-of-state and international rotations may be permitted after being approved by the appropriate Program Director or Department Head. House Officers may not be paid with state funds during these rotations. Prior to beginning such a rotation, funding, malpractice insurance, health and liability insurance, among other requirements, must be secured. House Officers assigned to facilities outside the state of Louisiana must provide additional professional liability coverage (other than coverage provided under LSA-R.S. 40:1299.39) with indemnity limits, as set by the House Officer’s Program Director.

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STATE MALPRACTICE DOES NOT COVER ROTATIONS DONE DURING VACATION TIME. IF A HOUSE OFFICER EXCEEDS ALLOWABLE VACATION TIME DURING A ROTATION, THE DEPARTMENT WILL BE LIABLE FOR THE SALARY.

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IV.H. Human Resources Policies

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IV.H.1. EEO

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Any individual who receives a complaint or becomes aware of a possible violation of this policy will immediately notify the HRM Employee Relations Manager, to obtain advice and assistance in responding to the complaint.

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IV.H.2. Harassment

Chancellor’s Memorandum (CM)-49 – Sexual Harassment / Gender-Based Harassment and Discrimination²⁵

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433 Bolivar Street

New Orleans, LA 70112

titleix@lsuhsc.edu Phone: 504-568-2211

The Title IX Coordinator will conduct procedures in accordance with Permanent Memorandum (“PM”) 73²⁶ for all complaints received related to sex or gender-based harassment and discrimination. Human Resource Management (“HRM”), in collaboration with the Chief of Staff, will assist the Title IX Coordinator, as necessary, in cases that involve an employee and/or a person that is both an employee and a student, in accordance with the policy contained in the following LSUHSC-NO publications: Faculty Handbook, University‘s Academic Catalog/Bulletin, and/or Residents and Fellows Policies and Procedures.

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For additional details regarding the policy and procedures related to Sex and Gender-Based Harassment and Discrimination, including Sexual Misconduct, please refer to PM 73. LSUHSC-NO will make every reasonable effort to ensure that all members of the LSUHSC-NO community are familiar with this policy. Questions or concerns regarding this policy should be directed to the Title IX Coordinator.

Nothing in this CM supersedes LSU Permanent Memorandum 73.

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IV.H.3. Disability Policy (CM26)²⁷

Louisiana State University (LSU) Health Sciences Center is an equal opportunity employer and makes employment decisions based on merit. LSU Health Sciences Center policy prohibits unlawful discrimination based on race, color, creed, sex, age, national origin, physical handicap, disability, medical condition, sexual orientation, or any other consideration made unlawful by federal, state or local laws. All such discrimination is unlawful.

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If LSU Health Sciences Center determines that unlawful discrimination has occurred, effective remedial action will be taken, commensurate with the severity of the offense. Appropriate action will also be taken to deter any future discrimination. Whatever action is taken will be made known to the House Officer and LSU Health Sciences Center will take appropriate action to remedy any loss to the House Officer as a result of the discrimination. LSU Health Sciences Center will not retaliate for filing a complaint and will not willingly permit retaliation by management employees or co-workers.

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IV.H.4. Diversity Policy Statement

The LSU Health Science Center believes that diversity among leadership, faculty, and learners is essential to fulfilling the institution’s academic mission. The contributions of individuals with diverse backgrounds and perspectives enriches the educational experience for all learners, enables us to better address health care inequities, increases cultural competency in clinical care, improves service to our community, and expands the scope of our scholarship. A diverse environment also fosters learner understanding, and effective delivery of care to individuals of diverse backgrounds, which is integral to the mission of the school. As an inclusive community, we embrace the full range of human difference: race, gender, ethnicity, age, culture, national origin, religious belief, physical ability, sexual orientation, gender identity, socioeconomic class, and political convictions.

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The effectiveness and progress of our pipeline program development will be evaluated through the implementation of systematic approaches to monitor trends in recruitment of students, residents, and faculty from target underrepresented communities. It is recognized that the creation of greater campus diversity may not be readily reflected among groups that are not easily measured. We will assess the impact of our outreach efforts within diverse target communities in terms of the quality of outreach messaging and programming. As we accept the opportunities to demonstrate leadership in our community in advancing health equity, we embrace the importance and value of continued growth of institutional diversity as an essential element of success in fulfilling this mission.

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IV.H.5. Media

The Office of Information Services is responsible for releasing information regarding LSU Health Science Center Programs, emergencies, crimes, controversies, issues involving the LSU Health Science Center, and other events to which the press has a reasonable claim. LSU Health Sciences Center personnel shall not release information about programs, events, and other activities to the media without the Office of Information Services. All questions from the media should be directed to Leslie Capo, Director of Information Services.

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1. LSUHSC personnel shall not release information about programs, events, and other activities to the media independent of the Office of Information Services.

2. No one is authorized to speak to the media concerning LSUHSC policy or significant matters affecting the HSC unless directed to do so by the Office of Information Services and the Chancellor’s Office.

3. All media contact to the campus must be directed to the Office of Information Services.

4. The Office of Information Services is responsible for coordinating efforts of the HSC to obtain coverage in the news media.

5. Faculty and staff should make every effort to apprise the Office of Information Services of events which may be newsworthy.

6. Faculty and staff shall work with the Office of Information Services to “be available” to representatives of the news media when requested.

7. HSC personnel contacted for an interview by media representatives shall immediately inform the Office of Information Services.

8. The Office of Information Services will conduct Media Training as necessary or requested, to prepare faculty and staff to deal effectively with media.

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IV.H.6. Social Media

All House Officers are required to comply with The LSU School of Medicine Social Media policy²⁸.

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IV.H.7. Payroll and Salary for House Officers

Self-funded training is not permitted in ACGME approved Programs. Trainees on J-1 visas are not permitted to hold gratis or self-funded positions. In extenuating circumstances, the Dean may make exceptions to this policy²⁹.

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All trainees will be appointed in the personnel system with the approved base salary for his/her level of training. Programs that have approval to pay residents or fellows a salary greater than the approved base salary can do so by paying the difference between the approved base salary and the greater amount by submitting a PER 3. The source of funds for this difference can be department/section funds, funds from an executed contract, a grant, or another source of funds. All trainees at the same academic level are to receive the same salary amount. An existing or renewed House Officer contract cannot be used to pay a higher salary than the approved base salary; a separate executed contract must be completed.

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Resident Scheduler System and System Functions (PS-RTS)

The PeopleSoft-Resident Scheduler System (PS-RTS) provides the information required to issue a paycheck to all House Officers.

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The PS-RTS is locked to all Coordinators a day before a payroll is run and is locked to the GME Coordinator on the day a payroll is run. Payroll issues a paycheck to a House Officer based on the information in PS-RTS. When PS-RTS is locked, any changes related to that payroll must be made on a PER 3 submitted to the GME Coordinator by the Program Coordinator.

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Verification of Schedules and Data Entry in RTS

Program Coordinators are encouraged to enter House Officer schedules for a new month prior to the end of the previous month. Coordinators can use the Unassigned/Under Assigned option in PS-RTS to view any unassigned or under assigned House Officers for a particular month or date range. The GME Coordinator also reviews the unassigned/under assigned option in PS-RTS before locking the PS-Resident Scheduler System for the pay period’s payroll run. The GME Coordinator contacts the program coordinator regarding any issues for clarification before corrections are made and the system is locked by the GME Coordinator.

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Discrepancies between the invoice and the information provided to the hospitals must be investigated and corrected, resulting in new invoices.

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IV.H.8. Resident Files

House Officers should have access to their records during normal business hours. In the case of an appeal in which the House Officer invokes the Due Process outlined in the House Officer Manual, the House Officer may be given copies of items from the folder necessary to present his/her case. In the case of a subpoenaed Resident file, there may be an applicable page charge³⁰.

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IV.H.9. Release of Records

The Office of Graduate Medical Education will not routinely respond to requests for information on House Officer performance without a properly executed release or a properly executed subpoena, only after conferring with LSU Counsel (if necessary). In most cases, the GME Office must receive a signed copy of the LSU Release of Information Form³¹ found on the Knowledge Base.

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IV.H.10. Record Retention

The LSU Health Sciences Center records retention policy allows records to be archived on microfilm with permission obtained to shred the physical copies. Permission may be obtained from the Secretary of State Archives and Records Services³². Additional information regarding the GME specific Record Retention Policy can be found on the Knowledge Base³³.

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IV.H.11. Freedom of Speech Policy

Chancellor’s Memorandum
CM-66 – Freedom of Speech and Expression³⁴

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Any person aggrieved by a violation of this policy may file a written appeal of the decision or action to the Vice Chancellor for Academic Affairs within fourteen (14) calendar days of the decision or action. Students may file an appeal in accordance with Chancellor’s Memorandum #56 – Student Responsibilities and Rights. Faculty may file an appeal in accordance with the relevant provisions in the Faculty Handbook. Staff may file an appeal with the Employee Relations section of Human Resources Management. The LSUHSC-NO shall reply in writing within fourteen days of receipt of the appeal, unless, for good cause, additional time is needed to ascertain all pertinent facts. The decision of the Vice Chancellor for Academic Affairs on the appeal shall be final.

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IV.H.12. Visiting House Officers Participation in Patient Care Activities

Visiting House Officers rotations are one month in duration and must not exceed three months per academic year.

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1. Provide a valid Louisiana Medical permit/license before the rotation begins. Visiting House Officers must contact the LSBME at (504) 568-6820 to obtain information on getting a temporary permit to practice medicine in LA. This process takes several months, so it should be initiated as soon as the visiting House Officer decides he/she wants to come to LA. A copy of the license/permit should be attached to the letter noted in Step 1.

2. Provide a valid ECFMG certificate, if he/she is a Foreign Medical Graduate; A copy should be attached to the letter noted in Step 1.

3. Obtain a visiting ID badge from HRM. The Program should contact HRM for instructions for the procedure to obtain a visiting ID.

4. Submit a Participating Site Appointment for Visiting House Officer Form to the GME Office for approval.

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IV.H.13 LSUHSC no longer allows Observerships for visiting House Officers.

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IV.I. Vendors

Relations to vendors and all other private entities are covered by the Code of Government Ethics and the policies established by the LSUHSC Conflict of Interest Committee via various Chancellors Memoranda. All state employees are bound by Louisiana ethics statutes, with the most relevant being Louisiana Code of Governmental Ethics Title 43, Chapter 15, number 6, page 14 – Gifts: “no public employee shall solicit or accept directly or indirectly anything of economic value as a gift or gratuity from any person if the public employee does or reasonably should know such a person conducts activities or operations regulated by the public employees agency or has substantial economic interests which may be substantially affected by the performance or nonperformance of the public employee’s duty.“ In addition to these statutes, the House Officer is further bound by the rules and policies of the training site where he/she is currently rotating, as well as the AMA Code of Medical Ethics statutes listed below:

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IV.I.1 AMA Code of Medical Ethics, Opinion 8.061, “Gifts to Physicians from Industry.”

(1) Any gifts accepted by physicians individually should primarily entail a benefit to patients and should not be of substantial value. Accordingly, textbooks, modest meals, and other gifts are appropriate if they serve a genuine educational function. Cash payments should not be accepted. The use of drug samples for personal or family use is permissible if these practices do not interfere with patient access to drug samples. It would not be acceptable for non-retired physicians to request free pharmaceuticals for personal use or use by family members.

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(7) No gifts should be accepted if there are strings attached. For example, physicians should not accept gifts if they are given in relation to the physician's prescribing practices. In addition, when companies underwrite medical conferences or lectures other than their own, responsibility for and control over the selection of content, faculty, educational methods, and materials should belong to the organizers of the conferences or lectures. (II)³⁶

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IV.J. Non-Competition

Restrictive covenants are not allowed by the School of Medicine or the ACGME.

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IV.K. Extreme Emergent Situation

Extreme emergent situation is defined as a local event (such as a hospital-declared disaster for an epidemic) that affects House Officer education or the work environment but does not rise to the level of an ACGME-declared disaster as defined in the ACGME Policies and Procedures.

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IV.K.1. Declaration of an Extreme Emergent Situation:

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The Program Director of each affected training Program shall meet with the DIO and other university/training site officials, as appropriate, to determine the clinical duties, schedules, and alternate coverage arrangements for each training Program sponsored by the Institution. ACGME's guidelines for development of those plans should be implemented, including House Officers must be expected to perform according to the professional expectations of them as physicians, considering their degree of competence, level of training, and context of the specific situation. House Officers who are fully licensed in the state may be able to provide patient care independent of supervision in the event of an extreme emergent situation, as further defined by the applicable medical staff by-laws. House Officers are also trainees/students. They should not be first-line responders without consideration of their level of training and competence; the scope of their individual license, if any; and/or beyond the limits of their self-confidence in their own abilities. Program Directors will remain in contact with the DIO about implementation of the plans to address the situation, and additional resources as needed. The DIO will call the ACGME Institutional Review Committee (IRC) Executive Director if (and, only if) the extreme emergent situation causes serious, extended disruption that might affect the Institution/Program's ability to remain in substantial compliance with ACGME requirements. The ACGME IRC will alert the respective Review Committee (RC). If notice to the ACGME, the DIO will notify the ACGME IRC Executive Director when the extreme emergent situation has been resolved. The DIO and GMEC will meet with affected Program Directors to establish a monitoring system. They system is to ensure the continued safety of House Officers and patients through the duration of the situation; to determine that the situation has been resolved; and to assess additional actions to be taken (if any) to restore full compliance with each affected House Officers’ completion of the educational Program requirements.

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IV.L. Disasters³⁷

A disaster is an event or set of events that causes significant alteration or interruption to one or more programs.

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6. Submission - Within 10 days, the DIO will contact the ACGME to regarding the next steps to be taken and what information should be provided to the ACGME. Within 30 days, the DIO will submit plans for program reconfiguration to the ACGME.

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IV.M. Closures and Reductions

If the University itself intends to close or to reduce the size of or close a House Officer program, the University shall inform the Designated Institutional Official, the GMEC, and House Officers as soon as possible of the reduction or closure. In the event of such reduction or closure, the University will make reasonable efforts to allow the House Officers already in the Program to complete their education or to assist the House Officers in enrolling in an ACGME accredited program in which they can continue their education⁴⁰.

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IV.M.1. Relocation of Residency Programs or Allocation of Positions

All Program Directors are mandated to notify the Associate Dean, Dean, Chancellor, and Director of Governmental Affairs of any proposed changes in House Officer allocations or program changes in any facility involved in the University’s educational mission. The information will be communicated by the Director of Governmental Affairs to the Systems Office, as well as to any legislators whose constituents might be affected by such a move.

PROGRAM DIRECTORS, COORDINATORS AND HOUSE OFFICERS ARE TO REFER TO THE LSU HOUSE OFFICER MANUAL⁴¹, THE GME WEBSITE⁴², AND THE GME KNOWLEDGE BASE⁴³ FOR A COMPLETE LIST OF REQUIREMENTS, POLICIES, AND PROCEDURES PERTAINING TO TRAINING.

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Appendix A
Sample Request for Adverse Action

June 23, 20XX

John Doe, M.D.

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