Office of Graduate Medical Education
2020 Gravier Street, Suite 602
New Orleans, LA 70112
504-568-4006 (Phone)
504-599-1453 (Fax) Revised January 2024

 

 

I. Structure and Function of the Sponsoring Institution

LSU School of Medicine – New Orleans (School of Medicine) serves as the Sponsoring Institution for the Accreditation Council for Graduate Medical Education (ACGME) residency and fellowship programs. The School of Medicine’s oversight of House Officer assignments and the quality of the learning and working environment extends to all participating sites.

The Graduate Medical Education Committee (GMEC) passed a resolution that each training program must have a policy and process for the following areas, outlining a method to monitor and assure effectiveness of each:

• Ensuring effective transitions (hand-offs)

• Encouraging residents to use alertness management strategies

• Monitoring resident use of strategic napping

• Monitoring frequency and intensity of house call events

• Ensuring each case in which a resident stays longer than 24+4 is documented and reviewed

• Ensuring continuity of care if a resident is unable to perform his/her duties

• Setting specific guidelines for when residents must communicate with their attending

• Ensuring residents and faculty inform patients of their respective role in patient care

• Demonstrating appropriate levels of supervision exist for all residents

• Developing rotational schedules associated with attending call schedules in New Innovations

• Developing guidelines for supervision

• Ensuring wellness

• Ensuring diversity, equity and inclusion in recruitment activities

All the methods noted above are monitored by the institution during Annual Program Evaluations (APEs), GME Program Performance Reviews, and Special Program and Focused Reviews¹.

I.A. GMEC Responsibilities

The GMEC maintains oversight of the School of Medicine’s ACGME-accredited programs. The committee has voting membership of the Designated Institution Official (DIO), Director of Accreditation, a representative sample of Program Directors, coordinators, peer nominated residents, and a patient safety and quality officer. The GMEC meets monthly (except) December and maintains meeting minutes that document execution of all required GMEC functions and responsibilities.

I.A.1. Oversight

The GMEC responsibilities include but are not limited to the oversight of:

1. The ACGME accreditation status of the Sponsoring Institution and each of its ACGME-accredited programs

2. The quality of the GME learning and working environment within the School of Medicine, including each of the accredited programs, and the participating institutions

3. The quality of educational experiences in the programs that lead to measurable achievement of educational outcomes

4. Annual Program Evaluations (APEs) and Self-Studies

5. Programs implementation of institutional policies for vacation and leaves of absence, including medical, parental, and caregiver leaves of absence

6. All processes related to reduction and closure of programs and participating sites

7. The provision of summary information of patient safety reports

8. The institutional performance indicators for the Annual Institution Review (AIR)

9. The Executive Summary to the Governing Body

10. Underperforming programs through a Special Review Process

I.A.2. Review and Approval

The GMEC must review and approve the following types of communication between programs and the ACGME review and recognition committee (RRC) prior to submission to the ACGME:

1. Recommendations to the administration regarding resident/fellow stipends and benefits;

2. all applications for ACGME accreditation of new programs and subspecialties;

3. changes in resident complement;

4. major changes in program structure or length of training;

5. additions and deletions of participating institutions used in a program;

6. institutional GME policies and procedures;

7. appointments of new Program Directors;

8. progress reports requested by any Review Committee;

9. responses to Clinical Learning Environment Review (CLER Reports);

10. responses to all proposed adverse actions;

11. requests for increases or any change in resident clinical and educational work hours;

12. requests for “inactive status” or program reactivations;

13. voluntary withdrawals of ACGME-accredited programs;

14. GMEC subcommittee actions that address required GMEC responsibilities;

1. appeal presentations to a Board of Appeal or the ACGME;

2. exceptionally qualified candidates for resident/fellow appointments who do not satisfy the institutions resident/fellow eligibility policy.

Should a program have a submission of an item listed above to the ACGME, it must notify the GME Office by the 5th of the month for the item to be placed on the monthly GMEC agenda (meetings are held the third Thursday of each month.). Programs are responsible for entering their submissions into the ACGME Web Accreditation Data System (WebADS), if applicable, prior to the GMEC meetings.

II. Institutional Resources

II.A. Institutional Operations

II.A.1. Absence of the DIO/Signature Authority Procedure

In the absence of the DIO, the Director of Accreditation reviews and cosigns all program information forms and any documents or correspondence submitted to the ACGME by Program Directors, including all items listed in IR IB4b)(1-15)².

II.A.2. Change in Program Director Request Policy

All requests for new Program Directors are initiated by the DIO through the WebADS. The DIO must also verify that the new Program Director meets the required qualifications and is approved by the GMEC. An email that provides login information is sent to the new Program Director upon the request of the DIO. The Program Director must log into WebADS to complete professional and certification information, as well as other required documentation. After the request is complete and submitted, the new Program Director’s name is posted in WebADS and the submitted material is forwarded to the Review Committee staff. The GME Office will notify Computer Services to complete a name change in the university email distribution lists.

II.A.3. Loss of Accreditation - Major Participating Institution

When a Major Participating Institution loses its accreditation or recognition, the Sponsoring Institution must notify and provide a plan of response to the Institutional Review Committee (IRC) within 30 days of such loss.

II.B. Program Administration

II.B.1. Program Sponsorship

The ACGME does not recognize co-sponsorship of residency training programs. It mandates that one sponsor assumes the ultimate “educational” responsibility for the accredited programs. The ACGME seeks assurance that the sponsoring institution ensures that adequate financial support exists for the residents to fulfill the responsibilities of their educational program. The sponsoring institution is held accountable for funding, including ensuring that funding sources do not have an adverse impact on the residents’ educational program. The Sponsoring Institution must maintain oversight of financial or other resident support issues.

II.B.2. Program Resident Position Numbers

Programs, through their departmental business offices, are responsible for keeping resident numbers within the quota approved in the participating institution contracts. Variances will be the responsibility of the department. Departments receive monthly Attestation Statements for confirmation.

II.B.3. Program Letters of Agreement

The ACGME requires all programs to execute Program Letters of Agreement (PLAs) with Participating Institutions (Affiliating Entities) where their residents rotate.   PLAs are not part of, nor take away from, the required Contracts, Affiliation Agreements, and Supplements that are administered through the LSUHSC Contracts Office. An original PLA must be executed through Adobe Sign requiring signatures of the Program Director, the Site Director who oversees the residents at the affiliating entity, the Designated Institutional Official and the signature of the affiliating entity (CEO, Medical Director, etc). Once completed, a fully executed PLA is automatically forwarded to the training program, the Director of Accreditation, and the participating institution.  The Letter of Agreement is valid for ten years unless there is a change of a Program Director or Site Director, which requires the execution of a new letter.  It is the responsibility of the individual programs to execute the PLAs. A template can be obtained on the Office of Graduate Medical Education Knowledge Base³.

 

II.B.4. Annual Performance Evaluation (APE)

All Programs are to submit an Annual Program Evaluation (APE) to the Director of Accreditation by August 30 of each academic year. The report should reflect the results of the Program Evaluation Committee (PEC) meeting. The information should include at a minimum:

1. APE datasheet

2. Minutes noting meeting date, time, location, and those in attendance (faculty and residents)

3. Review of Documents:
   Board Passage Rates, In-service Scores, Letters of Notification (Citations, Cycle Length), Special or DIO Review Results, Progress Reports, WebADS Data, Rotation Schedules, Curriculum, Lectures – Topics and Speakers, Goals and Objectives for each rotation; Faculty Development Programs, Policies and Procedures, Residency Manual, ACGME Resident and Faculty Survey Results, LSU End of Year House Office Questionnaire Results, Milestones Data Tracking; Procedure Logs, Evaluation Instruments and Feedback Results, Supervision Compliance, Wellness Initiatives, and Clinical and Educational and Hours Compliance

4. SWOT Analysis

5. Action Plan spreadsheet containing details and follow-up dates.
   
   

II.B.5. Program Experimentation and Innovation

If a program is interested in educational experiments and innovations that may deviate from Institutional, Common, and Specialty/Subspecialty-Specific Program Requirements, the program must get approval by the GMEC. The committee will monitor:

• Approval prior to submission to the ACGME and/or respective RRC

• Adherence to procedures for “Approving Proposals for Experimentation or Innovative Projects” in ACGME Policy and Procedures

• Monitoring quality of education provided to House Officers for the duration of the project

II.C. House Officer Forum

The School of Medicine coordinates a House Staff Association that allows House Officers from across the Sponsoring Institution’s accredited Programs to communicate and exchange information with each other relevant to their accredited Programs and their learning and working environment. Any House Officer has the opportunity to raise a concern directly to the Association. The Association is able to bring concerns raised at its meetings to the Academic Dean and the GMEC. Communication is disseminated through the Association webpage and announced through the GME Office.

II.D. House Officer Salary and Benefits

II.D.1. Salary

House Officers are paid the LSU Health Sciences Center approved compensation base salary at the assigned academic level in the training program regardless of the number of postgraduate years completed in other training programs. The LSU System Board of Supervisors votes to approve the proposed pay scale annually, which is recommended by the School of Medicine and voted upon by the GMEC.

Please refer to Section IV.H.7 of this manual for more details regarding compensation, payroll and appointments.

II.D.2. Benefits

House Officers receive all benefits as outlined in the ACGME Common Program Requirements. For detailed information regarding specific benefits provided please refer to the LSUHSC Human Resources webpage⁴ and the LSU House Officer Manual⁵.

II.E. Educational Tools

II.E.1 New Innovations

New Innovations Medical Education Management Suite is the software the Sponsoring Institution utilizes for the management of program documentation and requirements. Program Directors and Coordinators are required to maintain all House Officer demographic data, evaluations, rotation schedules, and clinical and educational work hours within the management system. New Innovations provides both online and telephone support to programs. The GME Office offers periodic workshops for additional training on an as-needed basis.

House Officers are required to comply with the institutional policy regarding clinical and educational work hour monitoring/recording using New Innovations. House Officers must record their work hours for ACGME compliance by entering the data in the designated module within New Innovations on a weekly basis. Periodic monitoring is done to ensure that hours are being logged into the system and comply with ACGME guidelines. Failure to comply with this policy may result in formal disciplinary action being taken, up to and including possible dismissal from the Program.

The GME Office provides periodic training sessions to Program Directors and coordinators. In addition, the GME Staff will provide additional training to program faculty and House Officers upon request.

II.E.2. AMA GCEP Core Curriculum and IHI Patient Safety & Quality Curriculum

To enhance the House Officer’s training experience, the GME Office provides a series of American Medical Association (AMA) and Institute for Healthcare Improvement (IHI) Core Curriculum Online Modules to improve House Officer knowledge in essential clinical and educational areas. All House Officers must complete all assigned modules by the specified date set by the Sponsoring Institution. Program Directors and Coordinators receive a quarterly list from the GME Office regarding House Officer status and completion rates. All incoming House Officers must complete eight specific IHI Patient Safety and Quality Modules prior to the start of residency training.

II.E.3. Email

LSU Exchange/Outlook e-mail addresses are available to Program Directors, core faculty and House Officers for the duration of their employment. This e-mail account should be utilized for all School of Medicine business. School of Medicine faculty and staff are forbidden to communicate with House Officers using personal e-mail accounts. As a primary method of communication and information dissemination, School of Medicine e-mail must be checked regularly.

II.E.4. Knowledge Base

The GME Knowledge Base serves as an open resource to all program coordinators and faculty. The Knowledge Base is available at https://lsugme.atlassian.net. This is a resource available for program staff for current, incoming and outgoing house officers, policies and procedures, payroll, recruitment, house officer selection & recruitment, accreditation, due process and a directory of all GME contacts.

II.E.5. Library

LSUHSC provides the John P. Isché ⁶and Dental⁷ Libraries serve all LSUHSC-New Orleans employees with a wide array of print and electronic databases, books and journals. Access to the on-line documents is provided 24 hours per day through the library website⁸.

II.F. Support Services and Systems

The School of Medicine, in partnership with GME Participating Sites, is committed to providing support services that minimize work unrelated to House Officer educational goals and objectives, ensuring their educational experiences are not compromised by an excessive need to fulfill non-physician obligations. Services and systems available to support House Officers education include patient support services, laboratory, pathology, radiology, and medical records. Provisions are made for a healthy and safe work environment with 24-hour food services, call/nap rooms, lactation rooms and appropriate security.

Meal Tickets for LCMC System Hospitals are distributed on a monthly basis to programs from the GME Office and are intended for those House Officers taking in-house call. All other Participating Institutions distribute meal cards from their home institutions.

III. Learning and Working Environment

III.A. Patient Safety

The School of Medicine and the Participating Institutions are committed to patient safety, including access to systems for reporting errors, adverse events, unsafe conditions, and near misses, in a protected manner that is free from reprisal, as well as opportunities to contribute to root cause analysis or other similar risk-reduction processes. Each Participating Institution has their own processes for House Officers to report patient safety issues. House Officers are responsible for reporting patient safety hazards.

III.B. Quality Improvement

The School of Medicine and the Participating Institutions are committed to quality improvement, including providing access to data to improve systems of care, patient outcomes and reduce health care disparities, as well as providing House Officers opportunities to participate in quality improvement initiatives.

The Enhancing Quality Improvement for Patients program is an institution wide initiative to engage residents and fellows in systems-based quality improvement programs. In cooperation with faculty supervisors and mentors, the EQUIP program empowers the House Officers to contribute to scholarly activity and the implementation of clinical quality improvement initiatives at affiliated training institutions, with the goal of improving outcomes for patients and inculcating a culture of quality improvement and patient safety.

III.C. Transitions of Care⁹

Programs must design House Officer clinical assignments to optimize transitions in patient care, including safety, frequency, and structure. Programs, in partnership with the School of Medicine and participating institutions, must ensure and monitor effective, structured hand-off processes to facilitate both continuity of care and patient safety. Programs must ensure that House Officers are competent in communicating with team members in the hand-off process. Programs and clinical sites must maintain and communicate schedules of attending physicians and House Officers currently responsible for care. Programs will ensure continuity of patient care if a House Officer may be unable to perform their patient care responsibilities due to excessive fatigue or illness.

This transitions policy was created in response to multiple studies that have shown transitions of care result in medical errors or increased risk to patient safety¹⁰. In addition to the policies outlined in this section, patient safety is further ensured by:

• Provision of complete and accurate rotational schedules in New Innovations

• Presence of a backup call schedule for those cases where a House Officer is unable to complete their duties

• The ability of any House Officer to, freely and without fear of retribution, report their inability to carry out their clinical responsibilities due to fatigue or other causes

House Officers receive educational material on Transitions at both orientation and as a core module of their AMA online training.

An adequate transition must be used whenever patient care is transferred to another member of the health care team. Although transitions may require additional reporting than outlined in this policy, the minimum standard of care includes the following:

• Demographics: name, medical record number, unit/room number, age, weight, gender, allergies attending physician phone numbers

• History and problem List: primary diagnosis(es) and chronic problems pertinent to this admission/shift

• Current condition status

• System based list: pertinent medications and treatments, oral and IV medications, IV fluids, blood products, oxygen, respiratory therapy interventions

• Pertinent lab data

• To do list: check x-ray, labs, wean treatments, etc. – and the rationale for each action

• Contingency planning: what may go wrong and what to do

• Anticipate what will happen to your patient: If this…then that…

• Code status/family situation

• Difficult family or psychosocial situations

Programs will periodically check transitions, including reviewing parts of a patient’s chart and interviewing incoming teams, to ensure that key elements have been transmitted and understood.

This information is located on pocket cards available for each House Officer. The information is distributed to House Officers through AMA Core Modules and Orientation presentations, as well as through a Compliance Module for faculty. In addition, this information is presented in program/departmental meetings.

How monitored:

Faculty are required to answer a question on effectiveness of witnessed transitions on each House Officer evaluation. Programs must add the following language to the end of each monthly evaluation form in New Innovations: “I have witnessed effective transitions in person and attest the essential elements as defined in the Transitions Policy were transmitted to and understood by the receiving team.” The process and effectiveness of each program’s transition system is monitored by the Sponsoring Institution through the Annual Program Evaluation and Special Review process. The institution and program will monitor this by periodic review.

III.D. Supervision¹¹

In the learning and working environment, each patient must have an identifiable, appropriately credentialed and privileged attending physician who is responsible and accountable for that patient’s care. This information must be available to House Officers, faculty members, all members of the health care team, as well as the patient. House Officers and faculty members must inform each patient of their respective roles in that patient’s care.

The specific policies for supervision are as follows:

Faculty Responsibilities for Supervision and Graded Responsibility:

House Officers must be supervised in such a way that they assume progressive responsibility as they progress in their educational Program. The following persons and/or factors determine a House Officer’s degree of progressive responsibility:

• Observations of House Officer performance by GME faculty on each service

• Assessment of the House Officer’s level of competence through frequent observation and semi-annual review by the Program Director and Chief Resident(s)

• Achievement of specific milestones (where applicable)

• Evaluation of performance in simulation labs and OSCEs (where applicable) prior to the House Officer performing specific procedures on patients

The expected components of supervision include:

• Defining educational objectives

• Faculty assessment of House Officer skill level through direct observation

• Defining the course of progressive responsibility allowed beginning with close supervision and advancing to independence as the skill is mastered

• Documentation of supervision by supervising faculty must be customized to the settings based on guidelines for best practice and regulations from the ACGME, JCAHO, and other regulatory bodies and should generally include but not be limited to:

• Progress notes in the chart written by or signed by the faculty

• Addendum to House Officer’s notes where needed

• Counter-signature of notes by faculty.

• A medical record entry indicating the name of the supervisory faculty.

In addition to close observation, faculty are encouraged to give frequent informal feedback and are required to give formal summative written feedback that is competency based and includes evaluation of both professionalism and effectiveness of transitions.

The levels of supervision are defined as follows:

Direct Supervision – the supervising physician is physically present with the House Officer during the key portions of the patient interaction; or, PGY-1 residents must initially be supervised directly, only as described as (a). A supervising physician must be immediately available to be physically present for PGY-1 residents on inpatient rotations who have demonstrated the skills sufficient to progress to indirect supervision.

(b) the supervising physician and/or patient is not physically present with the resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.

Indirect Supervision: the supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision.

Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members.

The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered

PGY 1 residents must be supervised by either faculty or more senior residents in the hospital setting.

The Sponsoring Institution will monitor implementation of these policies through Annual Program Evaluations and Special Focus Reviews. Furthermore, the Sponsoring Institution monitors supervision through a series of questions in the Annual Resident Survey. The Program will monitor supervision through feedback from House Officers and monitoring by Chief Residents and Program Directors.

Several of the essential elements of supervision are contained in the Policy of Professionalism.

Programs must specify level- and service type-specific criteria using the grids below.

Inpatient Services

 

Intensive Care Units

 

Ambulatory Settings

 

Consult Services

 

 

Procedure Rotations