Policy and Procedure Manual for
Graduate Medical Education

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

Policy and Procedure Manual for Graduate Medical Education
Table of Contents

Policy and Procedure Manual for Graduate Medical Education Table of Contents
Policy and Procedure Manual for Graduate Medical Education
I. Structure and Function of the Sponsoring Institution
- I.A. GMEC Responsibilities
  - I.A.1. Oversight
  - I.A.2. Review and Approval
II. Institutional Resources
III. Learning and Working Environment
IV. Institutional GME Policies and Procedures
Appendix A Sample Request for Adverse Action

Policy and Procedure Manual for
Graduate Medical Education

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:

The ACGME accreditation status of the Sponsoring Institution and each of its ACGME-accredited programs
The quality of the GME learning and working environment within the School of Medicine, including each of the accredited programs, and the participating institutions
The quality of educational experiences in the programs that lead to measurable achievement of educational outcomes
Annual Program Evaluations (APEs) and Self-Studies
Programs implementation of institutional policies for vacation and leaves of absence, including medical, parental, and caregiver leaves of absence
All processes related to reduction and closure of programs and participating sites
The provision of summary information of patient safety reports
The institutional performance indicators for the Annual Institution Review (AIR)
The Executive Summary to the Governing Body
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:

Recommendations to the administration regarding resident/fellow stipends and benefits;
all applications for ACGME accreditation of new programs and subspecialties;
changes in resident complement;
major changes in program structure or length of training;
additions and deletions of participating institutions used in a program;
institutional GME policies and procedures;
appointments of new Program Directors;
progress reports requested by any Review Committee;
responses to Clinical Learning Environment Review (CLER Reports);
responses to all proposed adverse actions;
requests for increases or any change in resident clinical and educational work hours;
requests for “inactive status” or program reactivations;
voluntary withdrawals of ACGME-accredited programs;
GMEC subcommittee actions that address required GMEC responsibilities;

requests for an appeal of an adverse action;

appeal presentations to a Board of Appeal or the ACGME;
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:

APE datasheet
Minutes noting meeting date, time, location, and those in attendance (faculty and residents)
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
SWOT Analysis
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

PGY	Direct by Faculty	Direct by senior residents	Indirect Available	Oversight
I
II
III
IV
V

Intensive Care Units

PGY	Direct by Faculty	Direct by senior residents	Indirect Available	Oversight
I
II
III
IV
V

Ambulatory Settings

PGY	Direct by Faculty	Direct by Senior residents	Indirect Available	Oversight
I
II
III
IV
V

Consult Services

PGY	Direct by Faculty	Direct by Senior residents	Indirect Available	Oversight
I
II
III
IV
V

Operating Rooms:

PGY	Direct by Faculty	Direct by Senior residents	Indirect Available	Oversight
I
II
III
IV
V

Procedure Rotations

PGY	Direct by Faculty	Direct by Senior residents	Indirect Available	Oversight
I
II
III
IV
V

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

III.E. Clinical and Educational Work Hours Policy

The Sponsoring Institution, along with GMEC, supports the ACGME Clinical and Educational Work Hour Requirements as set forth in the Common Program Requirements and related documents July 1, 2017, and subsequent modifications. Although learning occurs in part through clinical service, the training Programs are primarily educational; work requirements including patient care, educational activities, administrative duties, and moonlighting must allow House Officers to have adequate rest. The Sponsoring Institution supports the physical and emotional well-being of House Officers to ensure professional and personal development and to guarantee patient safety. The Sponsoring Institution has developed and implemented the following policies and procedures through the GMEC to assure specific ACGME policies relating to work hours are successfully implemented and monitored:

III.E.1. Maximum Hours of Clinical and Educational Work per Week

Work hours must be limited to no more than 80 hours per week, averaged over a four-week period, including all in-house clinical and educational activities, clinical work done from home, and moonlighting.

III.E.2. Mandatory Time Free of Clinical Work and Education

All Programs have an effective program structure that provides House Officers with educational opportunities and reasonable opportunities for rest and personal well-being. House Officers should have eight hours off between scheduled clinical work and education periods. If House Officers choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education, this must occur within the context of the 80-hour and the one-day-off-in-seven requirements.

House Officers must have at least 14 hours free from both clinical work and required education after 24 hours of in-house call.

House Officers must be scheduled for a minimum of one day in seven free of clinical work and required education (when averaged over four weeks). At-home call cannot be assigned on off days.

III.E.3. Maximum Clinical Work and Education Period Length of Work Assignments

Clinical and educational work periods for House Officers must not exceed 24 hours of continuous scheduled clinical assignments.

Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or House Officer education. House Officers must not be assigned additional patient care responsibilities during this time.

III.E.4. Clinical and Educational Work Hours Exceptions

A House Officer may elect to remain on or return to the clinical site after handing off all other responsibilities in the following circumstances: to continue to provide care to a single severely ill or unstable patient; humanistic attention to the needs of a patient or family; or to attend unique educational events. These additional hours of care or education will be counted toward the 80-hour weekly limit.

III.E.5. Maximum Frequency of In-House Night Float

Night float must occur as part of the 80-hour and one-day-off-in-seven requirements. The maximum number of consecutive weeks and months of night float per year may be further specified by the RRC.

III.E.6. Maximum In-House On-Call Frequency

House Officers must be scheduled for in-house call no more than every-third night when averaged over a four-week period.

III.E.7 At-Home Call

Time spent on patient care activities while on at-home call must count toward the House Officer’s 80-hour maximum weekly limit. The frequency of at-home call is not subject to the every-third night limitation but must satisfy the requirement for one day in seven free of clinical work and education, when averaged over four weeks.

At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.

House Officers are permitted to return to the hospital while on at-home call to provide direct care for new or established patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period”.

House Officers are required to log all work hours in New Innovations. Failing to log work hours or logging erroneous work hours may result in disciplinary action.

The School of Medicine and individual Programs are required to monitor and document compliance with clinical education and work hour requirements for all House Officers. This policy applies to every site where House Officers rotate.

To ensure compliance, the institution has implemented the following policies and procedures:

Each program director must sign a statement attesting to compliance with the requirements at all sites.
Each program will develop their own written clinical and educational work hour policy in compliance with the ACGME and LSUHSC Institutional policy. This policy will be distributed to all trainees and faculty with a copy provided to the GME Office. The policy must specifically address how compliance will be monitored and what actions will be taken to remedy problems. Yearly changes or revisions to policies must be forwarded to the GME Office.
Programs must monitor House Officers for fatigue. The Sponsoring Institution provides resources to educate faculty and House Officers about sleep deprivation and fatigue.
The Sponsoring Institution will ask each participating site to advise (where legally permissible) it of incidents or trends that suggest fatigue is an issue.
If the Program has instituted a method to monitor for individual House Officer clinical and educational work hour compliance (e.g. work hour logs) it will regularly share this data with the Sponsoring Institution.
In addition to other monitoring, the Sponsoring Institution encourages programs to add questions regarding clinical and educational work requirements to their monthly rotation evaluations.
The Sponsoring Institution will advise House Officers that the Ombud is available to field anonymous questions or complaints about clinical and educational work hours
The House Officer Agreement of Appointment/Contract includes a reference to clinical and educational work hours policy and an agreement to participate in institutional monitoring of clinical and educational work hours
Special Focused Reviews may include detailed review of clinical and educational work hours
An annual anonymous web-based questionnaire will be administered to House Officers regarding clinical and educational work hours by the GME Office
The GME Office will randomly audit programs for clinical and educational work hour compliance
Program-specific data will be presented annually in the PEC meeting minutes submitted to the GME Office
Violations of clinical and educational work hour requirements by participating sites may result in removal of House Officers from that site
Programs with constant violations will be regularly monitored by GMEC and may be subject to closure
Moonlighting must be approved in writing and strictly monitored to assure House Officer fatigue does not become a problem
House Officers may anonymously report violations to the Clinical and Educational Work Hours Hotline at (504) 599-1161.

III.E.8 Granting Clinical and Educational Hour Exceptions

If an ACGME Review Committee considers requests for exceptions, the GMEC will accept, review, and act on individual program requests to increase House Officer clinical and educational work hours up to a maximum of 88 hours per week when averaged over a four-week period.

Applications for such increases must be based on a sound educational rationale. Only programs in good standing with their Review Committee may apply for increases.

Process:

Programs must submit a written request as described below
After screening by the Graduate Medical Education Office to be sure the application is complete, it will be presented for consideration at the next regularly scheduled GMEC
GMEC will vote to approve or deny the request based on the merits of the application; the decision cannot be appealed
If approved, the DIO/Chair of GMEC will prepare a letter of endorsement to be included in the program’s application to their RRC along with a copy of the Institutions Policies and Procedures for Granting Clinical and Educational Work Hour Exceptions
The Sponsoring Institution will reevaluate the continued necessity and appropriations of the increase and patient safety aspects of the increased hours at each annual program review

Application Format:

The program must supply sufficiently detailed information on each of the areas below for GMEC to make an informed decision:

Patient Safety: describe how the program will monitor, evaluate, and ensure patient safety with extended House Officer work hours.
Educational Rationale: provide a sound educational rationale in relation to the program’s stated goals and objectives for the assignments, rotations, and levels of training for which the increase is requested; blanket exceptions for the entire educational program should be considered the exception, not the rule
Moonlighting Policy: include specific information regarding the program’s moonlighting policies for the periods in question
Call Schedules: provide specific information regarding House Officer call schedules during the times specified for the exception and explain how they will be monitored
Faculty Monitoring: provide evidence of faculty development activities regarding the effects of House Officer fatigue and sleep deprivation

III.E.9 Clinical and Educational Work Hours Attestation Statement

The following statement must be signed by every incoming Program Director of a LSUHSC training program.

As the Program Director of ____________________________________(program name) at LSU School of Medicine-New Orleans I have read the Institutional Policy regarding Clinical and Educational Work Hours and by signing this document I attest to compliance of the policy in the ___________________________________ (program name). I attest that a copy of the policy has been issued to each of the faculty members and House Officers within my program.

I attest that my program has developed a program specific clinical and educational work hours policy that is in compliance with the ACGME and institutional guidelines and it has been issued to the faculty and House Officers within my program.

I agree to monitor the House Officers for fatigue and educate the faculty and House Officers about the seriousness of sleep deprivation and fatigue on work performance. As Program Director, I agree to report to the Graduate Medical Education Committee (GMEC) semiannually regarding House Officer performance and compliance within my program to the clinical and educational work hours policy.

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.

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:

Patient identifying information for which they are remaining
The specific reason they must remain longer than 24+4
Assurance that all other patient care matters have been assigned to other members of the team
Assurance that the House Officer will not be involved in any other matter than that for which the exemption is allowed
Assurance that the House Officer will notify the Program Director when he/she is finished and leaving

If the House Officer does not reach out to the Program Director in a reasonable time (as specified by program), the Program Director or designee will locate the House Officer in person and assess the need for further attendance by the House Officer. House Officers caught in violation of this policy or who abuse this rare privilege will be subject to disciplinary action.

How Monitored:

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.

III.E.11 Moonlighting¹³

Moonlighting is any medical-type professional activity that is not part of the course and scope of the House Officers’ educational Program. Moonlighting must not interfere with the ability of the House Officer to achieve the goals and objectives of the educational Program. All medical and non-medical outside employment should be reviewed and approved by the Program Director in accordance with LSU System Permanent Memorandum (PM-11)¹⁴.

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:

The following behaviors are highly discouraged and, in some cases, may be illegal. The Louisiana State Board of Medical Examiners and the DEA may independently investigate and prosecute individual House Officers if the moonlighting House Officer:

Is not fully licensed and/or does not have his/her own malpractice and DEA number
Pre-signs prescriptions
Uses facility prescription DEA numbers outside assigned facility (number is site specific)
Signs documentation attesting that a patient was seen when the patient was not
Fails to date all narcotics prescriptions and prescribe them to patient's name and address
Asks a nurse to complete a task that are the physician’s responsibility
Fails to read the fine print; House Officers are held accountable for everything they sign
Fails to follow accepted practice guidelines, especially in the case of weight loss and pain patients
Fails to be cognizant of Medicare fraud and abuse guidelines
Treats family members.

Note: If a House Officer treats anyone, he/she must create a medical record which includes a history, physical and appropriate laboratory, and diagnostic tests in keeping with the standard of care. This activity is considered moonlighting and requires licensure, DEA and malpractice insurance independent of those provided as part of the training Program. House Officers are strongly advised to refer family members and friends to another practitioner.

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.

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.

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:

1. The Clinical and Educational Work Hours Policy states:

House Officers must have at least 14 hours free of clinical work and required education after 24 hours of in-house duty.
House Officers must be scheduled for a minimum of one day in seven off from clinical work and required education (averaged over four weeks). At-home call cannot be assigned on these off days.

2. All employees of LSUHSC must adhere to Chancellor’s Memorandum 37 (CM-37), the LSUHSC Fitness for Duty policy, which defines when employees are both fit and safe to work. It includes what are considered unsafe/impaired behaviors, the requirement for self or supervisor referral to the Campus Assistance Program, and what steps should be taken thereafter.

3. The Sponsoring Institution’s Policy of Professionalism and Learning Environment expands further upon the responsibility of House Officers to assure they are well rested and fit for duty:

House Officers must take personal responsibility for, and faculty must model behaviors that promote:

Assurance for fitness of duty
Assurance of the safety and welfare of patients entrusted in their care
Management of their time before, during and after clinical assignments
Recognition of impairment (e.g., illness or fatigue) in self and peers
Honest and accurate reporting of clinical and educational work hours, patient outcomes, and clinical experience data

4. The moonlighting policy anticipates potential trouble areas and describes a method for monitoring the effects of moonlighting on House Officers

5. Adequate sleep facilities are in place at each institution and the alertness management/fatigue mitigation policy encourages good sleep hygiene and recommends strategic napping and post-call naps.

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.

III .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:

1. Warning Signs

Falling asleep at conference/rounds
Restless and/or irritable with staff, colleagues, family
Rechecking work constantly
Difficulty focusing on care of the patient
Feeling like you just don’t care
Driving while drowsy

2. Sleep Strategies for House Officers

a. Pre-call Residents

Don’t start call with a sleep deficit; get 7-9 hours of sleep
Avoid heavy meals and/or exercise within 3 hours of sleep
Avoid stimulants to keep you up
Avoid ethanol alcohol to help you sleep

b. On Call Residents

Reach out to your Program Director, Chief Resident or Faculty if you’re too sleepy to work
Nap whenever you can (> 30 min or < 2 hours)
Best circadian window: 2PM-5PM & 2AM- 5AM
Avoid heavy meals
Strategic consumption of coffee (lasts 3-7 hours)
Know your own alertness/sleep pattern

c. Post Call Residents

Lowest Alertness 6AM –11AM after being up all night
Full recovery from sleep deficit takes 2 nights
Take a 20-minute nap or drink a cup coffee 30 minutes before driving

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.

III.G. Professionalism¹⁸

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

Patients receive safe, quality care in the teaching setting
Graduating House Officers provide safe, high quality patient care in the unsupervised practice of medicine
House Officers learn professionalism and altruism along with clinical medicine in a humanistic and quality learning environment

The Sponsoring Institution recognizes that patient safety, quality care, and an excellent learning environment are about much more than clinical and educational work hours and wish to underscore those policies address all aspects of the learning environment. These include:

Professionalism, including responsibility for patient safety
Alertness management
Proper supervision
Transitions of care
Clinical responsibilities
Communication/teamwork

House Officers must take personal responsibility for and faculty must model behaviors that promote:

Assurance for fitness of duty
Assurance of the safety and welfare of patients entrusted in their care
Management of time before, during, and after clinical assignments
Recognition of impairment (e.g., illness or fatigue) in self and peers
Honest and accurate reporting of duty hours, patient outcomes, and clinical experience data

The institution further supports an environment of safety and professionalism by:

Providing and monitoring a standard Transitions Policy
Providing and monitoring a standard Clinical and Educational Work Hours Policy
Providing and monitoring a standard Supervision Policy
Providing and monitoring a standard master schedule and process in New Innovations
Adopting an institution-wide policy that all House Officers and faculty must inform patients of their roles in that patient’s care
Providing and monitoring an Alertness Management and Fatigue Mitigation Policy that includes:
Online modules for faculty and House Officers regarding signs of fatigue
Fatigue mitigation and alertness management including pocket cards, back up call schedules, and promotion of strategic napping
Assurance of available and adequate sleeping quarters when needed
Requiring that programs define what situations or conditions require communication with the attending physician

III.G.1. Process for implementing Professionalism Policy

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

Program presentations of this and other policies at program and departmental meetings
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
Institutional Fitness for Duty and Drug Free Workplace policies
Institutional Clinical and Educational Work Hours policy
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
Comprehensive Moonlighting policy
Orientation presentations on Professionalism, Transitions, Fatigue Recognition and Mitigation, and Alertness Management

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:

Daily rounding and observation of House Officers in the patient care setting
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
Rotation and semi-annual competency-based evaluation of the House Officer
Annual Program Evaluations and Special Program Reviews.
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
Program and Sponsoring Institution New Innovations monitoring of work hours and procedure logging, as well as violations

III.H. Well-Being

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:

Paying attention to scheduling, work intensity, and work compression that impacts House Officer well-being
Evaluating workplace safety data and addressing the safety of House Officers and faculty members
Creating policies and programs that encourage optimal House Officer and faculty member well-being

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.

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.

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.

House Officers who work for the School of Medicine are expected to report to work in a fit and safe condition. House Officers taking prescription medication(s) and/or have alcohol, drug, psychiatric or medical condition(s) that could impair their ability to perform in a safe manner should contact the Campus Assistance Program (CAP).

The Campus Assistance Program (CAP) is a free service provided by LSU Health Sciences Center to assist faculty, staff, House Officers, and students in the resolution of personal problems.

CAP offers a multidisciplinary team that is equipped to assist House Officers with an array of problems, issues, or stressors. All services are confidential, and all client records are limited to CAP staff. If a House Officer or a family member needs CAP services, they should call 568-8888. A CAP counselor will answer any questions about their services or schedule an appointment.

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.

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.

Any individual who works for or is enrolled at Louisiana State University Health Sciences Center is expected to report to work/school in a fit and safe condition. An individual who has an alcohol, drug, psychiatric, or medical condition(s) that could impair their ability to perform in a safe manner must self-report their medical status to their supervisor and provide a signed medical release indicating their fitness for work/school to the Campus Assistance Program (CAP).

LSU Health Science Center requires all faculty, staff, House Officers, students or other LSU Health Sciences Center workers who observe an individual who is believed to be impaired or is displaying behavior deemed unsafe at work/school to report the observation(s) to their supervisor for appropriate action. Supervisors are required to make an administrative referral to the Drug Testing Program and CAP. An individual who is referred to CAP and found to be impaired must provide CAP, prior to returning to work, with a signed medical release indicating they are fit to resume their work or school responsibilities. LSU Health Science Center will, as a condition of continued employment/enrollment, require an “at risk” individual to sign a Continuation of Employment/Enrollment Contract and maintain a continued care plan either recommended or approved by CAP.

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.

IV. Institutional GME Policies and Procedures

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.

United States Citizens, Permanent Residents of the US, and J1 Visa holders sponsored by the ECFMG are the only applicants eligible for selection. As noted in Chancellor’s Memorandum 39 (CM-39), ECFMG sponsorship as a J-1 exchange visitor is the appropriate and only mechanism whereby foreign physicians may enter graduate medical education/training Programs at LSU Health Sciences Center.

First year House Officers must match through the NRMP Programs. Candidates may compete and be appointed individually only in the absence of an NRMP Matching Program in a particular discipline or at an advanced level of appointment. Such candidates must meet all ACGME Institutional and Program Requirements for selection of House Officers.

House Officers must be:

Graduates of medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME)
Graduates of colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association Commission on Osteopathic College Accreditation (AOACOCA)
Graduates of medical schools outside the United States who have a valid certificate from the Education Commission for Foreign Medical Graduates (ECFMG) prior to appointment or have a full and unrestricted license to practice medicine in a United States licensing jurisdiction in which the ACGME-accredited Program is located OR are graduates of medical schools outside the United States who have completed a Fifth Pathway Program by an LCME-accredited medical school

All fellow eligibility exceptions that meet the ACGME Resident Eligibility Exception Requirement must be approved by GMEC and the DIO before the candidate is ranked or offered a training position. Those accepted must have a Milestones Assessment completed by the program on their performance within 90 days of matriculation.

Eligible House Officer candidates are selected by Programs based on their preparedness, ability, aptitude, academic credentials, communication skills and personal qualities such as motivation and integrity. The number of House Officers accepted depends on available educational opportunities, patient population, levels of illnesses, types of procedures, number of staff available for supervision, financial resources of in-patient and out-patient care facilities, and recommendations of the ACGME Review Committees (RC). The Graduate Medical Education Committee and the Academic Dean supervise the overall number of positions offered and the individual House Officer quota among services and Departments.

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.

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.

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.

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.

IV.A.4 INP-55 Positions

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

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.

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.

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.

House Officers are not allowed to start work prior to receiving the results of the pre-employment drug screening and background check, in accordance with LSUHSC Human Resources policy.

All drug screenings for New House Officers starting July 1 should be completed in the month of April. House Officers should contact their program coordinator to schedule their drug screening. When appearing for their drug screening, House Officers should bring a valid driver’s license or state ID with photo or a valid passport, a list of prescription medication they are currently taking, a completed Agreement to Submit to Drug Testing/Release of Test Results Form, a Drug Notification Form. Once a House Officer is cleared for hire, the GME Office is notified.

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.

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

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.

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.

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.

The required paperwork:

Pays the new House Officers for the first pay period of July.
Pays the continuing House Officers at their promoted levels.
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.
Pays the transferring House Officers and transfers them to the correct program for July 1.

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

Due Process is for non-promotion, non-reappointment and termination but NOT probation.
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.
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.
Follow the Request for Adverse Action template in Appendix A. It should be detailed and include specific examples, dates, and witnesses.
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.”).
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.

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

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.

As per Legislation passed in 2017, all practitioners with a Controlled Dangerous Substance (CDS) license in Louisiana are now required to complete at least three hours of Board Pre-Approved continuing medical education (CME) that includes all 4 of the following topics: Best practices for the prescribing of CDS, Drug diversion training, Appropriate treatment for addiction, and the Treatment of chronic pain. The LSU New Orleans Controlled Substance (CDS)/Opioid Training is a board approved course. This is a once in a lifetime requirement under current law. This three-hour requirement will be considered a part of, and not in addition to, the prescriber’s annual CMD requirement.

The three hours of CDS-CME must be completed before the prescriber’s first license/permit renewal date. If the prescriber has not completed this requirement by his/her first renewal date, the Board will be unable to renew his/her license/permit.

As of January 1, 2019, licensure is available to graduates of medical school who complete the PGY 2-year, pass USMLE Step 3, and meet all other requirements of the LSBME.

Graduates of osteopathic schools follow the same procedure as the allopathic medical school graduates for interns and PGY2s and must pass USMLE Step 3 or Complex 3 before proceeding to the PGY 3 year of training.

Individuals that do not want to apply for a Louisiana Medical License are eligible for a Louisiana Medical Permit after completing the PGY 2 year if they have taken and passed USMLE Step 3.

All questions regarding permits or licensure should be directed to LSBME staff.

Permits
PGY 1

For up to 12 months
Issued to graduates of medical /osteopathic schools
For first year internship

To enter the PGY 2 year, interns (PGY1) must either apply for full licensure or renew their training permit. House Officers are encouraged to take and pass USMLE Step 3 in their PGY 1 year so that they are eligible for full licensure after the PGY 1 year. Applicants who do not pass USMLE Step 3 in their PGY 1 year may apply for a PGY2 permit for up to 12 months except for international medical graduates (IMGs). There is no extension of the training permit beyond 24 months of total training (i.e., PGY 1 and 2) without passing USMLE Step 3. Please see the LSBME site²¹ for rules governing obtaining full licensure for those who do pass Step 3.

PGY 2

For up to 12 months
Issued to graduates of medical/osteopathic schools
Can be issued to graduates of a medical/osteopathic school who have not taken and/or passed USMLE 3/COMLEX 3
If applicant has not previously received LSBME-issued PGY 1 permit (i.e., applicant from out-of-state moving to LA and applying for PGY 2 permit) applicant must complete a licensure application and provide letter from PGY 2 Program Director. Permits or licenses are generally not issued to applicants that have not taken and passed the USMLE Step 3/COMLEX 3 when the PGY 2 permit expires.

Starting in November/December Program Coordinators begin working with the GME Office to prepare for House Officer first renewal of license/permit requirements to submit to LSBME.

The following documents are needed for a one-year PGY 2 permit:

Permit fee-which is determined by the State Board
A promotion letter signed by the Program Director stating PGY 2 name and starting and ending dates in program as PGY 2.
CDS-CME Approved Training Course Completion Certificate (required for first renewal of license/permit).

All programs with PGY 2s must print the LSBME Program Director letter from the GME Online Appointment Form System link in the Knowledge Base, have the Program Director sign the letter for each PGY 2 informing LSMBE that the individual is a PGY 2 in their program for the upcoming academic year.

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.

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.

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.

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.

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.

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.

IV.E. Health and Disability Insurance

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

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.

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

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.

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.

In addition to the 6 weeks of Extended Medical, Parental and/or Caregiver Leave, the ACGME requires one (1) additional week or seven (7) days (inclusive of weekends) of paid personal leave to be used outside the 6 weeks of medical, parental, and/or caregiver leave. Like all other leave this special leave does not carry across academic years. LSUHSC provides PGY1 House Officers with twenty-one (21) days (including weekends) and PGYII House Officers with twenty-right (28) days (including weekends) of non-cumulative vacation leave that can be counted toward this additional week of required leave as required by the ACGME. If the week of vacation leave is used prior to the exhaustion of six weeks of the required ACGME leave, an additional week will not be granted. House Officers will only be granted the additional week of personal leave if all LSUHSC provided leave is exhausted for extended medical, parental and/or caregiver purposes.

Process for Requesting Extended Medical, Parental, Caregiver Leave

A House Officer anticipating the need for noncontinuous or continuous Extended Medical, Parental and/or Caregiver Leave should reach out to HRMFMLA@lsuhsc.edu. The process for requesting the additional ACGME required leave will coincide with the FMLA request process. Certification documents will be provided to the House Officers for completion by the House Officer/the House Officers’ family member’s treating physician. Completed certification must be returned to the office of Human Resource Management (HRM) at HRMFMLA@lsuhsc.edu within fifteen (15) days. The determination of whether the ACGME required leave will apply to the House Officer’s request will be made by HRM. If approved, the leave will run concurrently with FMLA (if House Officer meets FMLA eligibility requirements). More information about the process and qualifying events can be found on the HRM FMLA website.

A coordinator with knowledge of a potential ACGME qualifying event can reach out to HRMFMLA@lsuhsc.edu on behalf of the House Officer. Based on the information provided by the coordinator, HRM will determine if the House Officer qualifies for the additional leave provided by ACGME and coinciding FMLA (if eligible), or if additional medical information is needed. HRM will have the ability to designate eligible leave taken towards the ACGME required leave if applicable.

Once the determination of ACGME and FMLA qualification is made, HRM will notify the House Officers coordinator of the determination and the anticipated dates leave will be needed. If approved, the coordinator will determine the amount of applicable extended medical, parental or caregiver ACGME leave the House Officer has available to them and will apply that leave to the House Officers time out of work.

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.

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:

They are completing an away "research" year to fulfill a future fellowship requirement
They return to their country but will be returning to the US to complete training during the same academic year
They are in the medical school portion of the OMFS residency
Other circumstances occur as determined by LSUHSC

House Officers should be scheduled on LOA/LWOP with the LOA Combo Code/Account Number as soon as the program is notified that the House Officer will be on LOA/LWOP. If not able to enter the LOA/LWOP dates in Resident Scheduler contact the GME Office.

The Project Number (Combo Code/Account Number) to schedule LOA/LWOP is:
Medical School House Officers: 149760048A-505000
Dental School House Officers: 122600013A-505000

If the LOA account was not entered in Resident Scheduler and/or the House Officer was not paid correctly, two (2) PER 3s must be submitted to make the correction and pay or recoup the House Officer.

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

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.

A standard affiliation agreement for the University must be completed and approved. In those cases where outside facility insists on using their own contract (affiliation agreement), the University will require additional time for legal review and negotiation.

To assure timely processing of these agreements the following policies must be adhered to:

All out-of-state rotation requests should begin with the Department’s Business Manager in coordination with the School of Medicine’s Contracts Office, who will initiate a discussion with the host institution regarding the agreement to be used. If it is the LSU Affiliation Agreement, it will be routed as usual. If it is the host institution’s agreement, it should be completed by the program and forwarded to the School of Medicine Contracts Office for review and referral to LSUHSC legal counsel as needed. Discussions between the Contracts Office and the host institution must begin at least three months before the rotation begins.
After all parties agree on the final language, the affiliation agreement/contract will be routed for signatures. Contracts (including affiliation agreements) must be signed by appropriate institutional officials and not simply by the program or GME Office.
During this time, discussions should also occur between the program and the Vice Chancellor for Community and Security Affairs Office to assure that all issues regarding malpractice coverage are resolved.
Any international rotation requests are governed by Chancellors Memorandum 65 and the process it establishes for requesting exceptions. Program Directors wishing to sponsor a House Officer to participate in an international rotation must request permission to do so in writing no less than four months before the proposed activity.

Any time spent on rotations while a resident is taking vacation leave may not be counted as part of the educational program for credit purposes towards Boards. If applicable, the House Officer should be notified in writing that the rotation does not count towards satisfying educational requirements.

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.

IV.H. Human Resources Policies

IV.H.1. EEO

Chancellor’s Memorandum (CM)-10 – Equal Employment Opportunity Policy Statement²⁴

The Louisiana State University Health Sciences Center New Orleans (“LSUHSC-NO”) reaffirms its commitment to Equal Employment Opportunity policies and procedures in the recruitment, hiring, transfer, promotion, and other terms or conditions of employment without regard to race, color, ethnicity, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age (over 40), spirituality, socio-economic status, disability, genetic information, family status, protected veteran’s status, experiences, opinions or any aspect of one’s social identity or other non-merit factor which cannot lawfully be used as the basis for an employment decision. Any discriminatory action can be cause for disciplinary action, up to and including termination. Additionally, retaliation against any individual for having complained about discrimination on the basis of any protected status described above or participating in the investigation of such a claim is expressly prohibited.

The equal employment policy has been carried out through the development and maintenance of Affirmative Action plans on the LSUHSC-NO campus. The execution of this policy requires vigorous efforts to identify and attract qualified applicants from groups underutilized at all levels in LSUHSC-NO. The policy further insures that all applicants receive fair consideration for employment and that all employees are treated fairly. Such action shall include, but not be limited to, the following: employment; promotion or upgrading; demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; selection for training; and tenure.

The Human Resource Management’s (“HRM”) Employee Relations Manager has been designated to have primary responsibility for implementing the equal opportunity policy at LSUHSC-NO. Administrative heads of all divisions and departments who have responsibility for recruitment, appointment, employment, and evaluation of faculty and staff are charged with seeing that the plan is successfully implemented and for cooperating fully with the official who has primary responsibility.

COMPLAINT PROCEDURE:

Any member of the LSUHSC-NO community who believes that he or she has been subjected to discrimination and/or harassment in violation of this policy has a right to report the conduct to any LSUHSC-NO official, supervisor, or Human Resource Management. No student or employee is required to report or make a complaint of discrimination and/or harassment to the person who is engaging in the problematic conduct.

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.

IV.H.2. Harassment

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

LSU Health Sciences Center in New Orleans (“LSUHSC-NO”) is committed to providing a professional work environment that maintains equality, dignity, and respect for all members of its community. In keeping with this commitment, LSUHSC-NO prohibits discriminatory practices, including sex and gender-based harassment and discrimination, including Sexual Misconduct (e.g. sexual assault, stalking, dating violence, domestic violence, sexual exploitation, retaliation, etc.). Any sexual harassment, whether verbal, physical or environmental, is unacceptable and will not be tolerated.

Sexual harassment is illegal under federal, state and local laws. It is defined as any unwelcome sexual advance, request for sexual favors, or other verbal or physical conduct of a sexual nature when:

Submission to the conduct is made either explicitly or implicitly a term or condition of an individual's employment;

Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting the individual; or

The conduct has the purpose or effect of unreasonably interfering with the individual's performance, or of creating an intimidating, hostile or offensive working environment; or

The conduct effectively denies a person equal access to an education program or activity.

Examples of behavior that constitute sexual harassment may include, but are not limited to:

Unwelcome sexual flirtations, advances or propositions;
Derogatory, vulgar, or graphic written or oral statements regarding one's sexuality, gender or sexual experience;
Unnecessary touching, patting, pinching or attention to an individual's body;
Physical assault;
Unwanted sexual compliments, innuendo, suggestions or jokes;
The display of sexually suggestive pictures or objects.

Any member of the LSUHSC-NO community, who has a workplace sexual harassment complaint against a supervisor, co-worker, visitor, faculty member, or other person, has the right and obligation to bring the problem to the attention of LSUHSC-NO. Any employee, including any person that is both a student and an employee at LSUHSC-NO, who has knowledge of sex or gender-based harassment or discrimination, including Sexual Misconduct, must file a report with the Title IX Coordinator. Any supervisor who witnesses such conduct or receives a complaint from an employee or student must report the incident to the Title IX Coordinator. An employee who fails to promptly make a report without good cause or, with the intent to harm or deceive, knowingly makes a report that is false, shall be terminated, in accordance with R.S. 17:3399.13.3.

COMPLAINT PROCEDURE:

Any student, faculty and/or staff member, who believes he or she has been sexually harassed, should immediately report the incident to the Title IX Coordinator. Any recipient of a complaint involving sex or gender-based harassment and discrimination must similarly and immediately notify the Title IX Coordinator.

The Title IX Coordinator for LSUHSC-NO can be contacted at:

LSUHSC-NO Title IX Coordinator

Academic Affairs, RCB

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.

Actions taken to investigate and resolve sexual harassment complaints will be conducted confidentially to the extent practicable and appropriate in order to protect the privacy of persons involved. An investigation may include interviews with the parties involved in the incident, and if necessary, with individuals who may have observed the incident or conduct or who have other relevant knowledge. The individuals involved in the complaint will be notified of the results of the investigation. Faculty, staff, and students have an obligation to cooperate with the Title IX Coordinator and HRM in any investigation.

There will be no discrimination or retaliation against any individual who makes a good faith sexual harassment complaint, even if the investigation produces insufficient evidence to support the complaint. There will be no discrimination or retaliation against any other individual who participates in the investigation of a sexual harassment complaint. If the investigation substantiates the complaint, appropriate corrective and/or disciplinary action will be swiftly pursued.

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.

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.

LSU Health Sciences Center is committed to complying with all applicable laws providing equal employment opportunities to all individuals. That commitment applies to all persons employed by LSU Health Sciences Center and prohibits unlawful discrimination by all employees, including supervisors and co-workers.

To comply with applicable laws insuring equal employment opportunities to qualified individuals with a disability, LSU Health Sciences Center will make reasonable accommodations for the known physical or mental limitations of an otherwise qualified individual with a disability who is an applicant or an employee unless undue hardship would result.

Any applicant or employee who requires an accommodation to perform the essential functions of the job should contact the Department of Human Resource Management, Assistant Director, Employee Relations or Employee Relations Manager (504.568.4832) and request such an accommodation. The individual with the disability should specify the accommodation he or she need to perform the job. LSU Health Sciences Center will identify the barriers that make it difficult for the applicant or employee to have an equal opportunity to perform his or her job. LSU Health Sciences Center will identify possible accommodations, if any, that will help eliminate the limitation. If the accommodation is reasonable and will not impose an undue hardship, LSU Health Sciences Center will make the accommodation.

If a House Officer believes they have been subjected to any form of unlawful discrimination, they must provide a written complaint to the Department of Human Resource Management as soon as possible. Complaints should be specific and should include the names of the individuals involved and the names of any witnesses. LSU Health Sciences Center will immediately undertake an effective, thorough, and objective investigation and attempt to resolve the situation.

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.

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.

We are committed to fostering growth in the matriculation of African-American, Hispanic, Vietnamese, LGBT students as well as students from underserved rural regions of Louisiana. Institutional efforts to qualitatively strengthen the climate of inclusion and diversity of our learning community are inclusive of a focus on the development of effective pipelines for recruitment of students and residents from communities which are underrepresented in our region’s health professions workforce. The institutional mission of advancing the quality of the educational climate, promoting effectiveness of health equity research, and fully engaging equitable clinical service is supported by a focus on the recruitment and development of basic science and clinical faculty, and senior academic leadership who are underrepresented in our region’s academic medical community with an emphasis on women, African American, Hispanic, Vietnamese, and LGBT faculty.

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.

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.

The following procedures are established:

LSUHSC personnel shall not release information about programs, events, and other activities to the media independent of the Office of Information Services.
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.
All media contact to the campus must be directed to the Office of Information Services.
The Office of Information Services is responsible for coordinating efforts of the HSC to obtain coverage in the news media.
Faculty and staff should make every effort to apprise the Office of Information Services of events which may be newsworthy.
Faculty and staff shall work with the Office of Information Services to “be available” to representatives of the news media when requested.
HSC personnel contacted for an interview by media representatives shall immediately inform the Office of Information Services.
The Office of Information Services will conduct Media Training as necessary or requested, to prepare faculty and staff to deal effectively with media.

IV.H.6. Social Media

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

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.

House Officer level and compensation is based on the trainee successfully completing all requirements for academic promotion to the next PGY level. House Officers not academically promoted or who must repeat all or part of a year prior to academic promotion will be paid at the current PGY level until academically promoted by the Program.

To distinguish a fellow from a resident, the LSU Systems Office approved the following titles for fellows:

House Officer 8 – first year of fellowship program
House Officer 9 – second year of fellowship program
House Officer 10 – third year of fellowship program

These titles DO NOT relate to the postgraduate year of the individual.

House Officers will be paid the LSUHSC approved base salary at the assigned academic level in the training program regardless of the number of postgraduate years completed in other training programs. House Officers training in the same program at the same academic level must receive the same salary amount. No one will be paid more or less than another trainee at the same academic level in the same program.

All first-year residents and fellows will be paid a base salary no higher than the approved base salary for a first-year resident or fellow and a base salary no higher than the approved base salary for all other academic levels in the same program.

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.

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.

Programs should follow the guidelines below to appoint House Officers and input rotation schedules in the Resident Scheduler System:

Program Coordinators must send New Hire packets to all new hire House Officers
House Officers should complete the pre-employment drug screen, background check, and the New Hire packet and return the New Hire packet with all required documentation to the Program Coordinators.
Program Coordinators must attach any required personnel form to the New Hire packet and send the packet to the GME Office for review; the GME Office will then forward the packet on for approval, and then to Human Resources.
Human Resources receives the New Hire packet and enters the House Officers information in PeopleSoft.
Once the House Officer’s information has been entered into PeopleSoft by Human Resources, the Program Coordinator can enter the House Officer rotation schedules into PS-RTS.

A check will not be issued for any House Officer that is assigned to a non-paying account or assigned to Leave of Absence Action in PS-RTS. If a House Officer is assigned for less than 100% effort, his/her check will be issued based on the percent of effort he/she is assigned in PS-RTS.

Account Codes-Account Codes are issued by the Accounting Department once a fully executed contract for the rotation site is received. Accounting enters the account code information in PS-RTS and Program Coordinators schedule residents using the code for the House Officer’s rotation site for that period.

Facility Numbers-Facility Numbers identify the rotation site the House Officer is assigned to each period and is entered in PS-RTS when the Program Coordinator enters the schedule for the month.

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.

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.

Program Coordinators are encouraged to enter House Officer schedules for a new month prior to the end of the previous month, but they can begin scheduling for the next fiscal year once the new schedule is available. However, Program Coordinators can only schedule new House Officers once HRM has entered their information into PeopleSoft. The GME Coordinator can update PS-RTS schedules unless the PS-RTS system has been locked by the GME Coordinator.

Payroll Certification Reports and Signature Pages must be run by the Program Coordinator at the conclusion of every month. Each month, House Officers must review the Certification Report and sign by his/her name (or send an email response to the Program Coordinator) certifying the information on the report (or providing corrections and certifying the new information is correct). The Program Coordinator submits the Certification Report with the House Officer signatures or emails and the signed Signature Page to the GME Office (deadlines for submission are provided by the GME Office). If leave was taken during the month and it is not included on the report, or if the rotation site listed on the report is incorrect, the House Officer notifies the Program Coordinator, who corrects the Certification Report. Any account code changes require the Program Coordinator to initiate a CSOF ePAF (change source of funds electronic PER 3) detailing the account code change, which must be initiated at the time the Certification report is submitted to the GME Office. PS-RTS is also updated by the Program Coordinator on the CSOF ePAF. The GME Office reviews any corrections entered in PS-RTS from the CSOF ePAF that included PS-RTS updates. Accounting invoices the rotation sites based on the corrections and the information the House Officers certify on the Certification Reports.

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

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.

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.

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.

IV.H.11. Freedom of Speech Policy

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

Purpose

LSU Health Sciences Center - New Orleans (LSUHSC-NO) is fully committed to the principle that the free expression of ideas among students, faculty, staff, and visitors is fundamental to education, discovery, and dissemination of knowledge. Supporting this culture of freedom of speech includes a responsibility to allow expression of all ideas and opinions, including, without limitation, those which some may find unwelcome, disagreeable, or even deeply offensive, and to welcome all people into the discussion.

Policy Statement

In accordance with the First Amendment of the Constitution of the United States of America, with Article I, Section 7 of the Constitution of Louisiana, with other applicable laws and regulations, and with LSU Permanent Memorandum 79 - Freedom of Speech and Expression (PM-79)³⁵, all students, faculty, and staff at LSUHSC-NO, along with visitors lawfully present on campus, are free to discuss any topic, assemble, and/or engage in spontaneous expressive activity as long as such discussion, assembly, or activity is not unlawful and does not materially and substantially disrupt the functioning of the LSUHSC-NO. Outdoor areas on campus that are generally accessible to the majority of students, faculty, and staff are deemed traditional public areas under state law that are open on the same terms to any speaker.

Due to the compact nature of its campus, LSUHSC-NO reserves the right to impose limitations on the time, manner, and place of expressive activities on groups of any size, without regards towards the content of the views expressed, for the purposes of ensuring:

• The safety of faculty, staff, students and visitors.

• The free speech rights of all parties.

• The unimpeded flow of pedestrian and vehicular traffic on campus or into campus facilities.

• The undisrupted continuance of the normal activities of the educational mission.

Policy Administration

All definitions and policy requirements of LSU PM-79 are hereby incorporated into this LSUHSC-NO campus policy, which will be administered and enforced by the Vice Chancellor for Academic Affairs, the University Police, and such other campus officials as may be designated by the Chancellor.

Information about this policy shall be included in the LSUHSC-NO Faculty Handbook, the LSUHSC-NO Catalog Bulletin, annual training required of all students, faculty and staff, and in any other forms of publication that LSUHSC-NO may deem necessary to ensure wide understanding of the campus support for free speech and expression.

Visitors to the campus and all others violating this policy regarding time, place, and manner of speech and demonstration shall be subject to immediate eviction or removal from the campus without further warning by University Police and may be subject to appropriate legal action.

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.

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.

Visiting House Officers must:

Provide a letter from the LSUHSC department informing the GME office of the status of the visiting House Officer which includes the following:

Full name of visiting House Officer
Start and end date visiting House Officer’s training (not to exceed one month)
Paragraph stating what the training will include (for example, participating in clinics, scrubbing in Surgery, attending various academic conferences connected with the program) and the sites where the House Officer will rotate (see attached sample)
Paragraph stating there is no re-numeration or salary offered and that any costs incurred, including transportation, all living expenses and mandatory health insurance is the visiting House Officer’s responsibility (see attached sample)
Approval of rotation with signature line for Chairman, Program Director, Director of Graduate Medical Education, and visiting House Officer
- Once the letter is signed by all parties, copies are sent to Medical Education Office at the rotation site for privileges and the Vice Chancellor’s Office for malpractice issues. The GME Office keeps a copy, and the original is returned to the program.

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.
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.
Obtain a visiting ID badge from HRM. The Program should contact HRM for instructions for the procedure to obtain a visiting ID.
Submit a Participating Site Appointment for Visiting House Officer Form to the GME Office for approval.

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

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:

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.

(2) Individual gifts of minimal value are permissible if the gifts are related to the physician's work (e.g., pens and notepads).

(3) The Council on Ethical and Judicial Affairs defines a legitimate "conference" or "meeting" as any activity, held at an appropriate location, where (a) the gathering is primarily dedicated, in both time and effort, to promoting objective scientific and educational activities and discourse (one or more educational presentation(s) should be the highlight of the gathering), and (b) the main incentive for bringing attendees together is to further their knowledge on the topic(s) being presented. An appropriate disclosure of financial support or conflict of interest should be made.

(4) Subsidies to underwrite the costs of continuing medical education conferences or professional meetings can contribute to the improvement of patient care and therefore are permissible. Since the giving of a subsidy directly to a physician by a company's representative may create a relationship that could influence the use of the company's products, any subsidy should be accepted by the conference's sponsor who in turn can use the money to reduce the conference's registration fee. Payments to defray the costs of a conference should not be accepted directly from the company by the physicians attending the conference.

(5) Subsidies from industry should not be accepted directly or indirectly to pay for the costs of travel, lodging, or other personal expenses of physicians attending conferences or meetings, nor should subsidies be accepted to compensate for the physicians' time. Subsidies for hospitality should not be accepted outside of modest meals or social events held as a part of a conference or meeting. It is appropriate for faculty at conferences or meetings to accept reasonable honoraria and to accept reimbursement for reasonable travel, lodging, and meal expenses. It is also appropriate for consultants who provide genuine services to receive reasonable compensation and to accept reimbursement for reasonable travel, lodging, and meal expenses. Token consulting or advisory arrangements cannot be used to justify the compensation of physicians for their time or their travel, lodging, and other out-of-pocket expenses.

(6) Scholarship or other special funds to permit medical students and House Officers to attend carefully selected educational conferences may be permissible if the selection of students and House Officers who will receive the funds is made by the academic or training institution. Carefully selected educational conferences are generally defined as the major educational, scientific, or policy-making meetings of national, regional, or specialty medical associations.

(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

IV.J. Non-Competition

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

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.

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

Declaration of an extreme emergent situation may be initiated by a Program Director or by the DIO. Declaration of a qualifying local disaster is made by the DIO, in collaboration with the Participating Institutions Chief Executive Officer, the Chief Operating Officer, the Chief Medical Officer, affected Program Directors, and Department Heads. When possible, an emergency meeting of the GMEC – conducted in person, through conference call, or through web-conferencing – shall be convened for discussion and decision-making as appropriate.

After the Declaration of an Extreme Emergent Situation:

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.

IV.L. Disasters³⁷

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

1. The Plan - The Disaster Plan is designed to cover unanticipated and anticipated disasters that result in partial or complete loss of training facilities. In the case of anticipated disasters (e.g., hurricanes) the House Officer is expected to follow the rules in effect for the training site to which they are currently assigned (e.g., Code Gray at UMCNO). In the immediate aftermath, the House Officer is expected to attend to personal and family safety and then render humanitarian assistance where possible (e.g., temporary medical facilities). In the case of anticipated disasters, House Officers who are not ‘essential employees” and are not included in a clinical site’s emergency staffing plans should secure their property and evacuate, should the order come. If a House Officer has questions about his/her status, he/she should contact the Program Director before the disaster. House Officers displaced out of town will contact their Program Director as soon as communications become available. In most cases, temporary residency offices will be established at participating site hospitals (Our Lady of the Lake-Baton Rouge, UHC-Lafayette, and Chabert-Houma) soon after the disaster and House Officers who have not been able to contact their program can report there for instructions. In addition to the resources listed below, House Officers are directed to the ACGME web site³⁸ for important announcements and guidance. The ACGME, Program Directors and DIO will work closely together to assure as smooth a response as practical and to assist House Officers in their needs.

2. All LSUHSC employees are governed by the “Policy on Weather Related Emergency Procedures for LSUHSC-New Orleans (CM-51).”³⁹ The House Officer is expected to be familiar with this policy, especially the following:

Communication-all communication will be maintained via the Emergency Web Site (www.lsuhsc.edu), the Emergency Information Hot Line (866-957-8472), and statewide radio and television. In the event of complete loss of usual communication methods, PIN numbers for key administration and others will be listed on the Emergency Web Site.
1. Phone Trees-all academic units must submit phone trees and disaster plans to the Chancellor’s Office by May 1 of each year.
Personnel Availability-all employees are required to update their personal contact information on the LSUHSC-NO registry website.
The LSUHSC-NO campus will not serve as an evacuation site.

3. Administration will relocate and reestablish function at the earliest possible time in a central location, most likely on the main campus of LSU Baton Rouge; the location and further information will be listed on the web site. Communication will begin immediately between the DIO and Program Directors. Weekly or more frequent meetings with Program Directors will be held at a central site to coordinate the relocation of training program rotations and reassignment or transfer of House Officers where necessary.

4. Payroll – House Officers are paid by electronic deposit offsite, so no interruption to payroll is anticipated. House Officers are encouraged to bank with an institution that has at least regional offices.

5. Transfers - Two types of transfers are utilized by the Programs: temporary and permanent. The terms are often confused by accepting programs as are the rules regarding temporary transfer of Medicare funding. To protect the House Officer the following steps should be followed:

A.) Temporary Transfers-transfers where the program remains open and needs to assign the House Officer for a particular educational reason to an in- or out-of-state facility. Temporary transfers are sanctioned by the program and may or may not involve transfer of funding caps. Temporary transfers are not for the duration of the House Officers training except if a House Officer is in his/her final year of training and occur because the training program establishes the transfer for specific training experiences. Temporary transfer House Officers remain LSUHSC-NO employees and receive paychecks from LSUHSC-NO.

B.) Permanent Transfers –House Officers committed to a Program may develop a personal or professional need to transfer to another program in the case of severe catastrophes. This is not encouraged, but the program and institution will take reasonable steps to help this occur in a timely and smooth fashion if it becomes necessary. In the case of permanent transfers, the House Officer is leaving the LSU Program permanently to complete either all or their current period of training at another institution; the House Officers are no longer LSUHSC-NO employees, receive no paycheck from LSUHSC-NO and become employees of the accepting institution. All parties must recognize that LSUHSC-NO does not “own” residency caps (Medicare) and cannot transfer caps. House Officers who permanently transfer do not have funding or caps that transfer with them. In addition, the effects of a severe catastrophe may prevent traditional transfer procedures from being followed. Since time is often of the essence in obtaining a position, the institution has adopted the following procedures:

The House Officer emails his/her Program Director requesting permanent transfer and should include the new program’s name, the effective date and the names, phone numbers and email addresses of the new program’s Program Director and DIO. The House Officer’s email should indicate that the House Officer initiated the request, and it is not due to any actions on part of LSUHSC and that the House Officer expressly permits the Health Science Center to release information regarding his/her standing in the program, as well as relevant information regarding his/her program standing and performance. The LSU DIO must be copied on this email.
The LSUHSC-NO Program Director will email the accepting Program Director, copying the DIO of both institutions and the requesting House Officer, stating that the LSUHSC program releases the House Officer; the House Officer’s level of training and standing in the program will be noted, along with any other relevant information. The email must state that this is a permanent transfer and that no funding or GME caps will transfer with the House Officer, and the House Officer’s termination date should be included.
The accepting Program Director must reply to all parties his/her acceptance of the transfer and understanding of an agreement to the terms outlined in the transfer email.
The transfer is official once this process is completed; the House Officer should contact the LSUHSC-NO Residency Program Business Manager and/or the GME Office for instructions on termination.

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.

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.

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.

Appendix A
Sample Request for Adverse Action

June 23, 20XX

John Doe, M.D.

1 Audubon Place

New Orleans, LA 70XXX

Re: Request for Adverse Action

Dear Dr XXXXXXX:

Proposed Action:

After carefully reviewing your nurse, House Officer, student evaluations and discussing your portfolio with a committee of XXXXXX faculty, the XXX Program is recommending non-renewal of your contract (or termination or non-promotion, as the case may be) effective July 1, 20XX.

List of Deficiencies / Reasons for Action:

This recommendation for is based on the counsel of the XXXX committee and is due to your substandard performances in the following competencies:

Patient Care:
1. Weak XXXXX (specialty) knowledge as demonstrated by your substandard in service exam scores both in July 20XX and February 20XX compromising patient care,
2. Inability to apply your knowledge for both teaching students and interns, and for providing sound patient care. Examples of this include:
  1. XXXX
  2. XXXX
3. Lack of attention to detail compromising patient care. Examples of this include:
  1. XXXX
  2. XXXX
4. Poor organizational and time-management skills reflected in:
  1. Inability to write timely and accurate orders. Examples of this include:
    1. XXXX
    2. XXXX
  2. Execute the staff and House Officer’s therapeutic plans causing the supervisory House Officers to do much of your work. Examples of this include:
    1. XXXX
    2. XXXX
  3. Inability to work effectively as a team player. Examples of this include:
    1. XXXX
    2. XXXX
5. Failure to consistently follow through on patient orders that you were specifically instructed to complete. Examples of this include:
  1. Failure to look up the doses. This was seen :
    1. XXXX
    2. XXXX
6. Use of incorrect or deliberately approximate dosing in critical situations. Examples of this include:
  1. XXXX
  2. XXXX
7. Failure to follow a specific order on a medicine. Examples of this include:
  1. XXXX Rocephin
Medical Knowledge:
1. Weak XXSPECIALTYXX medical knowledge evidenced by:
  1. Poor performance on xxxxx in-service exams in July 2009 and February 2010
  2. Overall clinical performance on XXXX ward month in October 2009 and the XXXX team wards in June 2010.
  3. Lack of insight into areas of weakness as evidenced by comments made about your performance by peers and supervisory House Officers on “check out “rounds and other rounds where you are directly observed. Specific examples of this include:
    1. XXXX
    2. XXXX
Interpersonal Skills/Communication Skills:
1. Disrespectful, condescending behavior with fellows, House Officers, and students. Examples include
  1. XXXX
  2. XXXX
2. When questioned about the behavior, you rationalized this behavior as a defense mechanism used for survival. Specific examples of this include:
  1. XXXX
  2. XXXX
3. Continued disrespectful behavior after counseling by myself and others. This was specifically seen:
  1. XXXX
4. Lack of insight into your behaviors and performance level as reflected above as reflected in the following examples:
  1. XXXX
  2. XXXX
5. Rude and abrasive behavior with patients, families and peers as evidenced by:
  1. XXXX
  2. XXXX
6. Several peers strongly dislike working with you because of your failure to adequately and consistently complete the tasks assigned to you. Examples of this include:
  1. XXXX
  2. XXXX
Professionalism:
1. Rude and disrespectful behavior. Examples include
  1. XXXX
  2. XXXX
2. Inability of your peers to trust you. Examples include
  1. XXXX
  2. XXXX
3. Untruthful behavior. Examples include:
  1. XXXX
  2. XXXX
4. Your cavalier, overconfident behavior without the essential knowledge base is a dangerous combination that many House Officers feel will result in poor outcome for patients if you are not heavily supervised at all times.
5. Failure to arrive on time.
6. Unauthorized absences.
Practice-Based Learning:
1. Failure to read assigned materials as seen:
  1. XXXX
  2. XXXX Web MD, XXXXX, etc.
2. Failure to recognize, reflect on and correct mistakes despite being specifically counseled. Examples of this include
  1. XXXX
  2. XXXX

List of all known documentary materials to be used in a hearing

The above listing assumes there would be attached documentation supporting each or many of the listed deficiencies. If so, you would say “see attached documentation.”
You may add letters, evaluations, or anything collected to prove your point, but they would be added as an addendum if not already in the above-mentioned documentation.
If you do not plan to list and attach extensive documentation (a mistake!) then you can simply refer to the “House Officer file” which means you need to introduce the whole thing or select parts and attach them to the request.

List of Witnesses and Expected Testimony

It is assumed that in many of the above specific instances a specific person will be named as making the complaint or turning in the evaluation etc. that led to the item being included. If so you can simply state something like, “The witnesses who may testify are included in the charges listed under reasons and will testify to the validity of the information listed in that charge.”
Otherwise list them and say something brief like “they will attest to the evaluations in the file”, or “they will attest the House Officer didn’t show up” or “they will attest the House Officer lied”, etc.

Sincerely,

Jane Doe

Program Director

¹ Approved by GMEC-February 2011

² Approved by GMEC-October 2007

³ https://lsugme.atlassian.net/wiki/spaces/FORMDOCS/pages/11698563/Letter+of+Agreement

⁴ https://www.lsuhsc.edu/administration/hrm/benefits-about.aspx

⁵ https://lsugme.atlassian.net/wiki/spaces/FORMDOCS/pages/2654238/House+Officer+Manual

⁶ http://www.lsuhsc.edu/library/information/ische.aspx

⁷ http://www.lsuhsc.edu/library/information/dental.aspx

⁸ https://www.lsuhsc.edu/library/

⁹ Effective July 1, 2011

¹⁰ ACGME Teleconference-August 2010

¹¹ Effective July 1, 2011

¹² Effective July 1, 2011; revised 2017

¹³ Adopted July 28, 2016

¹⁴ https://www.lsuhsc.edu/administration/pm/pm-11.pdf

¹⁵ https://www.lsuhsc.edu/administration/pm/pm11form.pdf#page=1

¹⁶ https://www.lsuhsc.edu/administration/pm/pm-11.pdf

¹⁷ Effective July 1, 2011

¹⁸ Effective July 1, 2011

¹⁹ https://lsugme.atlassian.net/wiki/spaces/FORMDOCS/pages/37191681/DIO+Transfer+Approval+Packet

²⁰ GMEC May 2016

²¹ https://www.lsbme.la.gov/

²² Approved by GMEC-January 2009

²³ https://lsugme.atlassian.net/wiki/download/attachments/9306380/Benefits Guide for House Officers.pdf

²⁴ https://www.lsuhsc.edu/administration/cm/cm-10.pdf

²⁵ https://www.lsuhsc.edu/administration/cm/cm-49.pdf

²⁶ https://lsu.edu/administration/policies/pmfiles/pm-73.pdf

²⁷ https://www.lsuhsc.edu/administration/cm/cm-26.pdf

²⁸ https://www.medschool.lsuhsc.edu/LSUHSC SOM social media guidelines 8-14.pdf

²⁹ Approved by GMEC-July 2005

³⁰ Approved by GMEC-July 2008

³¹ https://lsugme.atlassian.net/wiki/download/attachments/2031722/Release Data FROM LSU.pdf

³² Louisiana State Law-LSA-R.S. 44:411

³³ https://lsugme.atlassian.net/wiki/spaces/POLICY/pages/2863792129/Records+Retention

³⁴ CM-66; December 18, 2018
https://www.lsuhsc.edu/administration/cm/CM-66.pdf

³⁵ https://www.lsuhsc.edu/administration/pm/PM-79.pdf

³⁶ Approved by GMEC-July 2007

³⁷ Approved by GMEC: June 21, 2007

³⁸ http://www.acgme.org/

³⁹ https://www.lsuhsc.edu/administration/cm/cm-51.pdf

⁴⁰ Approved by GMEC-October 2007

⁴¹ https://www.medschool.lsuhsc.edu/medical_education/graduate/HouseOfficerManual.aspx

⁴² http://www.medschool.lsuhsc.edu/medical_education/graduate/

⁴³ https://lsugme.atlassian.net/

Policy and Procedure Manual for Graduate Medical EducationTable of Contents

Policy and Procedure Manual forGraduate Medical Education

I. Structure and Function of the Sponsoring Institution

I.A. GMEC Responsibilities

I.A.1. Oversight

I.A.2. Review and Approval

II. Institutional Resources

II.A. Institutional Operations

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

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

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

II.B. Program Administration

II.B.1. Program Sponsorship

II.B.2. Program Resident Position Numbers

II.B.3. Program Letters of Agreement

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

II.B.5. Program Experimentation and Innovation

II.C. House Officer Forum

II.D. House Officer Salary and Benefits

II.D.1. Salary

II.D.2. Benefits

II.E. Educational Tools

II.E.1 New Innovations

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

II.E.3. Email

II.E.4. Knowledge Base

II.E.5. Library

II.F. Support Services and Systems

III. Learning and Working Environment

III.A. Patient Safety

III.B. Quality Improvement

III.C. Transitions of Care9

III.D. Supervision11

III.E. Clinical and Educational Work Hours Policy

III.E.1. Maximum Hours of Clinical and Educational Work per Week

III.E.2. Mandatory Time Free of Clinical Work and Education

III.E.3. Maximum Clinical Work and Education Period Length of Work Assignments

III.E.4. Clinical and Educational Work Hours Exceptions

III.E.5. Maximum Frequency of In-House Night Float

III.E.6. Maximum In-House On-Call Frequency

III.E.7 At-Home Call

III.E.8 Granting Clinical and Educational Hour Exceptions

III.E.9 Clinical and Educational Work Hours Attestation Statement

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

III.E.11 Moonlighting13

Special Considerations:

Moonlighting - Foreign Medical Graduates

III.F. Fatigue Mitigation Education and Services

III.F.1 Adequate Rest for House Officers Policy

III .F.2 Alertness Management / Fatigue Mitigation Strategies17

How Monitored:

III.G. Professionalism18

III.G.1. Process for implementing Professionalism Policy

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

III.H. Well-Being

III.H.1. Self-Care

III.H.2. Coverage of Patient Care

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

III.H.4. Fitness for Duty

IV. Institutional GME Policies and Procedures

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

IV.A.1 Match Policy

IV.A.2 Appointment of House Officers

IV.A.3 J-1 Visa House Officers

IV.A.4 INP-55 Positions

IV.A.5 Accepting House Officer from another Program

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

IV.A.7 Drug Screening and Background Check

IV.B. Agreement of Appointment/Contract

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

IV.C. Promotion, Appointment Renewal and Dismissal

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

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

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

IV.D.1. Medical Licensure

IV.D.2. Permits - Provisional Temporary

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

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

IV.D.5. Professional Liability Insurance

Medical Malpractice Verification Requests for House Officers

Policy and Procedure Manual for Graduate Medical Education
Table of Contents

Policy and Procedure Manual for
Graduate Medical Education

III.C. Transitions of Care⁹

III.D. Supervision¹¹

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

III.E.11 Moonlighting¹³

III .F.2 Alertness Management / Fatigue Mitigation Strategies¹⁷

III.G. Professionalism¹⁸

IV.H.3. Disability Policy (CM26)²⁷

IV.L. Disasters³⁷

Appendix A
Sample Request for Adverse Action

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