The Year in Review!

1. 2013 . . . very brief The Year in Review! • Programs • Policies • IMGs

2. New Programs Approved by GMEC: Neurology Movement Disorders (non-ACGME) David Schprecher, MD Neuromuscular Medicine (ACGME pending) J. Robinson Singleton, MD Emergency Medicine Wilderness Medicine (non-ACGME) Scott McIntosh, MD Otolaryngology Pediatric Otolaryngology (ACGME accredited) Harlan Muntz, MD Urology Pediatric Urology (ACGME pending) Brent Snow, MD IM-Cardiology Advanced Heart Failure/Transplant (ACGME accredited) Edward Gilbert, MD

3. New or Revised Policies

4. UNIVERSITY HEALTH CARE HOSPITALS AND CLINICS GRADUATE MEDICAL EDUCATION RESIDENT POLICIES AND PROCEDURES __________________________________________­­­­­­___________________________________ HANDOFFS AND TRANSITIONS OF CARE GME 9.6 Review Date: August 2012 Chapter: Training Environment I. PURPOSE To promote continuity of care and patient safety in residents’ learning and working environment, the Accreditation Council for Graduate Medical Education (ACGME) requires that programs and sponsoring institutions minimize the number of patient care transitions, implement a structured and monitored handoff process, train residents for competency in handoffs, and make schedules readily available that list residents and attending physicians responsible for each patient's care. In addition to resident-to-resident patient transitions, residents must care for patients in an environment that maximizes effective communication among all individuals or teams with responsibility for patient care in the healthcare setting.

5. UNIVERSITY HEALTHCARE HOSPTIALS AND CLINICS GRADUATE MEDICAL EDUCATION RESIDENT POLICIES AND PROCEDURES RESIDENT SOCIAL MEDIA POLICY GME 9.7 Approved: December 3, 2012 Chapter: Training Environment I. PURPOSE The Internet provides considerable benefit to residents by providing new opportunities for education and communication. However, the use of the Internet and social communication sites on the Internet can present issues in ethical behavior and professionalism. The purpose of this policy is to provide residents with guidelines for the appropriate use of social media and to emphasize the responsibilities that residents have in maintaining appropriate ethical and professional behaviors.

6. Cannot display, reveal, or post protected health information (PHI) • Cannot display, reveal, or post confidential operations/financial information • Must not “friend” patients or family members of patients • Must not offer medical advice • Must not post “offensive” information • Must not post anything negative about colleagues/patients/staff • Must monitor site to ensure no one else is posting inappropriate information • Residents are personally responsible for content • Should maintain professional boundaries; separate personal from professional • Recognize long-term consequences on medical careers • Never expect privacy • Recognize use by potential employers • CONSEQUENCES • May jeopardize standing in residency program • Written warnings • Probation • Dismissal • Ability to sit for specialty board certification exams

7. UNIVERSITY HEALTH CARE HOSPITALS AND CLINICS GRADUATE MEDICAL EDUCATION RESIDENT POLICIES AND PROCEDURES ________________________________________________________________ PROCEDURE FOR APPROVING NEW RESIDENCY TRAINING PROGRAMS, NEW RESIDENT/FELLOW POSITIONS, OR REQUESTING CHANGES IN EXISTING PROGRAMS GME 14.2 Review Date: April 2012 Chapter: Graduate Medical Education Committee All of the above must have approval of Department Chair – then apply to GMEC for approval Must not apply to RRC without prior GMEC approval Contains checklist of information to be included in GMEC request New program applications are now through ADS (instructions included) Includes changes in . . . program expansions rotation sites rotations, including experiments or innovations Changes cannot take place until ACGME has approved and GME Office is notified

8. UNIVERSITY HEALTH CARE HOSPITALS AND CLINICS GRADUATE MEDICAL EDUCATION RESIDENT POLICIES AND PROCEDURES ________________________________________________________________ GRADUATE MEDICAL EDUCATION COMMITTEE GME 14.1 Chapter: Graduate Medical Education Committee • Review the qualifications of faculty members who are not eligible for ABMS board certification but who supervise residents/fellows in ACGME-accredited programs. The GMEC will determine if these qualifications are acceptable in lieu of board certification. MEDICAL LICENSE, CONTROLLED SUBSTANCE, DEA NUMBER, NPI NUMBER, and MEDICAID PROVIDER REGISTRATION GME 1.3 Chapter: Conditions for Employment • The Graduate Medical Education Committee may approve exemptions from the license requirement in certain circumstances (per Utah Division of Occupational and Professional Licensing Act 58-1-307(1)(b)). If a resident or fellow is an international medical graduate with no prior residency training in the United States, or is unable to comply with the licensing policy due to overriding concerns or issues deemed by the Graduate Medical Education Committee to be substantial and justifiable, the Committee may grant an exemption from the medical license requirement for a period of time not to exceed the length of the training in the program requesting the exemption. Residents/fellows training with an exemption from the licensure requirement may not participate in moonlighting activities or any activities outside the scope of the training program. The Program Director and the resident will be notified in writing of such an exemption, and the exemption will be documented in the resident's file.

9. UNIVERSITY HEALTH CARE HOSPITALS AND CLINICS GRADUATE MEDICAL EDUCATION RESIDENT POLICIES AND PROCEDURES RESIDENT PROFESSIONAL CONDUCT POLICY GME 8.4 Chapter: Resident/Fellow Training The purpose of the Resident Professional Conduct Policy is to clarify the expectations of all house staff when interacting with others. All residents working at University Hospitals and affiliates must treat others with respect, courtesy, and dignity, and must immediately report conduct that is disruptive or otherwise inappropriate.

10. UNIVERSITY HEALTH CARE HOSPITALS AND CLINICS GRADUATE MEDICAL EDUCATION RESIDENT POLICIES AND PROCEDURES ______________________________________________________ FACULTY APPOINTMENT FOR RESIDENTS GME 5.1 Chapter: Faculty Appointments • Residents in training with a J-1 visa may not hold a faculty appointment. UNIVERSITY HEALTH CARE HOSPITALS AND CLINICS GRADUATE MEDICAL EDUCATION RESIDENT POLICIES AND PROCEDURES ________________________________________________________________ INTERNATIONAL MEDICAL GRADUATES - ELIGIBILITY AND EXAMINATIONS GME 15.1 Chapter: International Medical Graduates • Residents with J-1 visas may not hold faculty appointments • Residents with J-1 visas may not bill independently for any services • Residents with J-1 visas may not moonlight

11. J-1Clinical Visa Reminders • The J-1Clinical visa is, by policy, the only one acceptable for house staff • RARE exceptions have been made for fellows only • Must be approved by GMEC • VERY difficult and lengthy to change from J-1 Research visa • Many J-1 visa holders are not eligible for a Utah medical license • Not enough US training; not taken required exams • Can be problematic • Check eligibility with the GME Office • J-1 visa is only good for 7 years • Check years of prior training • Check with GME Office if questions • J-1 visas for non-ACGME programs are very complicated • Lengthy process • Lots of documentation • Ultimately up to ECFMG • Check with GME Office • Approvals are ultimately up to ECFMG and Department of State Check with GME Office!

12. More Bulletins! Encryption of Devices . . . All computers, laptops, etc., should now be encrypted Program are responsible for residents’ devices Any Hospital-owned computers (clinical areas) will not be able to download onto flash drives unless approved after 9/16/2013 FMLA Requests for House Staff New forms – throw away any old forms From GME or from GME web site Must determine makeup time if required Increasingly important for residents to keep ACLS up to date VA possibly beginning to pull residents off rotations One day after expiration—no tolerance Will advise if this becomes VA practice Emphasizes need for residents to stay current