New Program Coordinator Orientation

1. New Program Coordinator Orientation

2. Who’s Who in GME • The GME office is led by a Designated Institutional Official (DIO) (Dr. Alan Smith) in collaboration with the Graduate Medical Education Committee (GMEC). Together they administer all ACGME accredited programs of the sponsoring institution. The DIO and GME office are resources that you should never hesitate to contact with questions, feedback and just good communication. We are here to help you do your job.

3. Alan J. Smith, PhDDirector • DIO • Assistant Dean for Graduate Medical Education • Resident Ombudsman • Resident Performance-Due Process/Probation Procedures

4. Chris SpringmanAdministrative Manager • Institutional Accreditation • Staff Training • Duty Hours Monitoring/Reports • Resident Contracts • Resident Final Evaluations • UMA/AMA Memberships

5. Sharee Bracken Financial Manager • Budgets for Housestaff Salaries • Utilize and Maximize Housestaff Funding • Review and Approve Training Agreements • Review Rotation Schedules • Housestaff Payroll • Affiliated Hospital Billing • CMS and UMEC Liaison • Supervise GME Accounting

6. Breanna Stoll Education Coordinator for Credentialing • Credentialing • Licensing • Compliance • International Medical Graduates • SEVIS Reporting • J-1 Visas • New Hires and Terminations • New Housestaff Computer Accounts

7. Ronnie KoonEducation Coordinator for Accreditation • Resident Orientation; Resident Handbook • GME Policy Manual/Program Policies • NRMP Monitoring • GMEC Secretary/ GMEC Resident Members • Program Coordinator’s Meetings • New Coordinator Orientation • Program Director’s Retreat • Call Room Monitoring • Visiting Housestaff • Track Affiliated and Off-site Training Agreements • Notary Public

8. Renn ButterfieldAdministrative Program Coordinator for E*Value • E-Value Administrator • E-Value Trainer • Database Monitor • Liaison between GME and E-Value • Oversee Participation in E-Value

9. Melanie PowellInformation Coordinator • Credentialing • Resident Loan Deferments • Certificates • Compliance • Assist Education Coordinator for Credentialing • Notary Public

10. Kyle WheelerProject Coordinator • Front Desk/Secretary • DIO Assistant (Scheduling) • Verification Letters • Moonlighting/Additional Compensation • Pagers • Call Money • Parking Passes • Door Access • Long Distance Cards • Notary Public

11. Anne VinselStaff Development Educator • Residency Program Special Reviews • ACGME Compliance Monitoring • Resident Surveys • Educational Projects

12. GME at the U, why?The ACGME requires on-site overview and management of all ACGME Accredited ProgramsADAAOA • The DIO and GMEC oversee the following activities in particular: • Program compliance with ACGME requirements • Resident Supervision • Resident Responsibilities • Resident Evaluation • Compliance with duty-hour standards • Resident participation in patient safety and quality of care education

13. So what does a Program Coordinator Do? • Within the residency program, the program director, residency coordinator, and chief residents are responsible for the daily management of the program. In larger programs, the program director may also have one or more associate or assistant program directors to help with the administration of the program. Generally, the program coordinator’s role consists of supporting the program director, maintaining the program and trainee records, and serving as liaison to all those associated with the program in one form or another!

14. Program and Program Coordinator Responsibilities • ACGME requires every program to have certain specific policies, to be kept updated and made available to residents and faculty; GME will send reminders, approve content of policies, and keep electronic copies in the GME office. Policies must also be kept in the department. The following ten are the required policies: Work Hours, Supervision, Moonlighting, Standards of Performance, Evaluation, Academic Action, Resident Selection, Leave, Dress Code, and Technical Standards • ACGME requires that every resident/fellow have a signed contract, or Houseofficer Agreement, for each year of training. These are initiated by the Program Coordinator each year.

15. ROTATION SCHEDULES: Enter into the E-Value system a full annual rotation schedule for each resident in your program by the required date – usually May 31 for the following academic year. Contact the GME Office for assistance if needed. • ROTATION SCHEDULE CHANGES: Record changes, rotations, elective rotations, vacations, didactic days, and other absences in e-Value in a timely fashion. • OFFSITE ROTATIONS: ACGME and MEDICARE require Offsite Training Agreements for every offsite rotation, to be completed and signed BEFORE the beginning of the rotation; this requires keeping track of your residents; training agreements are needed BEFORE the beginning of the rotations. LIABILITY INSURANCE IS NOT PROVIDED FOR OUT-OF-STATE ROTATIONS! • VISITING HOUSESTAFF: If your program accepts visiting housestaff, approvals and training agreements MUST be completed and signed and on file in the GME Office BEFORE the visiting resident arrives and begins rotating. Call the GME Office for Visiting Housestaff Packets and to prepare training agreements properly. • WEB ADS: Updating of the ACGME online accredited data system (ADS) is an annual requirement for accreditation. Also monitor Resident and Faculty Surveys for timely completion. • ASSISTANCE WITH RESIDENT CREDENTIALING AND COMPLIANCE: Residents delinquent in providing credentialing or compliance information cannot rotate and may be subject to other disciplinary action. Programs will be contacted to assist in these matters.

16. PROGRAM REQUIREMENTS • Each program has very specific ACGME accreditation requirements. Programs are responsible for knowing their requirements. These are published on the web at www.acgme.org • ANNUAL SURVEY FROM ACGME • ACGME sends a survey to all residents and some faculty annually regarding their programs. Programs need to have 70% of residents and 60% of faculty fill out and return this survey. It is an important piece of the accreditation process and site visitors review the answers of residents when looking at various facets of the programs they are reviewing. Less than 70% / 60% response can trigger a site visit and citations. MISCELLANEOUS REPORTING RESPONSIBILITIES At various times the GME Office needs information from departments: On-Call meal money lists, Applications report, payroll forms/Spreadsheets, Housestaff Contracts, Work hours report, ACGME annual fees, Departmental Policies, New hire lists, Term lists and certificate information. • ATTEND COORDINATOR MEETINGS AND TRAINING SESSIONS! • These are scheduled on a monthly basis. There are usually 9 or 10 meetings a year. A light breakfast is always available. Attendance is important for keeping current on policies and requirements.

17. Know the resident policy manual!!! Access it through the GME website   http://medicine.utah.edu/gme

18. Resident have Responsibilities too! • Provide GME with necessary information to be credentialed • Take required exams on time and provide scores to GME • Maintain current ACLS certification and provide card to GME • Have annual flu shot and provide documentation to GME Office • Complete Utah medical license application materials by deadline and become licensed as required by department by deadline • Provide GME with copies of all licenses • Renew all licenses as needed and provide GME with current copies • Report elective rotations to department in a timely manner (before the rotation begins) • Get Program Director’s permission to moonlight and complete the necessary form • Report vacation and other leave days to department in a timely manner (E*Value, Rotation Schedules) • Report to department and GME any address/phone/pager/email changes • Check email regularly

19. E*Value is your residency management program • Set up an appointment with Renn.Butterfield@hsc.Utah.edu for a Tutorial • How to Enter in E*Value • Vacation • FMLA • LOA Didactics and Conferences • Duty Hours • Rotations • WORK HOURS MONITORING • EVALUATIONS

20. One of the most important duties of the GME Office is to ensure that all new hire residentsARE FULLY CREDENTIALED BEFORE WORKING! Full Credentialing Must Include: Primary source verification of medical school graduation Primary source verification of all prior training Primary source verification of all prior employment Primary source verification of ECFMG certification Primary source verification of any licenses in other states Security background check Report from the National Practitioner Data Bank Medicare/Medicaid Sanctions List Clearance Immunization records approved by Employee Infection Control

21. Proof of passing scores on USMLE exams • Proof of ACLS certification (Not Every Program) • Proof of completion of on-line EduCAT trainings • Proof of completion of on-line HIPAA training • Satisfactory pre-employment drug screen • Successful completion of powerchart training • VA paperwork and certificates completed • A credentialing packet is sent to all new hires and must be completed before they can begin work.

22. When a program has a new hire • Notify Breanna Stoll in the GME Office • Provide all required information to the GME Office • Requirements for all Residents/Fellows • Completed Welcome Packet and Hiring Paperwork (due to GME by April 30th for new interns) • GME office sends electronic copy of Welcome Packet by end of March (will mail if requested) • ACLS/BLS Certification must be current (if a program requires it) • This class should be taken in current location or resident should sign up for a class on clinical staff education website directly. (GME Office will not be arranging classes.) • Every new hire must be current in ACL/BLS and /or PALS • PGY2 and above must be current if the program requires current certification. • (See ACLS Policy). • Requirements for All Residents/Fellows • 2-step TB screening: Dates of 2 tests, one within the past 12 months and one within two (2) months prior to the first day of employment, unless there is a past history of a positive TB skin test or BAMT. Residents having a history of a positive TB skin test or BAMT must provide a copy of the written interpretation of their most recent chest x-ray (must have been taken within past 12 months). • Power Chart training is mandatory for all New Hires before they begin ANY clinical rotation. • VA • Complete online Educat training. (e-mail link sent April 15th) • VA Appointment Packet (Only if rotating at VA) • VA online training certificates (certificates are submitted to the GME office) • VA credentialing must be complete before ANY clinical rotations anywhere are started.

23. Contracts • Programs are responsible for all contracts (this includes Intern contracts) • All contracts are due in the GME office by May 15th • Contracts for J-1s are due sooner (preferably January) • Credentialing • GME office needs 30-45 days to fully credential residents • GME verifies Medical School, prior training, employment, ECFMG certifications, criminal background checks, drug screens, etc.

24. MEDICAL LICENSE, CONTROLLED SUBSTANCE, DEA AND NPI NUMBERS • All residents are required to obtain a Utah medical license, a Utah controlled substance license and a Federal DEA registration as well as an NPI number to participate in a training program at the University of Utah Affiliated Hospitals (unless specifically exempted in this policy) • PROCEDURES: • PGY1’s are required to pass steps 1 and 2 of the USMLE prior to beginning residency • They must show evidence of that as part of the credentialing process • All PGY1’s are required to take and pass USMLE Step 3, receive scores, and provide evidence of a passing score to the GME Office by the last day of their PGY1 year • All PGY2’s will submit a completed FCVS credentialing application and a completed Utah medical license application to the GME Office by July 31 of the PGY2 year • All FCVS credentialing and Utah medical license applications submitted by the stated deadline will be paid for by the GME Office. • All PGY3’s and above must be fully licensed by hire date. • Failure to submit these items by the above deadline may result in disciplinary action and will require payment of licensing fees by applicant.

25. REQUIRED DOCUMENTS TO BE SUBMITTED WITH FCVS (Federal CredentialAPPLICATION • A Certified Birth Certificate Or a valid current passport if a certified birth certificate cannot be obtained (if born outside the U.S.)  • A Certified Marriage Certificate if the last name has changed by marriage  • Any name change documentation  • 1 passport photo (color) (two photos for IMG’s)  • 1 photocopy of medical school diploma (must be exactly 8”x11”)  • A photocopy of any completed residency or fellowship training certificate  • If a foreign medical graduate: Must submit an ECFMG certificate  • Copies of the Utah medical license, Utah controlled substance license, and Federal DEA registration must be submitted to the GME Office within 30 days of receipt  • Instructions on how to obtain a Federal DEA registration and NPI number may be obtained in the GME Office  • Residents who do not follow through as necessary may be subject to disciplinary action.

26. PROGRAM EXEMPTIONS FOR DEA LICENSE • Some programs are specifically exempted from the Utah controlled substance and Federal DEA registration requirements. Residents in these programs are still required to apply for and obtain a Utah Medical License. • The Following Programs are Exempt from the Requirement for Utah Controlled Substance and Federal DEA License • Residents in these programs are still subject to the requirements for Utah medical license and NPI number • Neurogenetics • Pathology and Pathology Fellowships • Pediatric Critical Care • Radiology and Radiology Fellowships • (except Neuroradiology, which requires all • licenses) • Dental Residents are not required to be licensed • NPI Numbers • All residents are required to obtain a Utah medical license, a National Provider Identifier (NPI), a Utah controlled substance license, and a Federal DEA registration to participate in a training program at the University of Utah Affiliated Hospitals, in accordance with the policy herein. The NPI is the standard unique identifier for healthcare providers. Once issued, the NPI will remain with the provider regardless of job or location changes. • Any houseofficer who is not credentialed will not begin any scheduled rotations, including research, and will not be paid until credentialing is complete!

27. INTERNATIONAL • MEDICAL GRADUATES • The three most important things to remember . . . • Anyone who graduated from a medical school outside the US (except Canada) must have an ECFMG certification • Anyone who is not a US citizen (or green card holder) must come on a J-1 Visa • Consult with the GME Office if you have ANY questions—or even if you think you don’t! ECFMG CERTIFICATION The Educational Commission for Foreign Medical Graduates (ECFMG) is an agency authorized by the US Information Agency and the US Department of State to credential and sponsor international medical graduates as Exchange Visitors to train in US GME programs. (www.ecfmg.org)

28. Is this an applicant for a PGY1 position? • All applicants for PGY1 positions, including IMG’s, must come through the NRMP Match. The applicant must consult ECFMG for Match registration information, and must have an NRMP registration number before he/she can be ranked. The applicant may be in the process of obtaining ECFMG certification when interviewed, but must understand that the completed ECFMG certification is required in order to be on a program’s rank order list. • Is this an applicant for a PGY2 (+) position? • IMG’s applying for PGY2 positions in advanced programs must come through the NRMP Match. IMG’s applying for fellowships or positions not offered in the Match must have a current ECFMG certificate and, if applicable, a J-1 visa. Applicants coming into PGY2 positions must be eligible to apply for a Utah medical license and federal DEA license. Applicants coming into positions higher than PGY2 must be fully licensed before they start. • Is the applicant currently in another program? • If your applicant is currently in another ACGME-accredited program, that means he/she most likely has an ECFMG certificate. Check with the applicant. Advise the applicant of the J-1 Visa requirement. Instruct the applicant to contact ECFMG for permission to transfer to another institution.

29. Is the applicant eligible for a Utah medical license? • It is an institutional requirement that all PGY2 residents apply for a Utah medical license by July 31 of the PGY2 year. It is also an institutional requirement that all residents above PGY2 be licensed at the time they begin training. Many IMG’s are not eligible to apply for a Utah medical license because they have not had prior US residency training. Check with the GME Office. • Is any other visa acceptable? NO • How long can a trainee stay in the US? • Typically, until a program is completed, up to 7 years. • If someone has a green card, do they need a visa? • Permanent Resident status and a “green card” are the same thing. If someone is a permanent resident and has a green card, there is no need for a visa. • To be ECFMG certified one must take a pass USMLE Step 1 and USMLE Step 2CK and Step 2CS. Additionally, graduation from a world-accredited medical school must be verified by ECFMG. • ECFMG sponsors the J-1 visa necessary to be accepted into a residency program at University of Utah. • An IMG may not change programs without the approval of ECFMG. • An IMG may not stay longer than the duration of the program without the approval of ECFMG. • An IMG on a J-1 visa MAY NOT MOONLIGHT.

30. FUNDING • How are your residents/fellows funded? • Many residents are paid by the Hospital • Their salaries come through the Hospital budget • There is a cap on the number of residents • A large portion of funding comes from other locations where residents rotate • Many locations are billed on a monthly basis for residents who rotate there—these reimbursements go into resident salary and benefits accounts • Training agreements must be in place for every training location—these outline reimbursement details • It is vital for programs to send residents to training locations as specified in Training Agreements in order to receive adequate reimbursements for resident funding • Training Agreements and rotation schedules are audited by the GME Office regularly • Fellows are usually paid by departmental funds generated through clinical income • CMS (Centers for Medicaid and Medicare Services—federal government agency) pays Hospitals annually a subsidy for training residents. It is only a portion of the actual cost of training. It is for the purpose of meeting US medical/doctor needs. Payment is determined by auditing of the CMS Cost Report submitted each year, which consists of the detailed rotation schedule for every resident and fellow. • CMS auditors carefully audit every year’s submitted report • Rotations must be accurate • Discrepancies cause denials or reductions of payment • Every program’s funding details are different!

31. Please make an appointment with Sharee Bracken in the GME Office to understand your program’s funding: (801) 581-2401 Sharee.bracken@hsc.utah.edu

32. NRMP AND “THE MATCH” THE NRMP MATCH OVERVIEW The National Resident Matching Program conducts matches for residents and fellows by providing a uniform date for decisions about residency selection for both the applicants and the programs. Each program logs into the NRMP website with their AAMC ID number and password. This is usually done by the coordinator. If you forget this number, the GME office can help you retrieve it. If you forget your password, you will have to call NRMP to get it. The institution and the participating programs are required to sign a match participating agreement. This is done when you sign on to the website after the match has opened in the fall. Most PGY 1 positions are offered through the NRMP matching using the ERAS program (Electronic Residency Application Service).

33. There are three types of PGY1 positions offered • Categorical • Designed for broad specialties such as Family Medicine, Internal Medicine, Pediatrics, Emergency Medicine, Obstetrics and Gynecology, General Surgery, and Pathology. • Do not require preliminary training. • For residents who want to remain in the same program throughout their residency. • PreliminaryDesigned for residents seeking one or two years of clinical experience prior to another specialty. Available in Internal Medicine and General Surgery. If applying to an advanced program, students must apply separately for a preliminary program. • Transitional Positions • Generally designed for residents who have not decided on a medical specialty. May also serve as a substitute for a preliminary year. Advanced Program Positions Presumes the residents will complete a preliminary year. These are offered at the PGY2 level or above. Programs requiring a preliminary year: Anesthesiology Dermatology Physical Medicine and Rehabilitation Diagnostic Rehabilitation Radiation Oncology

34. The rank order list is the order in which a program lists its applicants. Applicants also complete a rank order list of programs. The ROL is submitted to the NRMP electronically. The ROL may be modified as often as desired until mid February when applicants and programs must certify a final ROL. CONFIDENTIALITY The NRMP does not allow programs or applicants to ask each other how they will be ranked. The ROL’s from both sides are confidential. Applicants must report a program that offers a contract outside of the match. Match Results Match Day is in Mid-March Applicant matched and unmatched information is posted to the NRMP web site at 12:00 noon Eastern time four days before match day. Filled and unfilled results for individual programs will be posted to the website also. Locations of unfilled www.nrmp.org

35. *SOAP is a new Supplemental Offer and Acceptance Program Newly implemented for the 2012 Match week. Programs that do not fill all positions in the Match must offer those positions through SOAP if they wish to fill them during Match Week. Unfilled positions may not be filled outside SOAP until Match Week is concluded. All programs sponsored by the institution, regardless of Matching Program participating status, must offer positions to US Allopathic senior students only through the matching program or other national matching plan. Matches and offers made and accepted through SOAP are binding agreements. Applicants must start the training program in good faith (i.e., intend to complete the program on the date specified on the appointment contract). Residents who terminate or resign their position within 45 days of the start date are in breach of their Match Agreement. IMPORTANT THINGS TO REMEMBER The Match Participation Agreement is a binding contract between the participating institution, its registered programs and the NRMP. Programs and applicants are not authorized to release each other from their binding match commitment. Strict rules apply to waiver requests from applicants or programs. It is a violation to recruit a 4th year allopathic medical student outside of the match even if the program is not registered for the match. Failure of an applicant, program or institution to honor the terms and conditions of the Match Participation Agreement may result in sanctions or withdrawal from the Matching Program.

36. Orientation for Interns and New Hires • Interns, June 23, 2014 • 7:30 a.m. to 3:00 p.m. • Residents and Fellows, July 1, 2014 • 7:30 a.m. to 3:00 p.m. • August 1st Hires, July 23, 2014 • 8:00 a.m. to 12:00 noon