Stony Brook Department of Anesthesia Policies

Basic Exam (ABA) 7-01-24	Attire for Surgical Procedures 7-01-24	Attendance 7-01-24	Academic Deficiencies 7-01-24	Working Environment 7-01-24	Transitions of Care 7-01-24
Supervision 7-01-24	Supervising Faculty Communication 7-01-24	Substandard Resident 7-01-24	Substance Abuse 7-01-24	Social Networking 7-01-24	Sexual Harrassment 7-01-24
Scheduling 7-01-24	Resident Responsibilities 7-01-24	Resident Oversight Med Students 7-01-24	Resident Administrative Responsibilities 7-01-24	Quality Improvement 7-01-24	Professionalism 7-01-24
Physician Wellness 7-01-24	Patient Safety 7-01-24	Moonlighting 7-01-24	Mistreatment/Bullying /Disruptive Behavior 7-01-24	Medication Management 7-01-24	Medical Record Documentation 7-01-24
Management of Resident after Patient’s Death 7-01-24	Leave of Absence 7-01-24	Expectations & grad reqirements 7-01-24	Expectations of faculty 7-01-24	Evaluation 7-01-24	Eligibility, Selection 7-01-24
Duty Hours 7-01-24	Dress and Comportment 7-01-24	Disruptive Resident Behavior 7-01-24	Dating 7-01-24	Counseling/ Support Impairment/ Substance Abuse 7-01-24	Clinical Competency Committee 7-01-24

POLICY: ABA BASIC EXAM PERFORMANCE, REAPPOINTMENT AND FUTURE RESIDENCY TRAINING

A resident who fails the ABA Basic Exam in CA1 (PGY2) year will receive an “Unsatisfactory” in medical knowledge report to the ABA for the 6 month period of time in which the failure exam report was received. The resident will then need to register for the fall ABA Basic Exam when the registration become available in August of his or her CA2 year (PGY3). A resident may request to use his or her unused book fund money for reimbursement for the exam fee and for other scholarly resources. A resident may request for changes to be made to his or her block schedule and vacation time, but there is no guarantee that those changes can be granted. The resident’s exam failure and performance improvement plan should not impact the training experiences of other residents who have passed the ABA Basic Exam or are yet to take the exam.

After notification of the failed exam performance, the resident must meet with the program director to create an individualized performance improvement plan for the next ABA Basic Exam. A written copy of this plan will be provided to the resident, CCC Chairperson and the resident’s mentor. Recommendations to meet with a learning specialist and/or heath care professional within the Resident Assistance Program may be included as part of the plan.

If a resident would fail the ABA Basic Exam on second attempt, then the resident would receive an “Unsatisfactory” in medical knowledge report to the ABA for the 6 month period of time in which the failure exam report was received. The resident’s reappointment would not be renewed for the following academic year and the resident would be terminated as of July 1 of the academic year immediately following the second failed ABA Basic Exam.

If a resident would pass the ABA Basic Exam on second attempt, then the resident would receive a “Satisfactory” in medical knowledge report to the ABA for the 6 month period of time in which the passing exam report was received. The resident’s reappointment would be renewed for the following academic year as long as the resident has no other unsatisfactory performance reports to the ABA or other reasons for remediation or termination.

The initial residency period (IRP) is the minimum number of years required for a resident to become board eligible in the specialty in which the resident first begins training. It is based on the minimum accredited length for residency programs as determined by the ACGME. Generally, Medicare determines the initial residency period at the time the resident first enters a training program. Every resident has just one IRP and it does not change, even if the resident later changes specialties. The residency program in which a resident begins training determines the number of years in which Medicare will make full direct graduate medical education payments to the hospital for the resident’s training (although the maximum number of years that can be counted as a 1.0 FTE is 5). If a resident has used up part of his or her IRP funding, there may be a negative impact upon future training opportunities. This information will be provided to the resident upon first failure of the ABA Basic Exam and can be found in the link below.

https://members.aamc.org/eweb/upload/Medicare%20Payments%20For%20Graduate%20Med%20Ed.pdf

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: ATTIRE FOR SURGICAL AND PROCEDURAL ANESTHESIA

Policy All persons who enter semi-restricted or restricted area of the Hospital’s designated surgical and invasive procedure areas wear approved attire to protect both patients and perioperative personnel.

Only hospital issued and laundered scrubs are worn in Operating Rooms (OR) and restricted Procedural areas. This attire is only worn by personnel who work in the designated restricted areas.

Definitions

• Restricted area - A designated space contained within the semi-restricted area and accessible only through a semi-restricted area. The restricted area includes the operating and other rooms in which surgical or other invasive procedures are performed.
• Semi-restricted area - The peripheral support areas of the surgical/procedural suite. The area may include storage areas for equipment and clean and sterile supplies; work areas for processing instruments; sterilization processing room(s); scrub sink areas; corridors leading from the unrestricted area (i.e. Nursing stations) to the restricted areas of the suite. Access to the semi-restricted area is limited to authorized personnel and patients accompanied by authorized personnel.
• Transition Area - Traffic is permitted to allow movement of personnel from unrestricted to semi-restricted or restricted areas. Personnel may enter in street clothing and exit into the semi-restricted or restricted area in surgical attire.
• Monitored unrestricted area - Permitted traffic includes authorized personnel, patient, and their families. Health Care Workers (HCW) in scrub attire use this area as a transition area for the purpose of patient management and hospital business.
• Restricted and semi-restricted areas include the Labor & Delivery suite, all Operating Rooms, the Cardiac Catheterization Labs, Electrophysiology lab, Cerebral Vascular Center (CVC) and Interventional Radiology. Areas are more specifically defined in the Operating/Procedure Room Area Designations.

Procedures:

1. Personnel are to don clean scrub attire daily. These are changed promptly if they become wet or contaminated. Home-laundering is not permitted.
2. Scrubs are not worn to and from work or between facilities. Scrubs are not worn outside at any time.
3. Persons entering the semi-restricted or restricted areas for a brief time (e.g. parents, spouses, facilities personnel, law enforcement officers) don either clean scrub attire, single-use scrub attire, or a single-use jumpsuit designed to completely cover personal apparel.
4. Hair
1. All persons cover their head and facial hair when in the semi-restricted and restricted areas -NO EXCEPTIONS.
2. Coverings must cover all facial hair, sideburns, and hair at the nape of the neck.
3. Fabric head coverings may be worn if covered by a disposable head covering.
4. Knight hoods and masks are required for covering facial hair.
5. If Knight Hood and/or mask do not cover all facial hair, a beard cover is used to contain any remaining exposed hair.
6. It is recommended that personnel should not remove surgical head coverings when leaving the perioperative area.
7. Head coverings are removed at the end of the shift or when contaminated.
5. Masks
1. Masks are worn in the presence of scrubbed individuals, or when open sterile supplies or equipment are present.
2. Masks cover the nose and mouth completely, fitting snugly beneath the chin.
3. Masks are changed after each use.
4. Personnel remove masks when leaving the semi-restricted and/or restricted area.
5. Masks are not to be left dangling from the neck.
6. Fluid proof calf-length coverage boots are required when the risk of splash/splatter of bodily fluids or chemicals is anticipated and are discarded immediately after use.
7. Personal clothing items that cannot be contained within the scrub attire are not to be worn.
8. Cover jackets
1. Clean, hospital-laundered scrub cover jackets are recommended to be worn in the restricted areas by all non-scrubbed personnel.
2. Scrub cover jackets are worn by those preparing and packaging items in the clean assembly area of the Central Sterile Services.
3. Only hospital-laundered coverings are permitted to be worn as cover jackets (Examples of acceptable hospital-laundered cover jackets include lab coats or scrub cover jackets. Note: personal track jackets, sweatshirts or similar garments are not permitted.)
9. Earrings, necklaces and all piercing jewelry must be contained and confined within the scrub attire or covered with tape, as applicable.
10. Hospital-issued IDs are visible if personnel are not scrubbed. Lanyards are not worn in the semi-restricted or restricted areas.
11. No personal belongings including but not limited to purses, backpacks, computer bags are taken into the semi-restricted or restricted areas unless placed in a clean, plastic bag.
12. Ceil blue procedural area scrubs may not be worn outside the building at any time. Changing upon return to the building is not an acceptable practice.
13. Ceil blue scrubs should only be worn by personnel working in designated procedural areas – the OR, cath/EP suite, Interventional Radiology, Central Sterile, and Labor and Delivery
14. You are not required to cover ceil blue scrubs when in the building. However, should you choose to do so, only a hospital laundered lab coat or blue snap jacket is permitted to be worn over blue scrubs while in the building. Jackets, sweatshirts or any other personal garment are not to be worn, regardless of Stony Brook logo.
15. Scrubs should be changed daily and removed from designated scrub dispensing machines before use. Clean scrubs should not be stored in lockers.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: ATTENDANCE POLICY

The Program considers conference attendance to be a reflection and measure of residents’ professionalism, and tracks attendance for individual residents. Attendance is recorded every conference and each individual resident’s attendance is added to his/her file.

Academic Wednesday Education Days
Mandatory for all residents unless post call, on vacation or on CTICU.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: ACADEMIC DEFICIENCIES AND DISCIPLINARY ACTIONS

Disciplinary and Grievance Procedures

(Please refer to relevant Institutional GME Policies which can be found at https://policymanager.uhmc.sunysb.edu/ for polices on the following:, Resident/Fellow Physician Disability Accommodation, Disruptive Physician Behavior, Resident Evaluation and Promotion, Annual Program Review of Program, Faculty and Resident/Fellows, Resident Responsibilities, ard Resident Performance, Termination, Grievance and Due Process)

Addressing Lapses in Performance in the Competencies: Evaluation, Discipline, and Improvement Plans Residents are evaluated on their performance in each of the 6 ACGME General Competencies: Patient Care, Medical Knowledge, Professionalism, Interpersonal and Communication Skills, Systems-based Practice, and Practice-based Learning and Improvement. Performance judged to be substandard in these areas may be brought to the attention of the Program Director through a variety of means including (but not limited to ) formal written evaluations, informal evaluations, verbal reports, direct observation, or a pattern of persistent lapses in performance.
Failure to perform adequately in any of these areas may result in corrective action up to and including termination. If a resident is not progressing adequately, the program has a responsibility to inform the resident of the deficiency and provide him/her an opportunity to correct the deficiency. At times it is possible and appropriate for the program to provide extra assistance or educational experiences for the resident to aid in this. It is ultimately the residents’ responsibility to take the steps necessary to meet expectations.

The program director, with the guidance of the Clinical Competency Committee, is responsible for selecting the most appropriate action among those listed below, based on the severity of the problem. Any corrective action decision must be communicated to the resident. Decisions to suspend, terminate, or non-renew a resident will be made in consultation with the Designated Institutional Official (DIO), with written documentation of same.

While individual instances of failure to meet expected standards in the competencies may be addressed in an informal manner by the program director of faculty, a particularly problematic episode or a pattern of substandard performance will trigger the remediation/disciplinary process.

The stages of discipline are as follows:

1. Verbal Warning:
   Verbal warning may be imposed for deficiencies for which some degree of correction is necessary. The deficiency will be clearly outlined for the resident, who will have a reasonable opportunity, within a specified timeframe, to correct the deficiency. Any educational interventions shall be specified and monitored with the resident receiving feedback in follow-up meetings with the program director. The program director will place a written note in the resident’s file specifying the deficiency and the outcome of the intervention. If the deficiency is corrected, no further action will be taken. If the deficiency is not corrected, the resident may receive a letter of concern, written warning or may be placed on probation, suspended, or terminated.


2. Letter of Warning:
   Letter of warning may be imposed for more serious deficiencies than described in verbal warning. This is a formal letter which goes to the resident’s file, and contains specific information regarding the nature of the lapse, the competencies to which it pertains, and may contain an improvement plan and expectations for future performance. It also outlines consequences which relate to the performance lapse, such as a requirement to extend training to allow for improvement in the competency (ies), jeopardizing receipt of credit from the American Board of Anesthesiology for the year. The program director shall discuss the conditions of any remediation with the resident and require the resident to sign the conditions to acknowledge their receipt. This signature documents the resident’s commitment to achieve remediation.


3. Probation:
   Probation may be imposed for substantial, continuing or multiple deficiencies. This is a formal letter which goes to the resident’s file, and contains specific information regarding the nature of the lapse, the competencies to which it pertains, and contains a remediation plan and expectations for future performance. It also outlines consequences which relate to the performance lapse, such as a requirement to extend training to allow for improvement in the competency (ies), jeopardizing receipt of credit from the American Board of Anesthesiology for the year. The conditions of the written warning or probation shall be specified by the program director in writing and signed by the program director. The program director shall discuss the conditions of any remediation with the resident and require the resident to sign the conditions to acknowledge their receipt. This signature documents the resident’s commitment to achieve remediation. As per the Stony Brook University GME policy, a period of probation may not exceed 3 months; at the end of this time a determination must be made regarding either successful remediation of the lapse or progression to a higher phase of action. Probation must be reported to state licensing boards and to potential employers seeking verification of performance and training during the resident’s time at Stony Brook.


4. Suspension:
   Suspension may be imposed for more serious deficiencies than described in the previous three paragraphs, including, but not limited to, those which may involve the safety of patients, the resident, or others. The conditions of suspension shall be specified by the program director in writing (including items a-g), signed by the program director, and delivered to the resident. The program director shall discuss the conditions of suspension with the resident and require the resident to sign the conditions to acknowledge their receipt and the resident’s commitment to achieve remediation. During suspension the resident will be removed from his/her clinical rotations and will not receive credit for training. Upon completion of suspension, the resident may be placed on probation. Suspension must be reported to state licensing boards and to potential employers seeking verification of performance and training during the resident’s time at Stony Brook.


5. Termination:
   This is a termination from the training program. Termination or non–renewal may be mposed for academic reasons, professionalism reasons, or if the resident is deemed to threaten the safety of patients, the resident, or others. Notice of termination or non-renewal in writing signed by the program director shall be delivered to the resident. This includes a formal letter that goes to the resident’s file, and contains specific information regarding the nature of the lapse, the competencies to which it pertains, and prior remediation and disciplinary actions. It also outlines additional consequences, which relate to the performance lapse, such as jeopardizing receipt of credit from the American Board of Internal Medicine for the year. Termination must be reported to state licensing boards and to potential employers seeking verification of performance and training during the resident’s time at Stony Brook.


6. A resident may challenge any actions hereunder in accordance with the Stony Brook GME Resident Due Process Policy for Grievance. Any resident suspended, terminated, or non-renewed shall be given a copy of the Grievance Policy.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: THE LEARNING AND THE WORKING ENVIRONMENT

Purpose: To establish a policy in the Department of Anesthesiology regarding the structure configured to provide residents with clinical and educational experiences as well as reasonable opportunities for rest and personal activities.

Residency programs must maintain and monitor the resident work hours. Stony Brook University Hospital (SBUH) abides by the New York State Health Code 405.4 established in July 1989 and ACGME requirements, updated as of July 2017 with regard to resident clinical work hours.

Clinical Experience and Education

1. Clinical work and education time is defined as all clinical and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient),administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Clinical work and education time does not include reading and preparation time spent away from the duty site.
2. Maximum hours of clinical and educational work must be limited to no more than 80 hours per week, averaged over a 4 -week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting.
3. Moonlighting is not permitted.
4. Mandatory Time Free of Clinical Work and Education
   All residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational and administrative activities. At home call cannot be assigned on these free days.
5. Maximum Duty Period Length
   Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments. Residents are encouraged to use alertness management strategies in the context of patient care responsibilities (ex. coffee, napping) – See the Department of Anesthesiology’s “Policy to Ensure Adequate Rest” for more information regarding alertness management strategies.
1. It is essential for patient safety and resident education that effective
transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional three hours.
2. Residents must not be assigned additional patient care responsibilities after 24 hours of continuous in-house work.
6. Clinical and Educational Work Hour Exceptions
   In rare circumstances, after handing off all other responsibilities, a resident, on their own initiative, may elect to remain or return to the clinical site in the following circumstances:
1. To continue to provide care to a single severely ill or unstable patient
2. Humanistic attention to the needs of a patient or family
3. To attend unique educational events
These additional hours of care or education will be counted toward the 80-hour weekly limit.
7. Minimum Time Off between Scheduled Clinical Work and Education Periods
1. Residents must have 8 hours off between scheduled clinical work and education periods.
2. Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call. Residents have a responsibility to return to work rested, and thus are expected to use this time away from work to get adequate rest. In support of this goal, residents are encouraged to prioritize sleep over other discretionary activities.
8. Providing residents with a sound didactic and clinical education must be carefully planned and balanced with concerns of patient safety and resident well-being. The anesthesia residency program ensures that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education must have priority in the allotment of residents’ time and energy. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients.
9. To monitor resident clinical work hours regularly for compliance, all resident schedules are entered into New-Innovations by the anesthesia program coordinator using the assignment scheduler. All residents must verify and approve their clinical work hours are accurate and truthful as is reported in New-Innovations. Clinical work hours are monitored also by the GME office for compliance.
10. On-Call Activities
    The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those linical work hours beyond the normal work day, when residents are required to be immediately available in the assigned institution.
11. Maximum In-House On-Call Frequency: Residents must be scheduled for in-house call no more frequently than every third night (when averaged over a four-week period).
12. The anesthesia residency program ensures that a resident will be alleviated immediately from a continuing assignment when fatigue due to an unusually active “on-call” period is observed. The resident or supervising attending may activate the back-up process by contacting the anesthesia program coordinator or Program Director.
13. On the GME website and in New Innovations there is a PowerPoint module developed by the American Academy of Sleep Medicine which explains fatigue and what the consequences are from sleep deprivation (SAFER curriculum). All residents are required to review this module. It remains available for residents to review again at any time for reference. All faculty review this module when onboarded.
14. At-Home Call
    Time spent on patient care activities by residents on at-home call must count toward the 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.
1. At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.
2. Residents are permitted to return to the hospital while on at-home call to care for new or established patients. These hours of inpatient patient care must be included in the 80-hour maximum weekly limit.
This requirement acknowledges the often significant amount of time residents devote to clinical activities when taking at-home call, and ensures that taking at-home call does not result in residents routinely working more than 80 hours per week. At-home call activities that must be counted include responding to phone calls and other forms of communication, as well as documentation, such as entering notes in an electronic health record. Activities such as reading about the next day’s case, studying, or research activities do not count toward the 80- hour weekly limit.

Resident Education in the Learning and Work Environment

The Department of Anesthesiology must provide an educational and work environment in which residents may raise and resolve issues without fear of intimidation or retaliation. The program will provide a professional, respectful, and civil environment that is free from mistreatment, abuse, or coercion of students, residents, faculty, and staff. Programs, in partnership with their Sponsoring Institutions, should have a process for education of residents and faculty regarding unprofessional behavior and a confidential process for reporting, investigating, and addressing such concerns.

The program is committed to and responsible for promoting patient safety and resident well-being in a supportive educational environment. The program and institution must ensure a culture of professionalism that supports patient safety and personal responsibility.

Residents and faculty members must demonstrate an understanding and acceptance of their personal role in the following:

1. Assurance of the safety and welfare of patients entrusted to their care.
2. Provision of patient and family-centered care.
3. Assurance of resident fitness for duty. It is the professional responsibility of faculty members and residents to arrive for work adequately rested and ready to care for patients. It is also the responsibility of faculty members, residents, and other members of the care team to be observant, to intervene, and/or to escalate their concern about resident and faculty member fitness for work, depending on the situation, and in accordance with institutional policies. The Program Director must be contacted immediately if a resident is deemed unfit for duty by either the resident himself, resident colleagues or faculty members. Back-up plans are integrated into all resident schedules. Any resident unfit for duty will be removed from service and back-up arrangements will be put in place by the Program Director. Residents who are removed from service due to fitness for duty issues may not return to work until cleared by the Program Director.
4. Management of their time before, during and after clinical assignments.
5. Recognition of impairment, including illness, fatigue, and substance use in themselves, their peers, and other members of the health care team.
6. Commitment to lifelong learning. All residents are required to have an Individualized Learning Plan (ILP) which is reviewed by the Program Director.
7. Monitoring of residents’ patient care performance indicators. All residents will receive at least bi-annual feedback on practice habits.
8. Honest and accurate reporting of clinical and educational work hours, patient outcomes and clinical experience data.

The program will provide an appropriate balance of supervised patient care responsibilities, clinical teaching and didactic education, to achieve the learning objectives of the program. The learning objectives of the program will not be compromised by excessive reliance on residents to fulfill non-physician service obligations.

The Department of Anesthesiology provides anonymous and protected systems for residents/fellows to address concerns:

1. Anonymous on-line site on GME webpage
   Residents can anonymously communicate electronically with the Vice Dean for GME regarding any concerns. This is communicated to residents at the time of orientation and is available on the GME webpage.
2. Open-Door Policy
   The Program Director maintain a neutral open-door forum where residents can address issues that are of concern. These issues may be brought to the GMEC or hospital administration without identification of the source.
3. Anonymous evaluations
   Residents are given the opportunity to evaluate their program, faculty, peers, and Program Director anonymously. These evaluations are reviewed by the Program Director and Department Chair. Corrective action is taken as needed. All anonymous faculty evaluations are distributed to the individual faculty.
   The anonymous program surveys distributed on paper to all residents and faculty. The survey contains queries about the program overall, the faculty, teaching, work environment, supervision, duty hours, resources, scholarly activity and other areas. The surveys responses are reviewed through the Program Education Committee during the Annual Program Review to determine those areas that are highly regarded and those that require attention.
4. Chief Residents act as liaisons between the residents and Program Director. They have an opportunity to voice concerns about the quality of education and work environment.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: TRANSITIONS OF CARE

PURPOSE: To establish protocol and standards within the Department of Anesthesiology at Stony Brook University Medical Center to ensure the quality and safety of patient care when transfer of responsibility occurs during duty hour shift changes and other scheduled or unexpected circumstances. STANDARDS: The department designs schedules and clinical assignments to maximize the learning experience for anesthesiology residents as well as ensure quality care and patient safety, and adhere to general institutional policies concerning transitions of patient care. Transitions of care are necessary in the hospital setting for various reasons. The transition/hand-off process is an interactive communication process of passing specific, essential patient information from one caregiver to another. Transition of care occurs regularly under the following conditions:

• Change in level of patient care, including inpatient admission from an outpatient procedure or diagnostic area or ER, transfer to or from a critical care unit, transfer to the nursing staff in the post anesthesia care unit (PACU).
• Temporary transfer of care to other healthcare professionals when provided with relief during an anesthetic for a surgical or diagnostic procedure, including shift changes, meal breaks, or changes in 0n-call status
• Discharge from the PACU
• Change in provider or service change, including rotation changes for residents.

POLICY/PROCEDURE: The transition/hand-off process from OR to OR or OR to PACU must involve face-to-face interaction. The transition process between anesthesia providers in the O.R. should include, at a minimum, the following information in the standardized format that is:

OR to OR Transfers “IPASS”

• Identification of patient, including name and date of birth
• Review of written anesthetic record in “IPASS” format to include:
• - ILLNESS SEVERITY: Recent events, medications, hospital course
• - PATIENT’S CONDITION: (Stable, “watcher” – at risk for detreating, unstable)
• - PATIENT SUMMARY:
• * Patient’s diagnosis, procedure, notable past history, allergies, abnormal lab values
• * Airway management (i.e., easy mask, Grade 1 intubation and intraoperative course
• * Anesthetic technique course, antibiotic doses
• * Progress of surgical procedure
• * Fluids and blood products given; estimated blood loss, urine output
• * IV lines, a. lines, ports, etc.
• * Present level of anesthesia – stable or requiring more or less
• * Labeling of drugs and concentrations on administration apparatus and syringes
• * Controlled substances status; availability and accurate recording for administration thus far
• * Current gas flows, anesthetic concentration, reading of oxygen analyzer
• * Clinical signs and vital signs before original anesthesia provider exits
• - ACTION LIST/SITUATION AWARENESS AND CONTINGENCY PLANNING
• * Need for anesthetics, fluids, other medications
• * Availability of blood products
• * Plan for post-operative respiratory and medication support
• * Time when the relieved anesthesia provider will return
• * Pending tests and studies which require follow up
• * Changes in patient condition that may occur requiring interventions or contingency plans
• * Plans for emergence/postop management
• - SYNTHESES BY RECEIVER
• * Receiver summarizes what was heard task questions
• * Receiver restarts key action/to do items

RECORD
Time of relief exchange and reliever’s name on anesthetic record
If the transition is for permanent relief, the anesthetic record should be updated to the personnel change

OR to PACU Transfers
The PACU nurse receiving report will complete the standardized SBAR for when receiving report from the OR anesthesia team when a patient is transferred to the PACU. The SBAR form is also used as a script for the anesthesia team member giving report.

The SBAR form includes:

• Patient’s name, allergies, weight, MRN number, vitals
• Procedure, surgeon, anesthesia type
• PMH/PSH, OSA status
• OR fluid intake/output, medications received in OR – does
• Assessment of IV’s, drains, O2 therapy, other recommendations

POLICY/PROCEDURE: The transition process which occurs outside of the (OR unit or ICU transfers) should include, as applicable, the following information presented in an organized fashion:

• Identification of patient, including name, medical record number, date of birth, allergies
• Identification of attending surgeon or primary physician
• Diagnosis and current status/condition of patient
• Important prior medical history, DNR status and advanced directives
• Recent events, including changes in condition or treatment, current medication/fluid/diet status, recent lab tests and results, anticipated procedures and actions to be taken
• Specific protocols/resources/treatments in place (DVT prophylaxis, insulin, anticoagulation, restraints, etc.)
• Pending tests and studies which require follow up
• Important items planned between now and discharge

UNIT TRANSFERS ( L & D, PACU )
There is a physician handoff tool within Cerner Powerchart which makes use of IPASS. We will be using this “Physician handoff” tool for PACU and Labor and Delivery where there are several patients to transfer care.

ICU TRANSFERS

• NICU: Transfer of care occurs bedside (in OR or NICU) between the Anesthesia Team and the NICU Team
• PICU: Transfer of care requires – Attending to attending, resident to resident, and nursing to nursing discussion, PICU resident has a script for receiving report.
• SICU: Transfer of care requires – attending to attending, resident to resident and nursing to nursing discussion
• CTICU: Transfer of care requires – Anesthesia to CTICU RN report prior to OR transfer, CTICU nurse has a SBAR form to script receipt of report.

The Anesthesiology program has developed scheduling and transition/hand-off procedures to ensure that:

• Faculty members are scheduled and available for appropriate supervision levels according to the requirements for the scheduled residents.
• All parties involved in a particular program and/or transition process have access to one another’s schedules and contact information. All call schedules are available on the Department of Anesthesia website and with the hospital operator.
• Patients are not inconvenienced or endangered in any way by frequent transitions in their care.
• All parties directly involved in the patient’s care before, during, and after the transition have opportunity for communication, consultation, and clarification of information.
• Safeguards exist for coverage when unexpected changes in patient care may occur due to circumstances such as resident illness, fatigue, or emergency.

The Anesthesiology program includes the transition of care process in its curriculum.
CA-1 residents during their orientation are instructed in proper handoff procedures for transferring a patient to the nurse’s care in the PACU and for accepting relief from other anesthesia providers in the operating room.

The CA-1 residents specifically receive departmental instruction and the opportunity to model proper handoff procedures for transferring a patient to the nurse’s care in the PACU and for accepting relief from another anesthesia provider in the operating room during their first several weeks of experience in the ORs.

Each CA-1 resident will be evaluated in the simulation lab for his/her ability to complete a proper patient transfer of care (hand-off) and/or will be observed individually by their faculty supervisor to assess their hand-off skills. Each resident will receive feedback regarding the proper technique to ensure that necessary information is transferred and understood by the team member who is receiving the patient. Intrinsic to the on-going faculty supervision of patient care during anesthesiology resident training, feedback about patient care, including hand-off skills, will be on-going.


Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: SUPERVISION OF RESIDENTS

Purpose: To set departmental standards for faculty supervision of anesthesiology residents that assures their education and our compliance with ACGME and institutional standards.

Standards
All patient care performed by residents during training will be under the supervision of a physician faculty member qualified to provide the appropriate level of care. This supervision must be documented in the medical record by the supervising physician or resident. Residents and faculty members should inform their patients of their respective roles in each patient’s care.

Levels of Supervision
Appropriate supervision of residents must be available at all times. Levels of supervision may vary depending on circumstances or skill and experience of the resident. Definitions relative to levels of supervision are:

• Direct Supervision:
  The supervising physician is physically present with both the resident and the patient.
• 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 direct supervision.
• Oversight:
  The supervising physician is available to provide review of procedures/encounters with feedback provided after the care has been delivered. Use of telecommunication technology for supervision: If telecommunication technology is used, concurrent monitoring of patient care through telecommunication technology by the supervising physician is considered direct supervision. Oversight and telecommunication is not permissible for anesthesia resident intraoperative supervision.

All patient care must be supervised by attending anesthesiologists. The Program Director ensures adequate supervision of residents at all times. Faculty daily work schedules are structured to provide residents with continuous supervision and ready consultation at all times. An attending anesthesiologist is assigned to supervise a resident in all facets of patient care, including preoperative assessment, intraoperative management, and immediate postoperative care. Two anesthesiology faculty attendings are always in-house 24 hours per day.

All cases will be presented to the supervising attending by the resident prior to the patient going to the operating room. The resident is required to contact the supervising attending physician immediately when there is a change in the patient’s condition or when the resident requires guidance. Procedures must be supervised by an attending staff as specified in individual resident capabilities. Supervision will be provided on a graded basis as residents’ progress through the program and based on individual evaluation of knowledge and skill. Level of supervision is also based on complexity of the specific case. Supervising physicians will supervise a maximum of two rooms. The supervising faculty member is immediately available as he/she is in physical proximity to return to the reestablish direct contact with the patient to meet medical needs and address any urgent or emergent clinical problems.

The responsible attending anesthesiologist must be present and/or immediately available throughout all anesthetics, whether general anesthesia, regional anesthesia or monitored anesthesia care. The responsible anesthesiologist must be present at, and document in the anesthesia record, his/her presence at induction, key portions of the case, and emergence, as well as periodic monitoring. On call faculty must remain in-house at night and on weekends. Subspecialty faculty (cardiac, neuro, pediatric and ICU) are on call from home but must be able to reach the institution expeditiously. In the event of a critical emergency requiring an immediate case start, the call resident may begin a case with the general call staff until the subspecialty call faculty arrives.

Daily Case Management
Each resident must discuss the preoperative evaluation of the patient and the anesthetic plan for the patient with the faculty member who is assigned to supervise the resident. If the resident knows the assignment on the evening before the day of surgery, the resident is required to contact the faculty member that evening to discuss the case.

On-Call
When on call, residents can use the faculty call schedule to identify the supervising physician who is immediately available at night.

The on-call attending physician must clearly communicate to the residents when and under which circumstances they expect to be contacted by the resident concerning patients. The resident must contact the attending prior to the start of the anesthetic to review the patient’s history and physical examination and to discuss the anesthetic plan. At a minimum, during an anesthetic, the resident must notify the attending of any significant changes in the patient’s condition. The resident must notify the attending when the patient is in the room at the start of the anesthetic so that the attending can be present for induction and when the surgery has finished so that the attending can be present for emergence. The resident must contact the attending regarding any emergent problems in the post anesthesia care unit.

Supervision of Consultations
The supervising attending must communicate with the resident and obtain a presentation of the history, physical exam and proposed decisions for each referral. This must be done within an appropriate time but no longer than 24 hours after notification of the consultation request. All required supervision must be documented in the medical record by the resident and/or the supervising faculty member.

Supervision of Procedures
At times residents will be called upon either by their house staff colleagues or attending physicians to provide services throughout the hospital (arterial or central line placement, intubations, ETT changes, etc.). Unless called upon to perform a procedure in an emergent situation (“Code”, respiratory arrest, critical patient condition), residents may not proceed with any procedure until notifying their attending, obtaining proper consent from the patient or family member, and arranging an appropriate time when an attending faculty anesthesiologist is free to supervise them.

The supervising faculty physician must be certain that procedures performed by the resident are warranted, that adequate informed consent has been obtained and that the resident has appropriate supervision during the procedure to include sedation. Whenever there is more than minor risk to the patient, the supervising physician must be present during the key part of the procedure. All required supervision must be documented in the medical record by the resident and/or the supervising faculty member. Please see the supervision matrix below.

Supervision of Emergencies
During emergencies, the resident should provide care for the patient and notify the supervising physician as soon as possible. All required supervision must be documented in the medical record by the resident and/or the supervising faculty member.

ANESTHESIA RESIDENTS PROCEDURAL SUPERVISION MATRIX

Procedure	PGY-1	PGY-2	PGY-3	PGY-4
Arterial line placement	D	D	IDA	IDA
Central line placement	D	D	IDA	IDA
Swan Ganz	D	D	D	D
Endotracheal tube placement (emergent, non-OR setting)	D	D	D*	D*
Intubation (as part of anesthetic in OR)	D	D	D*	D*
Nasogastric tube insertion	IDA	IDA	IDA	IDA
Spinal or Regional Block	D	D	D	D
Epidural	D	D*	D*	D*
Fiberoptic Bronchoscopy to confirm ETT placement	D	D	D	D*
TEE / TTE	D	D	D	D
Emergent LMA placement	D	D*	D*	D*
IV placement	IDA	IDA	IDA	IDA
Needle placement for tension pneumothorax	D	D	D	D
Acute pain consult**	IDA**	IDA**	IDA**	IDA**

D = Direct supervision requiring physical presence of a supervising physician
IDA = Indirect supervision with direct supervision immediately available
*Attending MUST be notified prior to procedure and must be present for procedure unless an EMERGENT situation.
** Residents at all levels can perform initial preliminary consult, but then must discuss their plan of treatment with their attending before initiating treatment.

An attending anesthesiology is ALWAYS available in the OR suite and able to be called at all times.

MONITORING COMPLIANCE

1. The quality of house staff supervision and adherence to supervision guidelines and policies are monitored to ensure proper supervision on the program’s clinical setting including nights and weekends. The anesthesiology residents are instructed that the attending anesthesiologist must be present and immediately available to supervise all anesthetics. If an attending is not immediately available or present for the mandatory events described above, the OR Anesthesia Coordinator is contacted by the resident. Attendings document compliance of presence at mandatory events in the electronic anesthesia record which is audited daily.
2. Faculty compliance is further monitored in a resident and faculty survey.

Graded Responsibility
Residents are assigned incrementally increasing responsibility and independence during their training appropriate for their demonstrated level of competency and professional development (as assessed by the attending physician and Clinical Competency Committee as guided by the Milestones), according to the format shown below. Specific learning objectives for each rotation can be found in goals and objectives.

CBY
All patient care is under the supervision of an attending physician; residents may provide direct patient care or consultative services. Residents care for patients in the following service areas:

• Operating Room – intraoperative care of an anesthetized patient during a surgical procedure
• Intensive Care Unit – patients with multisystem organ failure
• Emergency Room
• In-patient or Out-Patient Services
• Pain Service

Residents are expected to evaluate patients under their care, determine the relevant medical and surgical pathologies, co-morbidities, develop an appropriate management plan. Residents may also provide care for patients on wards and in the Emergency Department. Residents will work as part of the patient care team in the operating room, intensive care unit, pain service, wards or Emergency Department.

CA-1 (Months 1-5)
Residents are expected to function in the role of a team member requiring direct supervision from attending physicians and senior trainees. CA-1 residents are expected to evaluate patients and develop and execute their management plan under close supervision from the supervising attending physician. Residents should be assigned to cases in the operating room appropriate to their level of experience. In the first few months of CA-1 residents will care for patients undergoing minor to moderately complex surgical procedures. Towards the second half of the CA-1 year residents may care for patients undergoing more complex surgery.

CA-1 (Months 6-12), CA-2 Residents participate in rotations caring for patients in the various subspecialty anesthesia areas. Towards the end of the subspecialty rotation, a greater autonomy for patient care is expected and residents should be the first point of contact for questions regarding patient care. Supervision by attending physicians is required and consulted for any questions that residents can not immediately answer. In the general operating rooms, CA-2 residents care for complex patients undergoing surgery in the general operating rooms.

CA-3
As senior residents, CA-3’s are expected to assume a leadership role, coordinating the actions of the team, and interacting with nursing and other administrative staff. Senior residents are expected to develop more autonomy for patient care in the development and execution of their management or treatment plan, although ultimate responsibility lies with the supervising attending physician. CA-3 residents care for the most complex patients in the operating rooms and care for patients having off-site interventional procedures. Along with the attending physician, senior residents provide for the education needs of any junior residents and students.

	Level of Responsibility / independence by Proficiency Level
Function/Activity	CBY & CA-1	CA-2	CA-3
Clinical data collection	Independent, with staff supplementation	Independent, with staff confirmation	Independent, with selective staff confirmation
Formulation of clinical assessments/plans	Jointly with staff	Some jointly with staff/some independent, with staff confirmation	Independent, with staff confirmation
Communication of recommendations to teams	After discussion with staff	Preliminary, independent; final, after discussion with staff	Independent, with staff confirmation
Case conference preparation	Jointly with staff	Independent, with staff oversight and confirmation	Independent, with staff oversight and confirmation
Supervision of students/residents	Jointly with staff	Independent, with staff oversight	Independent, with staff confirmation
Research	Direct background reading, tutored skill development, new project development	Execution of existing projects with staff oversight, new project development, analysis and representation of results	Execution of existing projects with staff oversight, analysis and representation of results, new project development, independent conduct of research with staff review

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: CIRCUMSTANCES AND EVENTS REQUIRING SUPERVISING FACULTY COMMUNICATION

Stony Brook Anesthesiology Residency Training Program requires all residents to communicate with the supervising faculty member in a timely manner whenever a patient needs rapid response team criteria.

Rapid Response Team Criteria:

• Staff member is worried about the patient
• Acute change in heart rate to <40 or >139 bpm
• Acute change in systolic blood pressure to <90 mmHg
• Acute change in respiratory rate to <8 or >28 per min
• Acute change in saturation to <90% despite O2
• Acute change in conscious state
• Acute change in urinary output to <50 ml in 4 hours

**In addition, residents must contact the attending physician when any of the following occur:

• Any airway manipulation( i.e., changing an ETT, extubation, intubation)
• Acute life, limb, or organ-threatening event
• New unexplained acidosis pH <7.25
• Emergent intubation
• Acute change in mental status
• Unexpected oliguria or anuria
• New onset, sustained hypertension
• Unexpected critical lab value (s)
• Need to institute anti-arrhythmic, pressors or inotropes
• New onset tachypnea or significant change in respiratory rate/pattern
• Need for transfusion of blood or blood products if not planned in advance
• New onset seizures or prolonged seizure activity
• New onset, unexplained pain
• New onset fever

The PACU follows the above criteria with the following additions:

• Any airway manipulation( i.e., changing an ETT, extubation, intubation)
• Prior to transporting patients to SICU
• When paged for codes or intubations on the floor

The Anesthesiology Attending Physician of Record, or the designated covering attending is at all times responsible for the care and welfare of the patient.

The Attending on-call is responsible for assuring that the residents on-call are aware of the overall patient care plan and the parameters for when residents must communicate with the attending for each patient.

The attending on-call and attending of record must always treat residents with proper respect and dignity. The attending on-call must never criticize, belittle, mock or question the necessity for calls by the residents. In the event that an attending acts as described or in any other way acts to discourage any resident from calling the attending, residents should notify the Program Director, Chief of Service, Designated Institutional Official (DIO) and/or Chief Medical Officer (CMO). The resident may also utilize the Stony Brook Safe System for such an event as actions which discourage open patient-related communications create a safety hazard for patients.

The Chiefs of Service (Department Chair or site Department Chief) are responsible for the implementation of and compliance with this policy.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: SUBSTANDARD RESIDENT PERFORMANCE AND REMEDIATION

The Department of Anesthesiology adheres to the Stony Brook Graduate Medical Education policy on Substandard Resident Performance as listed below.

SBUH Residents are required to meet standards of training performance. If a resident is not meeting the standards then a due process procedure is implemented and followed.

1. Residents identified as not meeting the standards of training performance through mechanisms outlined in the Resident Evaluation and Promotion Policy and Procedure may be at risk for the following actions,
1. Written warning/ letter of counseling
2. Probation
3. Suspension
4. Termination

A decision to terminate a resident is subject to the due process procedure as outlined below. A decision to provide a warning to the resident or place a resident on probation is not subject to the due process procedure. The decision to provide a resident a warning or place a resident on probation is based on the decision of the Program Director on consultation with the Clinical Competency Committee of the program.
2. The Graduate Medical Education Committee (GMEC) recognizes that substandard performance may be reflected in the following assessments and areas:
1. Professionalism
1. Rotation evaluation forms addressing professionalism.
2. Composite evaluation forms addressing professionalism.
3. Insufficient interest and/or participation in required rounds and conferences.
4. Attendance related infractions such as excessive absenteeism or tardiness.
5. Failure to meet medical documentation requirements.
6. Failure to participate in credentialing process.
7. Difficulties in functioning as a cooperative team member.
8. Recurrent complaints by patients and/or hospital/clinic staff as reflected by letters or evaluation forms.
9. Any misconduct defined as “professional misconduct” under New York State Education Law 6530.
2. Medical Knowledge
1. Rotation evaluation forms addressing medical knowledge.
2. Composite evaluation forms addressing medical knowledge.
3. Quizzes.
4. Board exams.
5. In-training examination.
3. Patient Care
1. Rotation evaluation forms addressing patient care.
2. Composite evaluation forms addressing patient care.
3. Direct observation of resident by faculty, nursing or other healthcare personnel.
4. Practice-based learning and improvement.
1. Rotation evaluation forms addressing practice-based learning and improvement.
2. Composite evaluation forms addressing practice-based learning and improvement.
3. Failure to demonstrate adequate progress and achievement of expected milestones in a time concordant with level of training.
4. Failure to accept or incorporate formative feedback into practice.
5. Failure to utilize evidence from literature and/or accepted guidelines in the care of patients as appropriate to level of training.
6. Failure to make changes in patient care based on own practice data.
5. Systems-based practice.
1. Rotation evaluation forms addressing systems-based practice.
2. Composite evaluation forms addressing systems-based practice (including multi-source evaluation forms).
3. Failure to demonstrate willingness or competence in working in multi-disciplinary teams.
4. Failure to advocate for high quality patient care.
5. Failure to learn to identify system problems in care delivery and participating in quality improvement efforts.
6. Interpersonal and communication skills.
1. Rotation evaluation forms addressing interpersonal and communication skills (including multi-source evaluation forms).
2. Composite evaluation forms addressing interpersonal and communication skills.
3. Recurrent or persistent lapses in medical documentation.
4. Recurrent or persistent lapses in handoff procedure.
5. Rude, insolent, condescending or unprofessional/disruptive interactions with patients, families, staff, or other physicians.
6. Ability to accurately and completely relay patient information to patients, families and other caregivers.
7. Chronic failure to achieve satisfactory performance or failure to improve in performance.
8. Lack of interest in the educational process.
3. Residents identified as not meeting the standards of the training program or of the profession will receive written notice communicated by the program director. A warning letter serves as an alert that academic and/or professional performance are in need of remediation. Such notice will include:
1. Specific reference to area(s) of deficiency, including competency(ies) related to deficiency.
2. Suggestions for improvement, measures of success in improvement efforts, and time frame for which desired improvement is expected.
3. Mechanism of evaluation of deficiency remediation.
4. Consequences of incomplete/unsatisfactory improvement (such as probation, non-renewal, reporting on licensing and verification forms, loss of credit for the academic year) which may adversely affect promotion, graduation, credentialing and licensure.
5. Acknowledgement of receipt by resident attestation and signature.
4. Residents who have received a warning letter and have not demonstrated substantial improvement as previously outlined and communicated or incur repeat offenses shall be placed on academic or professional probation. Such notice will include and provide:
1. Deficiencies for which the individual has been counseled and for which no improvement has been made.
2. Explicit remediation plan with time frame for improvement. The time frame should not exceed three (3) months.
3. A faculty advisor/educator to assist with successful completion of the remediation plan.
4. A mechanism of evaluation, which may include but is not limited to:
1. 360 degree assessment
2. Global assessment
3. Direct observation
4. Patient simulations
5. Consequences of unsatisfactory improvement which may include termination, non-renewal, loss of credit for the academic year, reporting to licensing and credentialing authorities.
6. Acknowledgement of receipt by resident attestation and signature.
7. This letter will become part of the permanent summative evaluation and may be part of any verification request including but not limited to licensure, hospital privileges or medical staff appointment.
5. The chair of the GMEC will be notified, in writing, of all residents placed on Probation.
6. Residents who have not made satisfactory progress despite the above measures may be subject to non-promotion to the next level, non-renewal of appointment or termination under the due process procedure.
7. In the event that the resident’s actions or performance are determined by the Program Director on consultation with the Department Chair to be of a nature such that it represents an imminent threat to patient care, the Program Director or Department Chair may suspend the resident from patient care activities for a period not to exceed 10 calendar days. The resident will be notified immediately in writing of such action and the reason for such action. Any disciplinary action resulting in suspension or termination is subject to the due process procedures.
8. The permanent record of the substandard performance will include all summative evaluations for each educational year, any letter of probation or non-renewal/termination and the final summary evaluation at the completion of residency all acknowledge and signed by the program director and resident. See “Termination, Grievance and Due Process Policy”.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: SUBSTANCE ABUSE

Substance Abuse Policy
Chemical dependence is a medical disease and untreated or relapsing chemical dependence is incompatible with safe clinical performance in anesthesia.

Education is an important tool in the prevention of substance abuse. Substance abuse can be limited by closely controlling access to abusable drugs in the workplace.

Education
Substance abuse teaching sessions are part of the resident didactic curriculum.

Departmental Policy Toward Substance Abuse

1. It is the department policy for all members of the Department of Anesthesia to share their concerns about chemical dependence, in themselves or other members of the department, in confidence, with the Chairman of Anesthesiology.
2. The Chairman of the Department of Anesthesia or Clinical Vice Chairman in consultation with the Committee on Physician Wellness will determine whether any member of the department is suffering from untreated or relapsing chemical dependence whenever advised by others inside or outside the department of concerns regarding a department member.
3. Should the Chairman of Anesthesiology conclude, after inquiry or investigation, that a resident is suffering from active chemical dependence, the resident shall immediately be either suspended or have his/her employment contract terminated.
4. Should the Chairman determine that the resident is not suffering from chemical dependence, this diagnosis shall be expunged from his/her record and he/she shall be allowed to return to work without prejudice.
5. The terms of the resident’s return from suspension, or possible reemployment will be set by the Chairman of Anesthesia.

Intervention of the Chemically Impaired Resident

1. Investigation
1. Investigation will be done by the chairman of Anesthesiology or his/her designee. The investigation will be kept confidential.
2. Allegations of impairment shall be documented and verified. Information from a variety of sources shall be collected without compromising confidentiality. Anesthesia records and pharmacy sign-out records will be examined to detect a change in narcotic usage.
3. The Chairman of the Stony Brook Committee on Physician Wellness should be notified to review the results of the investigation and plan the interventions.
2. Intervention
1. After adequate information has been collected, it will be necessary to confront the resident concerning his/her illness. This intervention will be organized and scheduled by the Chairman of Anesthesia or his/her designee. Since intervention is always anticipated, it does not mean that the Chairman is limited in his/her ability to suspend or terminate until results of the intervention are known.
2. The intervention will be carried out by at least two people, one of whom will be the Chairman of the Stony Brook Committee on Physician Wellness or his designee. The other members will be appointed by the Chairman of Anesthesiology.
3. Preparation will be made, before intervention, for potential immediate inpatient admission to an evaluating facility. As the risk of drug overdose or suicide is great at this juncture, a designated person must be available to escort the resident to the facility.
4. If the resident chooses not to comply with the recommendations of the intervention team, he/she may be suspended or his/her employment contract may be cancelled at the discretion of the Chairman of Anesthesiology.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: Social Networking

Stony Brook University Hospital (SBUH) Residency and Fellowship programs will follow the Social Networking Policy established by the Stony Brook University School of Medicine. Residents and Fellows will abide by the guidelines set forth within this policy and will be monitored through the GMEC when infractions are found.

STONY BROOK UNIVERSITY SCHOOL OF MEDICINE - SOCIAL NETWORKING POLICY

Article I - Policy
Social and business networking websites, weblogs, or on‐line communities (hereafter referred to as social networks) such as MySpace, Facebook, LinkedIn, Twitter, and Flickr are being used increasingly by faculty, students, and staff to communicate with each other and by universities to post events and profiles to reach external audiences. As part of Stony Brook University’s commitment to building a community in which all persons can work together in an atmosphere free of all forms of harassment, exploitation, or intimidation when using University electronic resources to access on‐line social networks, members of the SBU SOM community are expected to act with honesty, integrity, and respect for the rights, privileges, privacy, sensibilities, and property of others.

Article II - Scope
This policy applies to all medical students in the School of Medicine at Stony Brook University. Students and residents should follow these guidelines whether participating in social networks personally or professionally, or whether they are using personal or SOM computing equipment. Regardless of whether you are posting items for University business purposes or personal use, you are never permitted to post SBU confidential information, including any patient information.

Article III - Use of Technology
Users are expected to be aware of, and comply with, current institutional policies regarding Use of Technology.

Article IV - Ethical/Professional Behavior

• University Business Use
  Only University employees authorized by their departments may use social networking websites to conduct University business. If authorized and in keeping with University policy, an employee may post on a social network profile: the University’s name, a University email address or University telephone number for contact purposes, or post official department information, resources, calendars, and events. For example, a student health advocate or educator is charged with student outreach and education within their job description. Student Health Services may authorize these employees to use an on-line social network site to communicate with students and post University resources.
• Personal Views
  Individuals or groups within the University community are not permitted to present personal opinions in ways that imply endorsement by the University. If the posted material may reasonably be construed as implying the support, endorsement, or opposition of the University with regard to any personal statements, including opinions or views on any issue, or if the poster’s University affiliation is evident in the posting, the material shall be accompanied by a disclaimer that the individual is speaking for himself or herself and not as a representative of the University or any of its offices or units. An example of a disclaimer is as follows: The contents, including all opinions and views expressed, in my profile [or on my page] are entirely personal and do not necessarily represent the opinions or views of anyone else, including other faculty, students, or staff in my department or at Stony Brook University. Stony Brook University has not approved and is not responsible for the material contained in this profile [or on this page].
• Posting Information About Colleagues and Co-Workers
  Respect for the privacy rights of colleagues and co-workers is important in a work environment. If you are in doubt about whether it is appropriate to post any information about colleagues and co-workers, ask for their explicit permission – preferably in writing. Making demeaning or insulting comments about colleagues or co-workers to third parties is unprofessional behavior. Such comments may also breach the University’s codes of behavior regarding harassment, including the Code of Student Conduct and the Sexual Harassment Policy.
• Posting Information Concerning Hospitals or Other Institutions
  Be aware of the need for the hospital, the University and other institutions to maintain the public trust. Consult with the appropriate resources such as the Office of Media Relations or the Medical Education Office, for advice in reference to posting material that might identify the institution.
• Offering Medical Advice
  Do not misrepresent your qualifications. As a trainee, provision of medical advice must be supervised by a licensed physician at all times.
• University Policies Extend To the Appropriate Use of the Internet
  Postings on social network sites are subject to the University’s policies, including but not limited to, the Code of Student Conduct, Sexual Harassment and Use of Technology policy. Students may be subject to disciplinary actions for violations of University policy, up to and including dismissal or termination.
• Copyright, and Proprietary information.
  Respect copyright or trademark laws. If you post content, photos or other images, you are implying that you own or have the right to use those items. University logos may not be used on any social media site unless approved in advance in accordance with University policy.
• Monitoring and Enforcement
  Any information you post on the internet is public information. You are responsible for knowing how to use social network sites, managing any information you share on such sites, and for being compliant with all applicable website and University policies. Since information posted on the internet is public, Stony Brook University may monitor social networking sites and, as with other electronic resources, University systems administrators may perform activities necessary to ensure the integrity, functionality, and security of the University’s electronic resources. Remember, other employers, organizations, and individuals may also monitor and share information they find on social networking websites. All professionals have a collective professional duty to assure appropriate behavior, particularly in matters of privacy and confidentiality. A person who has reason to believe that another person has contravened these guidelines should approach his/her immediate supervisor/program director for advice. An individual may also complain in writing to the Vice Dean of Undergraduate Medical Education.
• Privacy/Confidentiality
  
• Keep official medical school activities in SBU approved email-- not on a social networking site.
• Do not interact with patients on social networking sites.
• Keep all postings and communications on social networking sites in accordance with accepted ethical and professional practices of being a physician.
• Never share patient information with anyone on any social networking site.
• Maintain the privacy of colleagues, doctors and other University or hospital employees when referring to them in a professional capacity unless they have given their permission for their name or likeness to be used.
• Patient privacy measures taken in any public forum apply to social networking sites as well.
• Online discussions of specific patients should be avoided even if all identifying information is excluded.
• Under no circumstances should photos of patients or photos depicting the body parts of patients be displayed online unless specific written permission to do so has been obtained from the patient.
• HIPAA regulations apply to comments made on social networking sites and violators are subject to the same prosecution as with other HIPAA violations.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: SEXUAL AND OTHER FORMS OF HARASSMENT

Harassment is a form of sexual or other discrimination, and violates Title VII of the Civil Rights Act of 1964 and Title IX of the Educational Amendments of 1972. Stony Brook University reaffirms the principal that students, faculty and staff have the right to be free from sexual discrimination and any other form of discrimination inflicted by any member of the campus community.

Unwelcome sexual advances or requests for sexual favors and verbal or physical conduct of an abusive, sexual nature, constitute sexual harassment when such conduct interferes with an individual’s work or academic performance or creates an intimidating, hostile or offensive work or academic environment.

Discrimination/harassment based upon race, creed, ethnic background, etc., is also not tolerated by the institution. The Office of Affirmative Action/Equal Employment Opportunity (Administration Building, 632-6280) has professional staff trained to provide assistance with sexual harassment problems.

For reporting options and resources, contact Complaint Navigator (Samantha Winter): 631-457-9981 or Samantha.J.Winter@stonybrook.edu

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: SCHEDULING

Block Schedule
The work schedule shall be coordinated by the Chief Residents. Any requests for changes to the order of the yearly (“block”) schedule shall be made in writing to the Chiefs as well as to the Program Director and Dr. Eleanor Romano.

Vacation
The American Board of Anesthesiology requires a minimum of 33 months of anesthesiology training stating "absences in excess of sixty days, whether for vacation, sick leave, maternity leave, etc. must be made-up.”

The usual division of vacation time in the Anesthesiology Residency Training Program is taken in two two-week blocks:
PGY-1    4 weeks
PGY-2    3 weeks
PGY-3    4 weeks
PGY-4    5 weeks ( 1 week float for either PGY-2 or PGY-3 for Fellowhips and interviews )

Days Off
Requests for planned days off outside of vacation time must be submitted in writing to the chief residents and Program Director. This includes, but is not limited to: fellowship/job interviews, significant family obligations and religious holidays. Requests will be considered and potentially granted after program requirements and overall impact on the schedule. Such requests therefore should be made prior to construction of the relevant on-call schedule. Documentation of such appointments may be required 88 at the discretion of the Program Director. Planned days off for reasons other than those noted above are unlikely to be excused in order to ensure that the resident fulfills the American Board of Anesthesiology requirement for 33 months of training time.

Medical Appointments
ACGME requires that residents must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours, at times that are appropriate to their individual circumstances. Requests for attending these appointments must be made through the chief residents or the Program Director.

Call Schedule
The call schedule is published on a monthly basis corresponding to the start dates of our rotation blocks. Requests for preferences in the call schedule are solicited prior to its construction by the chief residents. Every attempt will be made to honor such requests within the constraints, however cannot be guaranteed. Once the schedule is published mutual switches of on-call responsibilities can only be made after approval by the Chiefs and/or Program Director.

Step 3 Scheduling
Step 3 must be taken in the first year of residency, preferably before December 31. Please notify the chief resident of the service impacted by your exam date. Prior to scheduling the exam, residents must discuss scheduling options with the Chief Residents. The exam should not be scheduled on a continuity clinic day or during an inpatient rotation.

Absence from Service
Anesthesia residents are expected to be present for all clinical assignments. In the event of unplanned absence, the resident MUST inform the anesthesia coordinator, division chief and chief residents via personal conversation. Email/voicemail/page/text message are never appropriate methods of communication for an unplanned absence and are considered unacceptable. Prolonged or multiple unplanned absences resulting in significant loss or work time will require an extension of resident service beyond 36 months, at the discretion of the PD and the Chair of the Department. All absences will be recorded by the Residency Coordinator and submitted time and attendance as required by Human Resources.

Resident Fatigue and Stress
It is recognized that residency training, while intellectually stimulating, is a physically demanding process. You will be working long hours, including overnight call and night rotations. This disruption in your regular sleep-cycle may lead to fatigue.

The Department of Anesthesiology supports high quality education and safe and effective patient care. The program is committed to meeting the requirements of patient safety and resident wellbeing. Excessive sleep loss, fatigue and resident stress are serious matters. Fatigue leads to increasing lapses of attention, declining memory, instability in alertness and vigilance and cognitive slowing. You may begin tasks well, but performance deteriorates when speed is required. Verbal processing and complex 89 problem solving may be impaired. In addition, sleep deprivation may alter an individual’s mood and lead to irritability, hostility, and indifference to interpersonal relationships.
Problems with fatigue at work may include:

1. Poor decision making and procedural skills in patient care activities
2. Poor driving skills
3. Poor overall health status

Appropriate backup support will be provided when patient care responsibilities are especially difficult and prolonged, and if unexpected needs create resident fatigue sufficient to jeopardize patient care during or following on-call periods.

All attendings and residents are instructed to closely observe other residents for any signs of undue stress and/or fatigue. Faculty and other residents are to report such concerns of sleepiness, tardiness, resident absences, inattentiveness, or other indicators of possible fatigue and/or excessive stress to the supervising attending and/or Program Director. The resident will be relieved of his/her duties until the effects of fatigue and/or stress are no longer present.

If you are experiencing fatigue as a result of your residency work hours:

1. If it is in the midst of active patient care activities, and you believe you are not able to provide optimal care to your patients, contact your supervising physician immediately. Most often this will be your senior resident or chief resident.
2. If you are becoming chronically fatigued so that your patient care activities are compromised, contact your supervising physician as above.
3. If you find that your schedule as laid out would put you in violation of the New York State Department of Health or the ACGME work hour regulations, contact your chief resident or the program director immediately.
4. Do not leave venues where you are actively caring for patients without first checking with your supervising physician.

Email
Residents are expected to read their email at least every 24 hours.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: RESIDENT RESPONSIBILITIES

POLICY

The residents, as individuals, must be aware of their limitations and not attempt to provide clinical services or do procedures for which they are not trained. They must know the graduated level of responsibility described for their level of training and not practice outside of that scope of service. Each resident is responsible for communicating significant patient care issues to the attending physician. Such communication must be documented in the patient record. Failure to function within graduated levels of responsibility or to communicate significant patient care issues to the responsible attending physician may result in the removal of the resident from patient care activities.

Commitment of Residents

1. The resident must acknowledge the fundamental obligation as a physician to place the patients’ welfare uppermost and to have quality health care and patient safety as the prime objectives.
2. The resident must demonstrate professional values of honesty, compassion, integrity and dependability.
3. The resident will adhere to the highest standards of the medical profession and conduct him/herself accordingly in all interactions. The resident will demonstrate respect for all patients and members of the health care team without regard to gender, race, national origin, religion, economic status, disability or sexual orientation.
4. The resident will learn from being involved in the direct care of patients and from the guidance of faculty and other members of the healthcare team. The resident should understand the need for faculty to supervise all of the interactions with patients.
5. The resident will secure direct assistance from faculty or appropriately experienced residents whenever confronted with high-risk situations or with clinical decisions that exceed his/her confidence or skill level to handle alone.
6. The resident will accept candid and constructive feedback from faculty and all others who observe his/her performance recognizing that objective assessments are indispensable guides to improving skills as a physician.
7. The resident will provide candid and constructive feedback on the performance of other residents, students and faculty. This is the life-long obligation as a physician to participate in peer evaluation and quality improvement.
8. The resident will assist both medical students and other residents in meeting their professional obligations by serving as a teacher and a role model.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: RESIDENT OVERSIGHT OF MEDICAL STUDENTS

Third year medical students are required to complete a two week mini-clerkship in Anesthesiology. The purpose of the clerkship is to introduce the student to the principles and practice of anesthesiology. Medical students are assigned to the following locations: Main OR, OB, Cardiac, Acute Pain Service and Pain Center.

Elective Rotations
Senior medical students may choose to spend 2-4 weeks working in the Department of Anesthesiology as an elective rotation or Advanced Clinical Experience (ACE) rotation. Rotation assignments are based on the interest of the student.

Teaching Medical Students
Every anesthesiology resident has a responsibility to teach medical students rotating in Anesthesia. The teaching obligation is inherent in the University teaching appointment of all residents at this Hospital. The commitment to medical student teaching is expressed in several different ways as described below.

Resident Responsibility Regarding Medical Student Procedural Skills
Residents and faculty are expected to directly supervise all medical students in the performance of procedural skills. Medical students have a short list of organized clinical skills that must be completed by the end of their rotation for which they may earn indirect performance status.

Resident Role in the Evaluation of Medical Students
Residents are expected to provide feedback on medical student performance in the Department of Anesthesiology. Residents are expected to complete the medical student clerkship competency-based evaluation form and then place the completed form in the provided envelope, sign the seal and return to the student the next day. It is expected that residents provide prompt and documented information to the Anesthesia Course Director in the event that a student rotating on Anesthesia is felt to be significantly deficient in any of the areas above, or in attendance or professional conduct. This is important so that remediation can be planned on a timely basis.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: RESIDENT ADMINISTRATIVE RESPONSIBILITIES

Conference Attendance

Educational Sessions
All residents are required to attend resident didactic sessions held through the Department of Anesthesiology. These include but are not limited to Key Words, Journal Club, Grand Rounds and Wednesday conferences. Residents are not expected to attend if doing so would constitute a violation in time off between shifts, if they are on vacation, or if they are on a rotation that requires them to provide patient care. Residents may attend post-24 hour call provided doing so would still allow them to have adequate time off until their next shift. Specific details regarding lectures are described below.

Wednesday Lectures
Lectures in the department of pediatrics occur on a regular basis, every Wednesday. They begin at 6:30 A.M. on Wednesday morning with Key Words followed by Grand Rounds and then proceed usually until 4:00 P.M. with various. These lectures are based on a three-year cycle so that all topics are covered during a resident’s tenure with the program.

It is an ACGME requirement that residents attend at least 70% of the lectures throughout the course of the year.

Since these lectures cover board-specific topics, most everyone is expected to attend with a few exceptions. Below is a summary of attendance requirements based on rotations:

• All UH and VA Anesthesia Rotations: All residents attend Key Words at 6:30 A.M. and Grand Rounds at 7:00 A.M. After Grand Rounds, one CA cohort attends education activities from 8:00 A.M. to 4:00 P.M.
• Night Float or Post-Call: Residents are excused from all lectures including Grand Rounds.
• CTICU: Residents are excused from Key Words, Grand Rounds and all Wednesday lectures.

Summary of Residency Administrative Professional Responsibilities
	PGY 1	PGY 2	PGY 3	PGY 4
EDUCATION
True Learn Test Prep		X	X	X
Senior Grand Rounds				X
IHI Patient Safety Modules		X
QI or Patient Safety Project participations		X	X	X
QI Project Completed or Patient Safety Project Completed				X
ITE	X	X	X	X
Mock Orals		X	X	X
ITE Review	X	X	X	X
Registration for Basic Exam and pass Basic Exam		X
Take USMLE step 3 and pass	X
ILP: 1x/year prior to PD meetings	X	X	X
CLINICAL DUTIES
End Rotation evaluations – completion within 2 weeks	X	X	X	X
Case logs up to date	X	X	X	X
EVALUATION
Self-assessment through 1x/year prior to PD meetings	X	X	X	X
Faculty evals through NI	X	X	X	X
Medical Student Evaluations	X	X	X	X
Lecture Evaluations		X	X	X
SELF-HEALTH MAINTENANCE
Annual health assessment during birthday month, including PPD	X	X	X	X
Annual Maslach Burnout Inventory completions prior to PD mtg.	X	X	X	X
Flu vaccine (Oct)	X	X	X	X
CREDENTIALING
Maintain BLS, ACLS	X	X	X	X
Maintain PALS		X	X	X
NYS Infection Control (annual)	X	X	X	X
Stony Brook infection control (annual)	X	X	X	X
Fatigue training quiz	X
Fire Safety	X	X	X	X
HIPAA	X	X	X	X
Family violence	X	X	X	X
NYS Pain and Opioid education program (3 hour on-line course) every 3 years	X
ISTOP (once)	X
Right to Know Annual training (NI)	X	X	X	X
OTHER
Request for reimbursement – paperwork required	X	X	X	X
Notify Chief Residents and Chairman of interview days			X	X

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: QUALITY IMPROVEMENT

The residency program will ensure each resident participates in Quality Improvement activities. The level of participation will vary depending on the functional role of the resident in patient care and the QI/PS activities currently underway within the clinical setting and institution.

1. Quality Improvement and Patient Safety Conferences (a.k.a., Q.A. Conference) are integrated in the curriculum. Quality Assurance Conferences are structured to emphasize patient safety and follow principles and methods of continuous quality improvement. A Patient Safety and Quality Improvement curriculum has been developed for the Anesthesiology Residency Program and is delivered during Wednesday Education Day.
2. Residents will conduct their QI under the supervision of an anesthesiology faculty member. Residents may be involved in more than one project.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: PROFESSIONALISM

Purpose
Residents are responsible for fulfilling any and all obligations that the GME office, Hospital, and Anesthesiology Residency Program deem necessary for them to begin and continue duties as a Resident/Fellow, including but not limited to:

• Attending orientations, receiving appropriate testing and follow-up if necessary for communicable disease, fittings for appropriate safety equipment, necessary training and badging procedures (all of which may be prior to appointment start date)
• Completing required GME, Hospital, and Program administrative functions in a timely fashion and before deadlines such as medical records, mandatory on-line training modules, and surveys or other communications
• All anesthesiology faculty are responsible for educating, monitoring, and providing exemplary examples of professionalism to residents

Professionalism – Code of Conduct
Residents are responsible for demonstrating and abiding by the following professionalism principles and guidelines. Physicians must develop habits of conduct that are perceived by patients and peers as signs of trust. Every physician must demonstrate sensitivity, compassion, integrity, respect, and altruism, and maintain patient confidentiality and privacy. A patient’s dignity and respect must always be maintained. Under all circumstances, response to patient needs shall supersede self-interest. A medical professional consistently transmits respect tor patients by his/her performance, behavior, attitude, and appearance. Commitment to carrying out professional responsibilities and adherence to ethical principles are reflected in the following expected behaviors:

1. Respect patient privacy and confidentiality
1. Knock on the door before entering a patient’s room
2. Appropriately drape a patient during an examination
3. Do not discuss patient information in public areas, including elevators and cafeterias
4. Keep noise levels low, especially when patients are sleeping
2. Respect patient autonomy and the right of a patient and a family to be involved in care decisions
1. Introduce oneself to the patient and his/her family members and explain role in patient’s care
2. Wear name tags that clearly identify names and roles
3. Take time to ensure patient and family understanding and informed consent of medical decisions and progress
3. Respect the sanctity of the healing relationship
1. Exhibit compassion, integrity, and respect for others
2. Ensure continuity of care when a patient is discharged from a hospital by documenting who will provide that care and informing the patient of how that caregiver can be reached
3. Respond promptly to phone messages and pages
4. Provide reliable coverage through colleagues when not available
5. Maintain and promote physician/patient boundaries
4. Respect individual patient concerns and perceptions
1. Comply with accepted standards of dress as defined by each institution
2. Arrive promptly for patient appointments
3. Remain sensitive and responsive to a diverse patient population including, but not limited to, diversity in gender, age, culture, race, religion, disabilities, and sexual orientation
5. Respect the systems in place to improve quality and safety of patient care
1. Complete all mandated on-line tutorials and public health measures (e.g., TB skin testing) within designated timeframe
2. Report all adverse events within a timely fashion
3. Improve systems and quality of care through critical self-examination of care patterns

A professional consistently demonstrates respect for patients and co-workers

1. Respect for colleagues is demonstrated by maintaining effective communication
1. Provide consulting physicians all data needed to provide a consultation
2. Maintain accurate and up-to-date medical records
3. Inform all members of the care team, including non-physician professionals, of patient plans and progress
4. Provide continued verbal and written communication to referring physicians
5. Understand a referring physician’s needs and concerns about his/her patients
6. Inform involved faculty of any changes in patient status
7. Provide informed and safe handoffs to colleagues who provide patient coverage
8. Acknowledge, promote, and maintain the dignity and respect of all healthcare providers
2. Respect for diversity of opinion, gender, and ethnicity in the workplace
1. Maintain a work environment that is free of harassment of any sort
2. Incorporate the opinions of all health professionals involved in the care of a patient
3. Encourage team-based care

Fitness for duty is defined as being physically and mentally capable of safely performing the essential functions of one’s job. Fitness for duty includes being free of alcohol and drugs that have not been legitimately prescribed and being free from impairment that affects job functioning due to use of prescription or nonprescription drugs, sleep and fatigue, and/or medical or emotional problems while on Medical Center or an institutional business. Fitness for duty also includes being free of infectious diseases.

In addition, all professionals are held accountable to specialty-specific board and/or society codes of medical professionalism.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: PHYSICIAN WELLNESS

Purpose
To establish a policy in the Department of Anesthesiology addressing physician well-being as it relates to the learning and working environment.

Background
In the current health care environment, residents and faculty members are at increased risk for burnout and depression. Psychological, emotional, and physical well-being are critical in the development of the competent, caring, and resilient physician. Self-care is an important component of professionalism; it is also a skill that must be learned and nurtured in the context of other aspects of residency training. The Stony Brook Anesthesiology Residency Program, in partnership with the Sponsoring Institution, has the same responsibility to address well-being as they do to evaluate other aspects of resident competence.

The Department of Anesthesiology understands that the creation of a learning and working environment with a culture of respect and accountability for physician well-being is crucial to physicians’ ability to deliver the safest, best possible care to patients. To achieve these goals, the following has been arranged:

1. Wellness sessions are included in the annual didactic curriculum. Topics included, but are not limited to, stress management, effective communication, strategies for dealing with difficult people/behaviors, life management skills, substance abuse and mindfulness.
2. To support and encourage optimal resident and faculty well-being, there are events scheduled throughout the year, such as the summer BBQ, holiday party, graduation party, annual bowling party and other social events.
   
   In addition, the institution has created a wellness program, Healthier U, to address general well-being, educate and encourage healthy lifestyles and healthy decisions. http://www.stonybrook.edu/commcms/healthieru/index.html
3. Well-being includes having time away from work to engage with family and friends, as well as to attend to personal needs to one’s own health. Resident yearly and block schedules are built, to the best of our ability, based upon the requests of the individual resident combined with the needs of the program.
4. Our program seeks to minimize non-physician obligations by providing clinical support staff, as well as administrative support to assist physicians with clinical and non-clinical responsibilities.
5. There are circumstances in which residents may be unable to attend work, including but not limited to fatigue, illness, and family emergencies. To ensure adequate coverage of patient care in the event that a resident may be unable to perform their patient care duties, there is a back-up system in place. The back-up system will be implemented without fear of negative consequences for the resident who is unable to provide the clinical work. Residents contact the Anesthesia OR Coordinator; resident to initiate the back-up system.
6. The ACGME has identified that work intensity and work compression can impact resident well-being. To this end, a night float system is in place to provide anesthetic care for overnight surgical cases.
7. Residents have the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours, at times that are appropriate to their individual circumstances. Contact the chief residents or program director to coordinate time off for appointments.
8. The program will educate all faculty members and residents in the identification of the symptoms of burnout, depression, and substance abuse in others and in themselves. In addition, the program will educate faculty and residents in the means to assist those who experience these conditions to seek appropriate care, as outlined below.
   
   To support physician well-being, the following services are available:
1. The Stony Brook Employee Assistance Program (EAP), is a voluntary, confidential and comprehensive worksite-based program for the purpose of enhancing the overall well-being and productivity of faculty, staff and the organization. EAP can be reached at 631-632-6085 or at the following website: http://www.stonybrook.edu/commcms/eap/
2. Dr. Marsha Tanenberg Karant is a Stony Brook psychiatrist available to provide mental health support for residents and fellows under a program funded by Stony Brook hospital. Dr. Karant provides free, confidential care, through confidential appointments for assessment, counseling, and other treatment including providing pharmacotherapy and other services. All services will be conducted without documentation in the electronic medical record, using only a confidential paper chart. Dr. Karant can be reached directly at 631-632-5877.
3. For urgent and emergent care 24 hours a day, seven days a week, contact Response Crisis Center Hotline of Suffolk County at 631-751-7500 or call 911.
4. New York State Office of Alcoholism and Substance Abuse Services offers the New York State HOPEline for professional assistance in alcoholism, drug abuse, and problem gambling. Calls are toll-free, anonymous and confidential. 1-877-8-HOPENY https://www.oasas.ny.gov/about
   
   Residents, fellows and faculty should contact the Program Director(s), Department Chair, or Chief Residents any time there is concern that another resident, fellow, or faculty member may be displaying signs of burnout, depression, substance abuse, suicidal ideation, or potential for violence.
9. Access to tools for self-screening, residents and faculty:
   
   The Patient Health Questionnaire (PHQ-9):
   https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf
   
   Center for Epidemiologic Studies Depression Scale (CES-D), NIMH:
   https://nida.nih.gov/sites/default/files/Mental_HealthV.pdf
   
   Compassion Satisfaction/Fatigue Self-Test for Helpers:
   https://ncwwi.org/files/Incentives__Work_Conditions/Compassion-Satisfaction-Fatigue-Self-Test.pdf
   
   Quick Inventory of Depressive Symptomatology (QIDS SR-16):
   https://alnursing.org/wp-content/uploads/2020/03/Depression-Questionnaire-QIDS-SR-16.pdf
   
   National Institute on Drug Abuse (NIDA) Drug Screening Tool: Quick Screen:
   https://nida.nih.gov/sites/default/files/pdf/nmassist.pdf
   
   Mindful Attention Awareness Scale (MAAS):
   https://ggsc.berkeley.edu/images/uploads/The_Mindful_Attention_Awareness_Scale_-_Trait_(1).pdf

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: PATIENT SAFETY

The Stony Brook Medicine Anesthesiology Residency Program is committed to and responsible for promoting patient safety and resident wellbeing in a supportive educational environment. The Program Director ensures that residents are integrated and actively participate in clinical quality improvement and patient safety programs. As such, the learning objectives of the program are accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events; and, not compromised by excessive reliance on residents to fulfill non-physician service obligations. The Department of Anesthesiology Leadership and the Program Director ensure a culture of professionalism that supports patient safety and personal responsibility. Opportunities for residents to be involved in Patient Safety activities include membership on the Patient Safety Quality Council, participation in Quality Assurance Conferences, participation in the Patient Safety Curriculum delivered during Wednesday Education Day, reporting of errors, near misses, and unsafe practices in SB SAFE, and collaboration on institutional and departmental Patient Safety Initiatives.

Residents and faculty members must demonstrate:

• Assurance of the safety and welfare of patients entrusted to their care;
• Provision of patient- and family-centered care;
• Assurance of their fitness for duty;
• Management of their time before, during, and after clinical assignments;
• Recognition of impairment, including illness and fatigue, in themselves and in their peers;
• Attention to lifelong learning;
• Monitoring of their patient care performance improvement indicators; and
• Honest and accurate reporting of duty hours, patient outcomes, and clinical experience data.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: MOONLIGHTING

PURPOSE
To establish a departmental policy regarding dual employment (i.e., moonlighting) for all anesthesia residents.

POLICY
All anesthesia residents are prohibited from moonlighting

Please see the Anesthesiology Department policy, “THE LEARNING AND WORKING ENVIRONMENT”.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: MISTREATMENT/BULLYING/DISRUPTIVE BEHAVIOR

The medical learning environment is expected to facilitate residents’ acquisition of the professional attitudes necessary for effective caring and compassionate health care. The development and nurturing of these attitudes requires mutual respect between teachers (including faculty, residents, nurses, and staff) and residents (including fellows) at all levels, and between residents and their peers. It is the responsibility of SBUH and the Department of Anesthesiology to provide a proper atmosphere for education; it is the responsibility of the resident to develop and maintain personal honor and integrity, as well as compassionate and ethical behavior. Residents must pledge their utmost effort to acquire the knowledge, skills, attitudes, and behaviors required to fulfill all educational objectives established by the residency/fellowship program.

This policy is set forth to promote and assist in the maintenance of an optimal learning environment and to affirm the importance of collegiality and respect for others within the teacher/learner relationship. To ensure that Residents have a mechanism through which to express concerns and complaints about the learning environment in a confidential and protected manner.

Responsibilities of the Faculty

• Demonstrate the professional virtues of fidelity, compassion, integrity, courage, temperance and altruism
• Maintain high professional standards in all interactions with patients, colleagues, and staff
• Ensure that all components of the residents’ educational program are of high quality
• Ensure an environment of inquiry and scholarship through nurture of the residents’ intellectual and personal development
• Respect all ACGME-required and other regulations governing residency and fellowship, including duty hours
• Respect residents as individuals, without regard to gender, race, national origin, religion, or sexual orientation
• Support the residents’ well being
• Be intolerant of abuse or exploitation of residents
• Encourage residents who experience mistreatment or bullying or who witness unprofessional behavior to report the facts immediately to appropriate faculty or staff; treat all such reports as confidential and do not tolerate reprisals or retaliations of any kind
• Devote sufficient time to the educational program in order to fulfill supervisory and teaching responsibilities

Responsibilities of the Residents

• Demonstrate the professional virtues of fidelity, compassion, integrity, courage, temperance and altruism
• Embrace the highest standards of the medical profession and maintain high professional conduct in all interactions with patients, colleagues, and staff
• Strive to acquire the knowledge, skills, attitudes, and behaviors required to fulfill all educational objectives established by the faculty
• Respect faculty members, students, residents, patients and medical staff as individuals, without regard to gender, race, national origin, religion, or sexual orientation
• Encourage fellow residents who experience mistreatment or bullying or who witness unprofessional behavior to report the facts immediately to appropriate faculty or staff; treat all such reports as confidential and do not tolerate reprisals or retaliations of any kind
• Demonstrate accountability and responsibility in the educational program and in the care of patients
• Assist fellow residents and students in meeting their professional obligations

DEFINITIONS: Mistreatment is behavior that adversely affects the learning environment and negatively impacts the learner/faculty relationship. Inappropriate and unacceptable behaviors promote an atmosphere in which abuse is accepted and perpetuated in the learning environment. In general, actions taken in good faith by faculty to correct unacceptable performance is not considered mistreatment. Pointing out during rounds, conferences, or other settings that a learner is not adequately prepared for his/her assignments or required learning material is not mistreatment unless it is done in an inappropriate manner.

The following are some specific illustrations of behaviors that would promote appropriate treatment of medical students and resident, and behaviors that would be considered inappropriate:

Examples of mistreatment include:

• Harmful, injurious or offensive conduct
• Insults or unjustifiably harsh language in speaking to or about a person
• Public belittling or humiliation
• Threats of physical harm
• Threats, coercion, bullying
• Physical attacks (e.g., hitting, slapping or kicking a person)
• Requiring performance of personal services outside of the educational environment (e.g., shopping, babysitting)
• Threatening with a lower or poor evaluation for reasons other than performance
• A pattern of intentional neglect or a pattern of lack of communication
• Disregard for resident safety
• Unnecessary or avoidable acts or words of a negative nature inflicted by one person on another person or persons intended to cause humiliation.

Under no circumstances will the Stony Brook Department of Anesthesiology consider it acceptable practice for faculty to demonstrate bias, prejudice, exclusion, or other unprofessional behavior such as humiliation towards our medical students or residents. Every effort will be made to protect alleged victims of mistreatment from retaliation if they seek redress. Retaliation will not be tolerated. To help prevent retaliation, those who are accused of mistreatment will be informed that retaliation is regarded as a form of mistreatment. Accusations that retaliation has occurred will be handled in the same manner as accusations concerning other forms of mistreatment.

Likewise, residents must appreciate that the provision of constructive feedback in a professional and objective manner by faculty is a desirable means of providing them with guidance in the learning process – such feedback is encouraged and in the best interests of our educational system for both medical students and residents.

Examples of appropriate behavior include:

• Conducting all interactions in a manner free of bias or prejudice of any kind
• Providing a clear description of expectations by all participants at the beginning of all educational endeavors, rotations and assignments
• Encouraging an atmosphere of openness in which students and residents will feel welcome to offer questions, ask for help, make suggestions and disagree
• Providing timely and specific feedback in a constructive manner, appropriate to the level of experience/training, and in an appropriate setting, with the intent of guiding students and residents towards a higher level of knowledge and skill
• Focusing such feedback on observed behaviors and desired outcomes, with suggestions for improvement
• Encouraging an awareness of faculty responsibilities towards all individual learners in a group setting
• Providing an educational experience of the highest quality, along with the time, preparation and research necessary to achieve that goal
• Basing rewards and grades on merit, not favoritism
• Focusing constructive criticism on performance rather than personal characteristics of the student or resident
• All staff at Stony Brook Medicine affiliated sites are expected to adhere to the expectation to treat students and residents with dignity and respect.
• The acknowledgement by learners of course or rotation expectations and the responsibility for fulfilling those requirements to the best of one’s ability
• Asking for feedback from professors, interns, residents nurses, and attending physicians as appropriate
• The acceptance of feedback provided by faculty in an objective manner and the incorporation of such feedback into future efforts so as to achieve the desired educational outcome
• An understanding that feedback is given with the intention of helping to further the student’s and resident’s progress in meeting course and/or rotation expectations
• Promptly and properly addressing, through appropriate administrative avenues, of any incidents and circumstances that fall outside the tenets set forth here
• An honest and earnest effort to provide constructive criticism—written, verbal or otherwise-- to peers and supervisors, when such feedback is likely to enhance their colleague’s skill as a physician

Exclusions from this Policy
Specifically, this policy is not intended to include complaints of sexual harassment or complaints of discrimination on the basis of disability, race, color, sex, creed, veteran’s status, age, marital or parental status or national origin. Residents can refer to the GMEC policy on Harassment. https://renaissance.stonybrookmedicine.edu/system/files/GME0033%20Sexual%20and%20Other%20Forms%20of%20Harassment%20pub%201.4.21.pdf

Procedure for Reporting and Dealing with Allegations of Mistreatment

Residents must pursue violations of this policy in accordance with the following procedures:

1. When it is felt that an incident of mistreatment has occurred, the parties directly involved should try to resolve the matter themselves. Many such situations are amenable to resolution in this manner. However, it is acknowledged that this informal approach may fall short at times, because of reluctance of the resident with a complaint to directly interact with the accused, intransigence of the accused or differing perceptions of the incident by the parties involved. In such cases, the following steps shall be taken:
2. When the matter cannot be resolved between the parties involved, the resident should seek assistance from the Program Director. The Program Director may be able to resolve the matter by counseling the resident with a complaint on appropriate
steps to take, by directly intervening with the accused, or by referring the matter to the next step. When the situation is elevated to the next step, anonymity of the resident and the accused can no longer be maintained. Nevertheless, confidentiality is critical, and no information may be given to those who are not directly involved in the process.
3. If the matter cannot be resolved at Step 2, the Program Director or the accuser (or a combination thereof) should directly consult the Department Chair. In the case where the accused is a faculty member, the Department Chair of the involved department should be notified so he/she can be involved in any discussions with the accused if appropriate. In a case where the accused is the Department Chair, the Vice Dean for GME (Designated Institutional Officer, DIO) should be notified. At any time during Step 3 or Step 4, Human Resources may be consulted by any of the parties involved.
4. It is anticipated that most situations will be resolved in Steps 1, 2, or 3. For those unusual cases that are not resolved, the resident should discuss the problem with the Vice Dean for GME/DIO or a representative of the Human Resources. If the accused is outside SBUH, the Vice Dean for GME/DIO will communicate the problem to the accused’s supervisor, and they will work together to determine the appropriate procedure for resolution.

Protection from Retaliation: Every effort will be made to protect alleged victims of mistreatment from retaliation if they seek redress. Retaliation will not be tolerated. To help prevent retaliation, those who are accused of mistreatment will be informed that retaliation is regarded as a form of mistreatment. Accusations that retaliation has occurred will be handled in the same manner as accusations concerning other forms of mistreatment.

Malicious Accusations: A complainant or witness found to have been dishonest or malicious in making the allegation of mistreatment may be subject to disciplinary action.

Education: Education is the cornerstone in the prevention of resident mistreatment. A thorough and on-going effort should be made to inform all involved individuals about the appropriate treatment of residents, and of this policy dealing with alleged mistreatment. This policy will be posted on the GME website http://medicine.stonybrookmedicine.edu/gme/policy

Reporting events involving non-physician staff
To report altercations or conflicts with non-physician staff that might be perceived as inappropriate or abusive, the Corporate Compliance hotline – reachable at 1-866-623-1480 is recommended by the Graduate Medical Education office for such reports. This hotline is always answered by a person, and is located outside of Stony Brook Medicine. Although anonymous reporting to the hotline is an option, there is a much better chance of resolution if the caller self-identifies so that there can be appropriate follow-up.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: MEDICATION MANAGEMENT

PURPOSE:
Appropriate management and documentation of drugs and narcotics in the operating room is the responsibility of all practitioners. The purpose of this policy is to assure appropriate handling, distribution, and waste of narcotics and drugs used with correct and accurate documentation. All anesthesia care providers will be held accountable for any discrepancies created while on service.

POLICY:
Syringes and ampoules of narcotics must never be left in an operating room unattended.

1. All syringes, ampoules, drugs and needles will be placed in waste bin or locked in pyxis prior to leaving the operating room.
2. Narcotics left unsecured or pyxis left unlocked (and/or drugs submitted to an attending
because they were left unattended) is considered a serious offence. Repeated offense may result in dismissal.
3. Loss of narcotics is serious offense and will result in suspension from the program if not resolved within 24 hours.

Documentation:
All documentation must be legible. Names are to be written in print, signed and dated.

1. Incomplete or inaccurate documentation on the anesthetic record will result in disciplinary action. Offenses will be reported to the Clinical Competency Committee. Repeated offenses may result in dismissal from the program.
2. All syringes must be accurately labeled with medication name, concentration initials, date, and time drawn up.
3. All IV solutions will be labeled with medication name, concentration, initials and date and time.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: MEDICAL RECORD DOCUMENTATION

The medical record is a crucial legal and medical document. It is each physician’s responsibility as well as in his/her own best interest to maintain each patient record completely, accurately and promptly. Stony Brook Anesthesiology policies on medical record documentation reflect those approved by the Medical Board of the University Hospital. Noncompliance with these policies will result in the inclusion of a deficiency in the physician’s credentialing file as delineated by the Medical Board of the University Hospital and may result in suspension of hospital privileges.

Medical Record Documentation Standards

1. Medical record documentation must occur on each patient each day and should be completed in a timely fashion, reflecting the time the patient was seen.
2. The proper note heading and type must be identified for proper electronic filing in the chart.
3. Attending physicians must review all resident notes.
4. SBAR: All complications and incidents affecting patient care must be objectively documented in the progress notes at the time of occurrence, in SBAR (Situation, Background, Assessment, and Recommendation) format.
5. Notification of all physicians by name should be documented.
6. All informed consent discussions must be documented. If the consent is being obtained over the phone, it must be obtained by two different staff members and documented appropriately.
7. Entries made into the medical record in error may be marked “in error” but will remain in the medical record.

SBAR notes: Any acute change in a patient’s condition requiring communication with an attending physician should be documented in SBAR format (situation, background, assessment, recommendation).

Procedure Notes: The following procedures require additional documentation in the medical record if not documented in an anesthesia record. These notes, as all others, should be filled out in real-time or as close to real-time as possible allowing for emergent patient care to supersede.

• intubation
• arterial line placement
• central line placement

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: Management of Resident after Patient’s Death

If a resident participates in the care of a patient who dies intraoperatively or in the immediate postoperative period, the resident should meet with one of the designated attendings to be assessed if the resident is able to return to clinical duty:

1. immediately
2. after a break
3. the following day or
4. the second day after the patient’s death or thereafter

The designated attendings include: Drs. Probst, Corrado, Schabel, Costa, Delemos, Poovathoor, an anesthesia coordinator or the on-call attending if the death occurs during a weekend shift. It will then be determined when the resident can resume clinical duties as outlined 1-4 above.

A non-OR clinical assignment or academic day may be assigned to the resident in order to cope with the emotional component related to the death. If the resident is given a non-OR or academic day, then the resident will resume OR clinical duties the following day unless not ready to do so. If not ready to resume clinical duties by the second day after the patient’s death, then the resident will be referred to the resident assistance program for counseling (Dr. Karant : marsha.tanenberg-karant@stonybrookmedicine.edu. A resident may also leave a confidential voicemail at Dr. Karant’s desk 632-5877, 2-5877 from in-house). A resident may also contact the employee assistance program for counseling. The resident will be encouraged to seek out assistance from the resident assistance program and/or employee assistance program even if able to immediately resume clinical duties.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: LEAVE OF ABSENCE

Vacations and Sick Leave Policy
In accordance with the ABA and ACGME, all anesthesia residents will be given 60 days of leave over the CA-1 through CA-3 academic years to be used for both vacation and sick leave. Attendance of scientific meetings, not to exceed five working days per year, is considered part of the training program. Duration of absence during the clinical base year is a total of one month to be used for both vacation and sick leave. There is no carryover of vacation or sick time from one year to the next. Training must be extended to make up absences exceeding the 60 days over the CA-1 through CA-3 years.

All vacation requests must go through the program coordinator. All requests for a change in vacation must be made AT LEAST 6 weeks in advance. Individual vacation requests will be considered if they do not interfere with patient care responsibilities.

A resident who needs to call in sick must notify the anesthesia coordinator (for main OR rotation), OB attending (for OB rotation), CTICU attending (for CTICU rotation) and Chronic Pain attending (for Chronic Pain rotation) at least 1 hour prior to the start of their shift. Residents need to be honest regarding sick leave. Sick time coverage requires others be "pulled" to handle departmental professional responsibilities. Residents should make arrangements for child care ahead of time.

The program coordinator will keep track of the number of times a resident calls in sick.

Professional and Academic Leave
The Department recognizes the need for residents to schedule interviews for post-residency practice or fellowship and to present scholarly activity. Educational leave must be scheduled to create minimal disruption to the resident’s schedule. Arrangements must be made with the Chief Residents, OR Anesthesia Coordinator and schedule maker.

Unauthorized Leave
Unexcused or unsupportable absences or unauthorized leave and therefore significant tardiness from any mandatory clinical or educational activity constitute unprofessional conduct. Under your signed employment contracts, unprofessional conduct is one behavior which will subject the resident to discipline for non-academic reasons. Such discipline may result in a written warning, probation, suspension, or termination.

Policy on Effect of Leave for Satisfying Completion of Program
All residents must meet the forty-eight month training requirements established by the American Board of Anesthesiology before September 30 of the year they intend to sit for the Certification Examination. Residents may miss one month per PGY-1 year, including vacations, sick leave, LOA, etc., and 60 days during their CA-1 through CA-3 years. Time in excess of three months over three years, whether for vacations, sick leave, maternity or paternity leave, must be made up to meet this requirement, which will extend your training.

Any request for LOA/planned leave should be considered carefully, as it will invariably create difficulties for the training program and fellow residents. A requested LOA must be discussed with the Residency Program Director. The Residency Program Director must approve the request at least three months prior to the requested LOA date. Exceptions may be made if the request falls under the definition of the Family Medical Leave Act (FMLA).

Personal Leave of Absence (LOA)
Family emergencies and personal leaves will be considered on a case-by-case basis by the Program Director. Only under UNUSUAL circumstances, such as a personal or family emergency, will a Personal LOA be granted. Such a LOA will be subject to the general conditions outlined above. All personal time must be made up.

Parental Leave: Maternity/Paternity Leave
A resident may take 6 weeks of maternity/paternity leave. This may be used to care for a newborn or newly adopted child. This is counted as “sick leave” if maternity, and “family sick leave” if paternity. Up to 30 days of sick time may be used for this. Maternity and Paternity leave may extend residency training, based on the amount of time requested. Please speak with the Program Director if you are considering a maternity or paternity leave – the earlier the better. You will also need to file paperwork with Human Resources.



Reviewed and Approved: July 1, 2024

return to table of contents

POLICY:

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: EXPECTATIONS OF RESIDENTS AND GRADUATION REQUIREMENTS

1. Duty Hours: As a minimum, residents shall be allowed an average of 1 full day in 7 days away from the institution and free of any clinical or academic responsibilities, including planned educational experiences. The chief residents will attempt to ensure that this requirement is being upheld. However, in the rare case that your schedule violates RRC duty hour regulations, please notify the chiefs and program coordinator immediately. Additionally, please be aware of RRC duty hour requirements when arranging schedule changes/ switches. All schedule changes/switches must be approved by the chief residents.
2. Conference Attendance: The program should require that residents participate, on average, in at least 70% of the educational experiences offered (excluding vacations and post-call approved reasons). Although you are required to attend 70% of conferences, we encourage you to attend all educational conferences. If an unexpected emergency occurs and you are unable to attend a conference, you must contact the Program Director to discuss the reason why.
3. Case Logs: Programs must maintain a record of all procedures performed by each resident. ACGME case logs will be monitored on a quarterly basis by the Program Director. Failure to document all cases and procedural experience may result in a delay in progressive responsibilities/ promotion. All residents are required to achieve the required case numbers by June of their CA-3 year to fulfill graduation requirements.
4. Resident Scholarly Activity: Each program must provide an opportunity for residents to participate in research or other scholarly activities, and residents must participate actively in such scholarly activities. All CA-3 residents are required to give a Senior Grand Rounds presentation. The Grand Rounds Advisory Council provides guidance with the scholarly project starting in their CA-2 year and residents are expected to meet the preparation timeline.
   Residents are also required to participate in a QI or Patient Safety Project that must be:
1. Completed by April of their CA-3 year
2. Submitted for presentation at the annual departmental Research Evening in their CA-3 or CA-2 year
   Residents are encouraged to participate in departmental research and present scholarly work at local, regional or national meetings.
5. Unexpected Absences: Any unexpected absence must be communicated to the chief residents by a phone conversation prior to your absence.
6. Step 3: Step 3 must be passed in the PGY-1 year.
7. Basic Exam: All CA1 residents are expected to pass the Basic Exam in June of their CA-1 year. If a resident should fail the June Basic Exam, they are expected to pass the November Basic Exam. Failure to pass the Basic Exam on the second attempt will lead to release from the residency program.

The above requirements will be monitored and then officially documented at your semi-annual review. If you do not comply with these requirements – a letter of warning will be placed in your file, and there will be a specific plan of remediation.

I have read the above and will comply. I will notify the Program Director immediately if I anticipate any problems with compliance before it becomes a problem.

Resident Signature: _________________________________

Resident Name: _________________________________

Date: _________________________________

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: EXPECTATIONS OF FACULTY

Per ACGME requirements:

• “Faculty must devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities; and to demonstrate a strong interest in the education of residents.” All faculty must “administer and maintain an educational environment conducive to educating residents in each of the ACGME competency areas.”
• “The faculty must establish and maintain an environment of inquiry and scholarship with an active research component. The faculty must regularly participate in organized clinical discussions, rounds, journal clubs, and conferences.”
• “Faculty should encourage and support residents in scholarly activities.”
• “All faculty members involved in the education of residents should participate in programs to enhance the effectiveness of their skills as educators, based on their roles in the program…They should participate at least annually.”
• “The faculty must evaluate resident performance in a timely manner during each rotation or similar educational assignment, and document this evaluation at completion of the assignment.”
• “The physician faculty must have current certification in the specialty by the American Board of Pediatrics.”

Faculty are kept updated regularly through departmental faculty meetings and individual reviews.

Faculty Education Expectations

1. Remind resident to select topic for discussion during pre-op phone call; select for them if needed
2. If working with a resident, dedicate at least 5 minutes either before or during the working day to discuss the selected topic
3. Complete a DDF with the topics discussed entered in the “Topics Discussed” section

Faculty Education Leader Expectations

1. Send welcome to rotation email to residents starting the rotation. Indicate that the plan is to discuss selected topics with them during the rotation. Attach a checklist of topics that includes a section for feedback on “resident practice habits”
2. Meet with resident during the last week of the rotation to assure topic checklist completion and to give feedback on “resident practice habits.” Bonus: mini oral exam to assess knowledge learned during the rotation. Written exams not required.
3. Complete Resident New Innovations End Rotation Evaluation within 2 weeks of end of rotation.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: EVALUATION OF ANESTHESIOLOGY RESIDENTS AND SUPERVISORS

The Program Director is responsible for ensuring the quality of the educational experiences of the training program.

Evaluation of Anesthesia Residents and Supervisors
Residents are provided feedback through various methods:

Formative feedback on an ongoing basis is provided by faculty, nurses, peers, patients, and office staff members throughout the course of the training program. Summative feedback from supervising faculty is provided at the completion of each rotation through New-Innovations. Each anesthesia resident will be assessed of the general competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal skills and communication, professionalism, and systems-based practice and milestones). Evaluations will occur at the end of each rotation. Written evaluations will be available for the resident to review on New-Innovations.

The Clinical Competency Committee meets monthly to review the progress of each resident through careful evaluation of all New Innovations evaluations, informal feedback, case logs, scholarly activity progress, and completion of professional administrative tasks. The committee provides formal milestone ratings semi-annually.

All residents take the American Board of Anesthesiology annual In-Training Examination. The results of these examinations provide the resident feedback on medical knowledge and test-taking skills. Residents are recommended to adjust their personal study plans semi-annually based upon the results of these exams.

Through our one-to-one mentor program, residents meet with a faculty advisor at least four times annually. The advisor provides guidance on resident academic progress, including procedure completion and other administrative tasks, career track selection and career planning, scholarly activity progress, creation of an individualized learning plan, work-life balance, and any other topics the resident wishes to discuss. Advisors may also play a role in the coaching or remediation of a resident.

If a resident's performance or conduct is judged to be detrimental to the care of a patient(s) at any time, action will be taken immediately to ensure the safety of the patient(s).

Each resident will be given the opportunity to complete a confidential written evaluation of attending physicians and of the residency training program. Such evaluations will include the adequacy of clinical supervision by the attending physician. The evaluations will be reviewed by the Program Director. Once reviewed, anonymous faculty evaluations will be distributed to the individual faculty members as a faculty feedback tool. The Department Chair is informed of any faculty with inadequate performance evaluations. All written evaluations of residents and attending physicians will be kept on file in New-Innovations

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: ELIGIBILITY, SELECTION AND APPOINTMENT OF RESIDENTS, FELLOWS AND TRANSFERS

PURPOSE
To establish a departmental policy regarding the selection and appointment of residents, fellows, and transfer candidates which is compliance with the institutional policy.

POLICY
The University Hospital Graduate Medical Education programs share common criteria and processes for the recruitment and selection of residency and fellowship training candidates. The application process meets all requirements of the Equal Employment Opportunity and the Americans with Disability Act, in insuring that all qualified applicants are afforded a review without discrimination based on sex, race, age, religion, color, national origin, disability or any other applicable legally protected status.

Minimum requirements General and minimum requirements for eligibility for consideration for a training program at University Hospital are:

1. Graduation from a medical school in the United States or Canada, accredited by the Liaison Committee on Medical Education (LCME), OR
2. Graduation from a college of osteopathic medicine in the United States, accredited by the American Osteopathic Association (AOA), OR
3. Graduation from a medical school outside of the United States or Canada AND meeting one of the following additional qualifications:
1. holds a current valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) prior to appointment, OR
2. holds a full and unrestricted license to practice medicine in a United States licensing jurisdiction in his or her current ACGME specialty/subspecialty program, OR
3. has graduated from a medical school outside the United States and has completed a Fifth Pathway program provided by an LCME-accredited medical school.
4. The “12 Week Rule”
   
   The following medical schools have been approved by the New York State Education Department to allow students to complete more than 12 weeks of clinical clerkships in New York State. The medical school may be acceptable in other states but not be acceptable in New York State. The approved schools are updated regularly on the NYS education website.
   
   The 12 week rule would be applicable to U.S. sponsored foreign medical schools.
4. A US citizen, permanent resident, has employment authorization identification, or has a J-1 visa sponsored by ECFMG. Stony Brook University Hospital does not sponsor H1B visas for GME training.
5. Fellowship applicants must have successfully completed an ACGME-accredited residency program and demonstrate successful completion of USMLE Step 3 before entering the program.
6. Residency Appointment is contingent upon demonstrating successful completion of USMLE (Step 1 by 2nd attempt, Step 2 CK by 2nd attempt and Step 2 CS on the 1st attempt) or COMLEX (Level 1 by 2nd attempt, Level 2 CE by 2nd attempt and Level 2 PE on the 1st attempt) examinations.

The program director is responsible for verification of the applicants' credentials.

Applicants who do not meet the above criteria cannot be considered for any graduate medical educational programs at University Hospital, SUNY at Stony Brook.

Resident Selection
A selection committee, the Residency Admissions Committee, exists within the Department of Anesthesiology and consists of the program director, associate program director, and a several faculty member who are chosen at the discretion of the program director.. The program director is responsible for reviewing all application and selecting applicants for interview. The committee is responsible for participation in the interview process, assistance with decisions related to ranking. The final choice of applicants to be ranked in the NRMP match or offered contracts independent of the match when this option is allowed will be made by the program director.

All applicants meeting the minimum criteria above, plus meeting program-specific criteria (such as requirements for prior training), will be reviewed by members of this committee. Applicants will be selected on the basis of residency program-related criteria such as preparedness, ability, aptitude, academic credentials, communications skills and personal qualities such as motivation and integrity. Academic credentials include medical school grades and performance as reflected in documentation received directly from the school and United States Medical Licensing Examination (USMLE) scores. Prior graduate medical education training, where applicable will also be considered. Formal educational and/or testing results submitted by the applicant may also be considered. Letters of reference from supervisors, educators and peers, when appropriate, serve to provide additional information on personal characteristics are required and evaluated as well.

The selection committee then invites selected candidates for an individual interview, which may be conducted in person (preferred) or rarely by telephone if travel to this site presents a personal hardship to the applicant. The interview allows in person confirmation of information provided in the written application as well as an opportunity to assess communication skills.

Confidential evaluations by each applicant interviewer will be collected and reviewed by the selection committee, and become part of the application file. Programs will only accept applications through ERAS, if applicable for that specialty. All current fourth year medical students from United States medical schools are required to apply through the NRMP process or other appropriate match processes. SBUH participates in the NRMP all-in policy and programs will only review applications through ERAS.

Applicants meeting the above eligibility requirements, and the required additional documentation (letters of reference and interview) will be considered by the selection committee for positions remaining open in the program after the NRMP match, and will be offered positions by the program director if considered qualified. All candidates who are interviewed shall be given a copy of the SBUH agreement of appointment and a copy of this policy. Programs will document that the candidate has received a copy of the agreement of appointment by obtaining their signature at the time of interview.

Transfers Before accepting a resident who is transferring 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 resident.

Residents are considered as transfer residents when moving from one program to another within the same or different sponsoring institution. The term ‘transfer resident’ and the responsibilities of the two program directors do not apply to any resident who has successfully completed a residency and then is accepted into a subsequent residency program.

Purpose of the Process The following components of the resident selection process have several general purposes:

First, a specific selection committee reviews all eligible applicants to insure that all eligible candidates' applications are given careful, fair, and consistent review.

Second, documentation of eligibility and successful performance at the medical school and on required licensure examinations is required to insure that applicants possess proper academic credentials and are sufficiently prepared to benefit from graduate medical education.

Third, letters of reference are required and reviewed to gain insight into the applicant's personal characteristics such as motivation, integrity, attitude, and ability to work with others, as viewed by a group of educators, mentors or peers.

Fourth, recognizing the central role of communication in providing medical care, a personal interview is required to further evaluate the applicant's interpersonal skills, and ability to communicate both in an individual interview and in a group setting.

Appointment The following procedure is required before any resident can be officially appointed as a resident:

Primary verification of all credentials is required. The Residency Program in conjunction with the Medical/House Staff office will conduct this verification. It is the responsibility of the resident to provide sufficient information to allow these verifications to be conducted.

At a minimum, Stony Brook University Hospital must be able to obtain primary source verification on the following:

1. Certification of graduation from any accredited medical school or ECFMG certified medical institution. This documentation must be submitted directly from the academic institution granting the degree or from ECGMG directly to the residency program.
2. Letters of recommendation
3. Documentation accounting for any lapses between the end of medical school and the present. Large gaps of time exceeding 1 month that are not verifiable will disqualify candidates for consideration for a GME program
4. Proper documentation of employment and/or work performed since graduation from medical school. The standard for proper documentation will be imposed by the GME program
5. Passing a criminal background check
6. Passing of all 6 competencies in a summative evaluation from the program director for any resident/fellow completing training or transferring from preliminary training or another institution.

Applicants who do not meet the above criteria cannot be appointed to any graduate medical educational program at Stony Brook University Hospital. Completion of primary source verifications renders an applicant eligible for appointment, but does not in and of itself result in automatic appointment. Residents are eligible to proceed through the appointment process.

Once all information is completed and reviewed, the applicant will be sent a letter of appointment.

The official start date is contingent upon the resident completing all required paperwork (demographic/tax form, etc.) clearance by employee health service (resident must submit a complete history and physical form) and appropriate visa, if applicable.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: DUTY HOURS

Duty Hours
Duty hours are defined as all clinical and academic activities related to the training program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. When averaged over any 4-week rotation or assignment, residents must no spend more than 80 hours per week in patient care duties.

Our program’s duty hour assignments recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. Back-up support systems are provided in the program for times when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.

Our residency program maintains and monitors the resident work hours as outlined in the New York State Health Code 405.4 established in July 1989 with regard to inpatient care responsibilities and the revised ACGME duty hours of:

1. Clinical and education work hours must be limited to no more than 80 hours per week, averaged over a 4-week period.
2. Residents must have 8 hours off between scheduled clinical work and/or educational activities. There may be circumstances when residents choose to care for their patients or return to the hospital with fewer than 8 hours free of clinical work and/or education.
3. Residents must have 14 hours free of clinical work and/or education after a 24 hour in-house call.
4. Residents must be scheduled for at least 1 day in 7 free of clinical work and/or required education from the program when averaged over 4 weeks.
5. Scheduled clinical work and/or educational activities must not exceed 24 hours of continuous clinical assignments. Up to 4 hours of additional time may be used related to patient care, patient safety and/or resident education.
6. Moonlighting is not allowed.
7. In-house night float must occur within the 80 hour and 1 day off in 7 requirements.
8. Resident must be scheduled for in-house call not more frequently than every 3rd night when averaged over a 4 week period.
9. At home call does not count toward duty hours unless the resident is in-house providing patient care or spending time on patient care activities while at home. At home call must satisfy the requirement for 1 day in 7 free of clinical work/or required education from the program when averaged over 4 weeks.
10. On-duty assignment of residents in the Emergency Room shall not exceed 12 consecutive hours.

Implementation
Schedules of resident anesthesia call are devised by the anesthesiology chief residents with approval of the program director.

Monitoring
Duty hour audits occur monthly by the program administrator and are reviewed by the program Director if violations appear.

Resident Responsibility
Trainees are required to notify the program director if they are non-compliant with scheduling policy.

Reporting Duty Hours
Duty hours are entered into New Innovations by the residency coordinator. Residents are responsible for confirming duty hours in New Innovations, making any necessary adjustments, and providing justification for going over duty hours.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: DRESS AND COMPORTMENT

It is expected that residents use professional, responsible conduct in all interactions with patients, families and hospital staff, as delineated below.

Confidentiality of Patient Information
Discussions among professionals about patients. patient diagnoses, new findings or management plans, or any other privileged information should take place in private consultation spaces. Such information should never be discussed in elevators, cafeteria lines or in other public spaces. The single exception to this is the discussion of patients at the bedside during rounds. When this is done, and the family is present, it is the responsibility of both faculty and residents to address the child and family about what was said or what was planned, in language that the family understands.

Proper Dress and Proper Grooming
Residents are expected to dress in accordance with their professional role. It is expected that men will wear slacks and dress shirt, and in parallel, women will dress in acceptable slacks, dresses or skirts for clinic assignments. Tee shirts, shorts and blue jeans are not acceptable. Sneakers are only acceptable when wearing scrubs. Scrubs are not to be worn at clinic and should always be clean. Any scrubs soiled by bodily fluids should be exchanged immediately. The resident's laboratory coat should be maintained in clean condition and in good repair. The laundry is on UH level one. Please see “Attire for Surgical Procedures” policy.

Residents are expected to maintain appropriate grooming and hygiene during service hours. It is important to maintain the highest quality of personal care both as a measure of prevention against disease and as a matter of comfort to patients and families with whom the resident is likely to interact closely. Other specific guidelines for dress code and conduct on behalf of the Department of Anesthesiology is as follows:

• ID badge must be worn above the waist
• Natural finger nails are to be neatly trimmed and maintained at a length no longer than ¼” beyond the finger tip
• Artificial nails, nail enhancements of any kind (including nail "gels") and chipped nail polish are not permitted for clinic assignments.

Use of Shared On-Call Space
On-call space is shared space. It is the resident's responsibility to maintain order and cleanup after oneself. This will facilitate use of that space by others and ensure that the Housekeeping Department can regularly. Residents should be sure not to leave personal belongings in the on-call space that would delay or interfere with housekeeping efforts. You are also advised to refrain from leaving valuables in the call space.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: DISRUPTIVE RESIDENT BEHAVIOR (GME Policy GME0009)

It is the policy of the Graduate Medical Education (GME) Committee and the Medical Staff Office of Stony Brook University Medical Center that all practitioners who are members of any resident training program at this facility shall conduct themselves in a professional, cooperative and appropriate manner, and shall not engage in disruptive behavior. It is expected that residents treat all staff and patients with courtesy and respect, show respect for patient autonomy and maintain confidentiality of patient information.

Disruptive behavior includes but is not limited to:

• Conduct that interferes with the provision of quality patient care
• Conduct that disrupts hospital operations
• Conduct that constitutes sexual harassment including sexual discussions or innuendos
• Making or threatening reprisals for reporting disruptive behavior
• Shouting or using vulgar, profane or abusive language
• Making racial or ethnic slurs
• Abusive behavior including threats of violence, retribution, or financial harm towards patients or staff
• Physical assault or inappropriate physical affection
• Behavior that is intimidating, belittling or implies incompetence
• Refusal to accept medical staff assignments or cooperate with other staff members
• Conduct that adversely affects the community’s confidence in the hospital’s ability to provide quality patient care

Residents are expected to:

• Accept and incorporate feedback in a non-resistant and non-defensive manner
• Address dissatisfaction through appropriate offices
• Cooperate and communicate with all providers displaying regard for their dignity
• Be truthful in all written and verbal communication

1. Residents identified as demonstrating disruptive behavior may be at risk for the following actions:
1. Written warning/ letter of counseling
2. Probation
3. Suspension
4. Termination
A decision to terminate a resident is subject to the due processes procedure as outlined. A decision to provide a warning to the resident or place a resident on probation is not subject to the due process procedure.
2. Any written or oral report of alleged disruptive resident behavior must be sent to the program director, who shall initiate an investigation as he/she deems appropriate to identify or rule out the existence of disruptive behavior. Issues not resolved at the program director level will be forwarded to the Chair of the GME Committee for resolution.
3. During the investigation, the program director will meet with the resident to review the alleged behavior and the requirements of this policy. Both the program director and the resident may be accompanied at this meeting by other practitioners that the program director or resident feel are necessary to explain the disruptive behavior. The program director will also meet with the person(s) toward whom the disruptive behavior was directed.
4. At the completion of the investigation, the program director and department chair will make a determination as to whether the resident engaged in disruptive behavior. The written summary of the investigation will document the following:
1. the date and time of the questionable behavior
2. if the behavior affected or involved a patient, and the patient's name and medical record number
3. the circumstances that precipitated the behavior
4. a factual, objective description of the behavior
5. the consequences of the behavior for patient care or hospital operations
6. the dates, times, and participants in any meetings with the resident, staff, etc. about the behavior.
7. acknowledgement of receipt by resident attestation and signature
5. If the program director determines that the resident has not engaged in disruptive behavior, he/she will advise the resident and the person(s) to whom the allegedly disruptive behavior was directed of such determination, and will prepare a written report (as outlined above) to be filed in the program director's file, with a copy given to the resident.
6. If the program director and department chair determine that the resident has engaged in disruptive behavior, they will meet with the resident to counsel the resident concerning compliance with this policy and assist the resident in identifying methods for structuring professional and working relationships and resolving problems without disruptive behavior.
   
   The program director will advise the person(s) to whom the allegedly disruptive behavior was directed of such determination. Depending on the nature of the behavior, the program director may refer the resident to the Committee on Physician Well-Being for assistance. A letter of warning will serve as an alert that this disruptive behavior has been documented and will include a plan for monitoring future compliance with and violation of this policy. This letter along with the written report (as outlined above) will be filed in the program director’s file, the resident’s file with a copy given to the resident.
7. Residents who have received a warning letter and have not demonstrated substantial improvement as previously outlined and communicated or incur repeat offenses shall be placed on academic or professional probation.
8. If a second report of alleged disruptive behavior is made concerning the same resident, the program director will confirm that this is a second incident of disruptive behavior and will refer the matter to the Chair of the GME Committee.
1. The Chair will make a determination based on the documentation from the program director. Referrals for counseling (to the MSSNY committee on Physician Health, the Medical Director of the hospital, and the Committee on Physician Well-being) may also be part of this process. The determination will be documented and filed in the program director’s file, the resident’s file with a copy given to the resident.
2. The Chair may also appoint an adhoc committee to further investigate the issue. This adhoc committee will meet with the resident and attempt to further assist the resident in identifying methods for structuring professional and working relationships and resolving problems without disruptive behavior. This committee will also develop a plan for monitoring future compliance with or violation of this policy. At its discretion, the committee may consult with the person(s) who was the object(s) of the disruptive behavior. The committee will send a written report to the program director and the Chair of the GMEC. The committee report shall remain in the program director's file, and the resident’s file.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: DATING

Residents may not initiate a dating relationship with any trainee (student or house staff) while the resident is on a rotation with that trainee in a supervisory position. This can create an uncomfortable work environment and may be interpreted as sexual harassment.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: COUNSELING AND SUPPORT FOR PHYSICIAN IMPAIRMENT/SUBSTANCE ABUSE

Physician Impairment
Program directors and faculty are responsible for monitoring resident stress, including mental or emotional conditions inhibiting performance or learning and drug or alcohol-related dysfunction.

Program directors and faculty should be sensitive to the need for timely provision of confidential counseling and psychological support services to residents.

Program directors and faculty should be aware of services available at Stony Brook and offer these services to residents when appropriate.

Substance Abuse
In compliance with the Federal Drug-Free Workplace Act of 1988, the following policy must be adhered to as a condition of employment. T

The unlawful use, possession, manufacture, dispensation or distribution of a controlled substance in all Stony Brook University Hospital work locations is prohibited. The term “controlled substance” means a controlled substance in Schedules I through V of the Section 202 of the Controlled Substances Act (21 USC 312).

Employees who unlawfully manufacture, distribute, dispense, possess or use a controlled substance will be subject to disciplinary procedures consistent with applicable laws, rules, regulations, and collective bargaining agreements. Penalties sought may include termination. Any illegal activity involving drugs or alcohol is considered MISCONDUCT and may be reportable to the Office of Professional Medical Conduct or any other regulatory agency as applicable. Employees must notify their program director of any criminal drug statute conviction occurring in the workplace or at a worksite no later than five (5) days after such conviction.

Counseling Services
The Stony Brook University Employee Assistance Program (EAP) assists faculty, staff, family members and retirees with personal, family and jobrelated issues. It is a voluntary and confidential service established in 1985 and staffed by mental health professionals. The EAP's focus is on the health and well-being of our employees so that they can lead productive lives both at work and at home. The EAP offers educational workshops on health and wellness topics, provides a lending library for employees and conducts supervisory training. Additional information can be obtained on the website at www.stonybrook.edu/eap.

Further information can be found in:

1. The Stony Brook University Hospital Faculty and Professional Employee Handbook offer information about the University Counseling Center as well as the Employees Assistance Program. This support and referral service is set up for employees and families facing health, emotional, alcohol, drug abuse, financial strain or legal problems. It is free and strictly confidential. The University has also established an Alcohol and Drug Abuse Advisory Panel composed of faculty, professional employees, and students to promote the ongoing education of the University community with regard to alcohol and drugs. For additional information call 632-6085.
2. Stony Brook University Hospital offers chaplaincy services with a multidenominational staff that gives support to the human and emotional needs of the faculty, house staff and patients. Call 444-8157.
3. There is an institutional wellness committee, a GME wellness committee and some programs have their own wellness committee and/or policy. Some issues addressed, in addition to abuse, are burnout, depression, fatigue mitigation, stress management, mindfulness and self-assessment tools. There is a psychiatrist available for resident referral. All encounters are strictly confidential and are not recorded in the EMR. To facilitate this service for a resident contact the GME office.
4. The Committee for Physicians Health (CPH) is a division of the Medical Society of the State of New York and not part of any government agency. CPH is authorized by Section 230-11 of the Public Health law to confidentially contact and refer to treatment, physicians who are troubled with behavioral health concerns including substance abuse and other psychiatric disorders. CPH activities are confidential, its records are not discoverable and the law provides immunity for those who make referrals. Physicians are encouraged to contact CPH to obtain confidential assistance for themselves and their colleagues. CPH will coordinate appropriate treatment and notify the respective program director when the practitioner is medically cleared for duty and appropriate monitoring is in place.

Reviewed and Approved: July 1, 2024

return to table of contents

POLICY: CLINICAL COMPETENCY COMMITTEE

Policy
The Clinical Competency Committee (CCC) for the Anesthesiology Residency Program is charged with monitoring house staff performance and making appropriate recommendations for disciplinary decisions. At all times, the procedures and policies of the CCC will comply with those of the Graduate Medical Education Committee as outlined in the Graduate Medical Education policy titled “Termination, Grievance Policy and Due Process.”

Background
The Accreditation Council for Graduate Medical Education (ACGME) requires that the CCC make a consensus decision on the progress of each resident. The committee’s assessments integrate New Innovations data, including individual educational milestone assessments. The CCC serves as an early warning system if a resident fails to progress in the education program, and assists in their early identification and movement toward improvement and remediation. General minutes of all meetings are maintained.

Procedure
Membership
The Chair of the CCC is appointed by the Program Director and the Department Chair. The CCC Chair, after consultation with the Program Director and Associate Program Director, appoints all committee members. The Program Director and Associate Program Director are included.

Responsibility of Members
At all times, the committee maintain strict confidentiality. Members attend quarterly committee meetings as well as ad hoc meetings to address pressing resident issues. The milestone scoring determined by the committee is based upon careful review of resident evaluations and clinical performance. The Program Director is responsible for submitting all semi-annual milestone scores to ACGME. The committee is also responsible for making recommendations to the program director for resident progress, including promotion, remediation, and academic status (including warning, probation, and dismissal).

Interventions for remediation may include (but are not limited to) assigning a mentor with expertise in a given area of deficiency, additional required readings, direct observations with feedback, sessions in a skills lab, added rotations in a given area, rotation schedule changes, or other methods aimed at addressing identified problems.

All resident evaluations regarding academic status are documented in New Innovations and when appropriate, also in the resident’s personal file. The program director has final responsibility for the program’s evaluation and promotion decisions.

The committee reviews all resident evaluations on a semi-annual basis for the purpose of documenting the residents’ semiannual performance.

The committee is responsible for providing feedback and input to the program director on the selection of the chief residents.

Schedule of Meetings
The Committee meets quarterly. In addition, the Committee Chair may schedule ad hoc meetings to address pressing issues that cannot wait until the next regularly scheduled meeting.

On a quarterly basis, the committee reviews any resident on warning, probation, or who has not satisfied the Supervisory Privilege. In addition, the committee discusses any resident who may have new concerns or flags that require closer monitoring and early intervention with informal remediation. The goal of early intervention is to prevent progression to warning, probation, or termination. In the case that a full committee cannot be convened in a timely fashion for urgent matters, a Competency Committee Executive Committee will make decisions regarding resident academic status. These decisions are communicated to the full committee at the next scheduled meeting.

Twice per year, the committee formally evaluates all residents by assessing milestone level achievement.

Resident Review
A resident may be brought up for discussion by the Clinical Competency Committee for any of the following reasons: recommendation by the Program Director for any reason, consistently low or unsatisfactory evaluation scores, consistent lack of adherence to program requirements, or a specific incident that requires review.

Reviewed and Approved: July 1, 2024

return to table of contents