GME Orientation Manual 2015 - Rady Children`s Hospital

Resident and Fellow Manual
2014-2015
Welcome to Rady Children’s Hospital San Diego
This 475-bed acute care facility includes the latest technology and advancements
in pediatric medical care. From our Trauma Service, PICU, Pediatric ED Acute
Services to our Family-Centered care model with ethics, rehabilitative medicine and
hospice care, RCHSD campus offers a wide spectrum of services for all children and
adolescents. From it’s beginning in the 1970’s, the mission of the hospital has been to
dedicate itself to caring for all children. Outreach programs, involvement in multiple
community satellite offices as well as integration with hospitals countywide has brought
pediatric expertise to San Diego and neighboring counties. During your rotation at
RCHSD, you will have the opportunity to interact with specialists in all fields of pediatrics
who have committed themselves to excellence in research academics and clinical
medicine.
In this manual you will find basic information that will be of help to you. In
addition, please visit www.rchsd.org/gme to access a variety of information on
schedules, contacts, “how to” and more. As always, if you have any questions, please
do not hesitate to contact the GME Coordinator, Marian Toscano, or myself. The GME
office can be reached at (858) 576-1700 x6138 or [email protected].
Enjoy your time at Rady Children’s San Diego!
Sincerely,
Sara Marchese, M.D.
RCHSD Medical Director of Graduate Medical Education
Marian Toscano
GME Administrative Coordinator
2
Table of Contents
I.
Hospital Basics
II.
a. Campus Map
5
b. Rotation Contact List
6
b. Navigating the Halls
7
c. Function of the Hospital
9
d. Computer Access (how to set up)
10
e. ID Cards and Parking Access
11
h. Emergency Codes
12
i. JCAHO and Patient Safety
13
IV.
Verbal Orders
14
II.
Abbreviations
15
III.
National Patient Safety Goals
16
IV.
Six Core Competencies
17
Working in the Hospital
a.
b.
c.
d.
III.
I.
Admissions Criteria –Bed Resource Managements
SBARN (N) Technique
Vascular Access Device Training
Social Worker Role
21
22
24
Surgical Services
a. Surgical Services Orientation
25
b. Your Privileges in the O.R.
35
c. Preventing Surgical Fires
36
d. Medical Staff Privileges in the O.R.
39
Job Descriptions and Policies
a. Fellow Job Description
42
b. Resident Job Description
45
c. GME Policies
V.
VI.
VII.
I.
Acceptable Use of the Internet
51
II.
Admission Criteria for Inpatient Service
53
III.
Disruptive Behavior
55
IV.
Discipline, Dismissal and Due Process
57
V.
Managing Impaired Residents
58
VI.
GME Trainee Use of Non-Licensed Facilities
60
VII.
House Staff Rules and Regulations
61
VIII.
Sexual Harassment
66
IV.
UCSD Moderate Sedation Policy
68
X.
Trainee Oversight and GME Compliance
70
XI.
Resident Work Hours
72
XII
Maintaining Appropriate Boundaries
74
XIII
RCHSD Commitment to Quality and Safety
78
Fatigue and Stress Management
a. Fatigue and Sleepiness On-the-Job
95
b. Getting A Better Night’s Sleep
97
c. Stress Management
98
Academics
a. Evaluations
100
b. Noon Conference – Core Topics
101
Research
a. RCHSD Research Approval Process/IRB
105
b. RCHSD IRB Forms & Submission Information
10
3
Hospital Basics
4
5
Rotation Contact Information
Once you have a rotation scheduled @ RCHSD, make contact with the corresponding
administrator below. They can help you with scheduling requests and other
department-specific information (what to where, what time/where to show up, etc).
Department / Rotation
Allergy/Immunology
Anesthesiology (UCSD and Navy
Residents)
Anesthesiology (Regional Fellows)
RCHSD Contact
Seema Aceves, MD
David Frankville MD / Chriss
Lee
Alex Rodarte, MD
Phone
x5961
Email
[email protected]
Program Director
John Bastian, MD
x5856
[email protected]
David Frankville, MD
x5856
[email protected]
Ed Mariano, MD
Cardiology
Dana Bowny
X4815
[email protected]
Paul Grossfeld, MD
CF Clinic
Becki Hughes
x5846
[email protected]
Mark Pian, MD
Chadwick Center
Roberta Joseph
x5841
[email protected]
Jenn Davis, MD
CT Surgery
Dee Isbell
x8030
[email protected]
John Lamberti, MD
Dental
Angela Brown
(619) 205-1950
x 6825
[email protected]
John Neves DDS
Dermatology
Patti Oden
x4269
[email protected]
Developmental/Behavioral Pediatrics
Melanie Marshall
(858)246-0046
[email protected]
Emergency Medicine
Richelle Belen
x8036
[email protected]
Endocrinology
Claudia Juarez
x4032
[email protected]
Gastroenterology
Nicole Bloom
x8907
[email protected]
Hematology / Oncology
Jessica Liu
Patti Evertsen
Lynne Robert
(858)246-0149
(858)966-5808
x5648
[email protected]
[email protected]
[email protected]
Hospitalist Fellowship
Billye Ingle
x5841
[email protected]
Infectious Disease
Robin Morrison
x7785
[email protected]
William Roberts, MD
Cindy Kuelbs, MD
Erin Stucky Fisher, MD
Steve Spector, MD
Inpatient Wards Sub-I
UCSD Peds Chiefs
page Chief
[email protected]
Chris Cannavino, MD
Nephrology
Amparo Godoy
x8052
[email protected]
Robert Mak, MD
Neurology
Lurenette Griffin
x5819
[email protected]
John Crawford, MD
NeuroSurgery
Angelica Garcia
x8574
[email protected]
Michael Levy, MD
NICU
Kelly Burke
x5818
[email protected]
Mark Speziale, , MD
Ophthalmology
Joyce P. McHugh
(858)534-8858
[email protected]
Preeti Bansal, MD
OR (RCHSD)
Cheryl Sosa
x5228
[email protected]
Orthopedics
Heather Johnston
x5822
[email protected]
Otolaryngology
Rose Chavez
X6168
[email protected]
Pathology
Pat Lapiezo
x5944
[email protected]
Pediatrics (Inpt Wards)
Donald Bailey
x5841
[email protected]
PICU
Evelyn Lizasuain
x5863
[email protected]
Pamela Lugo
(619)543-5887
[email protected]
Susan Hansen
(619)543-6084
[email protected]
Chris Cannavino, MD
Susan Duthie, MD
Bradley Peterson, MD
Steven Cohen, MD
Amanda Gosman, MD
Marek Dobke, MD
Psychiatry
Linda Young
x7759
[email protected]
Ellen Heyneman, MD
Psychiatry- CAPS
Stacey Spencer
x8575
[email protected]
Ben Maxwell, MD
Pulmonary
Brenna Vanderpool
x5846
[email protected]
Mark Pian, MD
Radiology
Denise Smith
x8954
[email protected]
Peter Kruk,, MD
Rheumatology
Priscilla Mendoza
x6089
[email protected]
Hal Hoffman MD
Surgery
Andrea Alvarez
x7714
[email protected]
Karen Kling, MD
Urology
Donna Soul
x8276
[email protected]
George Chiang, MD
Genetics-Dysmorphology
Plastic Surgery –Dr Cohen &
Dr Gosman
Plastic Surgery - Dr. Dobke
Lawrence Eichenfield,
MD
Sheila Gahagan, MD
Yi Hui Liu, MD
Paul Ishimine, MD
(Fellowship)
Seema Shah, MD
(Residency)
Michael Gottschalk,
MD
Jeanne Huang, MD
Albert La Spada, MD
Various (Case-by -case
supervisors)
Dennis Wenger, MD
Maya Pring, MD
Seth Pransky, MD /
Anthony Magit, MD
Robert Newbury, MD
6
NAVIGATING THE HALLS OF RCHSD
(And other pearls of wisdom)
Rady Children’s Layout: Basic Floor Plan
The basic configuration of Children’s is such that there are two floors of wards in the
Rose Pavilion and 3 floors of wards in the Acute Care Pavilion. The Helen Bernardy
Center and the CAPS unit are in the Nelson Pavillion
The second floor of the Rose Pavilion is the Medical floor consisting of 2 main pods
(Medical North and Medical South). Each main pod consists of a general reception
station and three mini pods (A, B, C). The three mini pods are arranged such that they
are in a triangular configuration. The “A” pods have lights in the shape on an upside
down triangle or “A”, the “B” pods have lights in the shape of a bowl or “B” and the “C”
pods have lights in the shape of a ball or circle which takes the shape of a “C”. Each
mini pod has a designated nursing area and a physician work area in the back behind
the mini pod. Try to stick to the physician work areas, or some of the nurses will bark at
you.
The second floor of the hospital connects to the cafeteria, inpatient pharmacy,
pathology, and ultimately MRI. The MRI center is shared between Children’s and Sharp
Hospitals in the “tunnel”.
The third floor consists of a Pediatric ICU (Critical Care North), which is located over
medical North and the Intermediate Care Unit (Critical Care South), which is located
over Medical South. As with the medical floors, the IMU and PICU each have three mini
pods (A, B, C).
The Acute Care Pavilion currently houses 3 floors of patients. The Hematology
Oncology patients are on the second floor. The Rehabilitation and Surgical patients are
on the third floor and the fourth floor is for Medical Behavioral Unit (MBU) and the
Pulmonary patients. The Operating Rooms are on the first floor of the Acute Care
Pavilion.
The Medical Office Building (MOB) is the four-story building between the north parking
structure and the hospital. In the MOB is the outpatient pharmacy, the Children’s
Specialists offices, and rooms where many conferences are held - MOB #113, MOB
#213, MOB 4th floor #s 2 and 3.
Rose Pavilion Layout: The Pods
The Chiefs office (Peds Chief Resident), the Corridor (main) and the Cafeteria are
located in close proximity to the mini pod, Medical North C. The cafeteria is easily
reached from the 2nd floor corridor outside Medical NC There is an easy and short way
to cut from South to North pods without having to access the main corridor. However, it
is very easy to be disoriented in doing so. The pneumonic to avoid such pitfalls is that
7
you SCAN your way from one pod to the next as in S-C connects with A-N, South C
connects with A North.
Food
There are two main places for obtaining food. The first is the main cafeteria, which is
located at the end of the 2nd floor corridor. The other main dining is McDonalds’s which
is located in the South wing of the lobby. There is also a cappuccino coffee stand
behind the Rose Pavilion McDonald’s is open from 8:00 AM to 9:00 PM, Monday
through Sunday.
Scrubs
If you require scrubs and are not participating in a case in the main OR or outpatient
day surgery, please have your staff contact the OR directly to discuss access to scrubs.
Meal Cards//Hospital Special Events
Meal cards may be available for you depending on your agreement with your program
director. Many conferences supply food as well, which can offset food costs.
Hospital special events include fairs, free BBQ lunches, and other sponsored events.
You are welcome to any of these events.
Library Services
The library at RCHSD is located in the hallway near the cafeteria. On the Internet are
various journals, MD consult, and Pub Med. Specialized searches as well as minicourses on literature searches techniques are easily available.
You can send literature requests to [email protected]
For questions, please contact Lisa Naidoo [email protected]
7 AM -3:30 PM Monday through Friday
8
Function of the Hospital
"What we can do for you"
Social work, RT, RN, and Child life specialists for each unit
Discharge planner on unit to help with e.g. equipment needs
Clinical pharmacists available for question/kinetics
Pharmacy interns to round with select teams
RT and RN evaluations together in the bedside chart
Code Blue Team- all should initially respond; if it's your pt. you
should stay to help and learn
Rapid Response Team – available to all clinicians concerned
about deteriorating patients.
Deaths- call the decent affairs officer (x1700) and
attending/Nursing supervisor
Access to library staff, inter- and intranet, PubMed, MD consult
In house “24/7” trauma surgeon, PICU fellow and/or attending,
ED attending(s)
Team leaders on each unit; bedside nurses have personal phones
for facilitating communication
Alpha-paging system allows for messaging housestaff and the
Hospitalist (located at www.chsdpicu.org or on the intranet under
“Web Paging”)
9
Computer Access
The Office of Graduate Medical Education is your point of contact in order to secure your
computer access codes. These codes allow use of the EPIC and Chartmaxx systems, the
intranet for RCHSD, and the Internet. Your annual submission of the GME Paperwork (located
on the web) is the first step in the process.
At least two weeks prior to your rotation start date:
1. Visit http://www.rchsd.org/professionals/gme/forms/index.htm (www.rchsd.org/gme 
click on “forms”)
2. Fill out, sign, and fax paperwork to GME Office @ 858-966-7477.
a. Resident/Fellow GME Form
b. Badge Request Form
c. Confidentiality Form
d. Letter of Verification (if you are rotating from outside San Diego)
3. In addition, provide copies of your
e. Med School Diploma (and ECFMG Certificate, if foreign grad)
f. CV
g. Medical License
h. TAD Orders (Military Residents Only)
NOTE: If you do not submit the GME paperwork prior to your rotation start date,
your first few days of rotation will be complicated by lack of computer access.
A day or two prior to your rotation:
You will get an email from GME Coordinator with your computer access codes, along with who
to contact in case of problems.
The first day of your rotation:
1) Call the GME office if you did not receive the email with your computer access codes.
2) Call Health Information to get your Dictation Code (x5905)
Access Time-out:
Your computer access codes will automatically time out after periods
of non-use. If you have multiple rotations at Children’s throughout the academic year, it is
recommended that you touch base with the GME Office prior to your arrival to verify your
access.
To “hit the ground running” on your first
day, you MUST submit the GME
paperwork at least 2 weeks prior to your
start date.
***It is impossible to “rush” the granting of computer access codes***
10
RCHSD Identification Badge/Parking Access
All trainees must wear a RCHSD Badge while on RCHSD’s Campus. The GME Office
will authorize your ID badge upon receipt of your completed GME Paperwork. The
information you include on your Badge Request Form will be used to create your badge
and determine your access to the parking lots/hospital doors.
When you arrive for your rotation, your department contact will either have your badge
with them or direct you to the badging office to retrieve it.
 The badging office is located In Bldg 12, Occupational Health and Safety. See map on pg. 4.
PICTURES: you are expected to wear your picture ID from your sponsoring
institution in conjunction with your RCHSD badge. Your RCHSD badge will NOT have a
picture.
PARKING: Your proximity (access) card will be given to you by the division through
which you are rotating. You must visit your rotation’s administrative coordinator to
retrieve your proximity card.
As a resident or fellow, you have access to park in either parking structure, at the
entrances marked “Employee.” Parking is free at this hospital.
***On your first day, park in VISITOR parking.*** The division through which you are
rotation will validate your first-day parking.
DOOR ACCESS: Access to some units in the hospital requires an active proximity
card (NICU, OR, ED, IMU, CAPS). These units are restricted to necessary personnel
only, so your rotation assignment will determine your ability to open these doors. If you
find you do not have access to a door that is required for your rotation, please do not
hesitate to call the GME office.
11
Emergency Codes
(Also included with your RCHSD ID Badge):
CODE BLUE: Medical Emergency
CODE RED: Fire
CODE PINK: Infant Abduction
CODE PURPLE: Child Abduction
CODE YELLOW: Bomb Threat
CODE GREY: Combative Person
CODE SILVER: Person with Weapon or Hostage Situation
CODE ORANGE: Hazardous Material Spill/Release
CODE GREEN: Missing High Risk Patient
CODE EXTERNAL: External Emergency (i.e. Multi-car crash)
CODE INTERNAL: Internal Emergency
If you have an emergency, call x5555.
IN CASE OF FIRE:
 Rescue Patients & Staff
 Activate Alarm, call x5555
 Contain by Closing Door
 Extinguish or Evacuate
 EXTINGUISHERS
Pull the Pin
Aim the hose at base of fire
Squeeze handle gently
Spray base side to side
 EVACUATION
Horizontal: Move from room to corridor, from corridor
through fire door to area of refuge
Vertical: Do the above, use stairwell; Assist injured to
evacuate or wait in stairwell for firemen; Go to designated
waiting area
12
JCAHO Safety Q&A
JCAHO (Joint Commission for Accreditation of Hospital Organizations) mandates all
hospital education about safety issues. Please keep this in your notebook while at
Children's Hospital- San Diego.
1. What would you do in the case of a fire?
RACE: Rescue, Activate, Confine, Extinguish. Call 5555 and report the fire location.
Refer to your badge!!!
2. Can food products, specimens or medications be in the same storage area?
NO
3. How do you shut off the oxygen to unit or wing you are on?
On every wing there is an 02 shutoff valve, near the outer stairs.
4. What is you policy for violence in the work place?
Security Department has a program. It is part of orientation.
5. Describe your emergency preparation program. How do you know what to do if your
power fails?
RCHSD has a Task Force and everyone on the Task Force has assigned duties.
Emergency Department is the command center. Physician Leaders are Buzz Kaufman
and Herb Kimmons. Interns and student report to your senior residents. Residents help
on floors to triage, move patients. IF YOU HAVE QUESTIONS, ASK THE
HOSPITALISTS ON SERVICE. Power failure is part of the emergency preparedness
plan. Assure life support areas have adequate staff. Generator will provide power. Red
plugs should be used only for emergent drips/meds.
6. Why would there be capped needles in the needle box?
If used the syringe only or if used single-handed re-capping.
7. How do you dispose of biohazardous waste?
Biohazardous waste = body parts and fluids. Use red bags.
8. What do you do if you get injured on the job?
All trainees (students, residents, and fellows) should notify RCHSD occupational health
(x5865) and their attending of record.
i. UCSD trainees should notify UCSD Occupational Health (619-471-9210). A nurse
practitioner is also available to answer questions at pager 619-290-1447. If the exposure
happens after hours and there is concern that post exposure prophylaxis is needed, go
to the UCSD emergency department.
ii. All trainees funded by Children’s Specialists of San Diego should access the
CSSD website http://www.childrensspecialists.com/ to log in and click on “Safety and
Work Related Injuries” or call 309-6297 for information on what to do. These CSSD
trainees should have an orange badge card, available from CSSD Human Resources.
US Healthworks is the occupational medicine provider for CSSD. There are multiple
sites around the County that can be reached.
iii.All other trainees should contact their institution’s office of Occupational Health.
9. What is PDSA?
PDSA = Plan, Do, Study, Act. It is our performance improvement plan.
10. What is the hospital’s mission?
To restore, sustain and enhance the health and developmental potential of children
through excellence in care, education, research and advocacy.
11. What is a MSDS? Where can you find information on Hazardous Materials?
MSDS = Material Safety Data Sheet. Available in yellow notebooks on the units. Tells
you how to clean up hazardous spills
13
Verbal Orders Can Be Dangerous
Physician Order Entry Is Always
Preferred!
Verbal or Telephone Orders are to be discouraged:
Verbal or telephone orders are ONLY ACCEPTABLE if …
 The physician does not have access to EPIC and outside the
hospital
 Or is in the facility but is NOT available to the patient in a
reasonable time
Verbal or telephone orders are NOT ACCEPTABLE if …
 The physician is present, and available to the patient.
 As a matter of convenience.
 To order chemotherapy.
 To designate a patient’s status as “Do Not Resuscitate”
When a Verbal Order is Necessary Staff Must Provide
MD With the Following:
 Patient’s full name
 Medical record number
 Weight, allergies
 List of current medications
After hearing and writing a verbal or telephone order
in the patient’s medical record, the staff member
MUST verify their understanding by: “readingback” the complete order to the practitioner and
receive verbal confirmation of correct order.
Enter it… Read it Back…
14
Abbreviations Are DANGEROUS!
The following abbreviations and expressions may not be used in any document at
RCHSD:

Best Practice: DO NOT abbreviate the name of a medication.
Do Not Use Type Out
Potential Error
Read as 0 for 10 X
U
Units
overdose
IU
International Units
Read as IV or 10
q.d.
Every Day or Daily
Read as qid
q.o.d.
Every Other Day
Read as qid
q.n.
Every Night
Read as qh for hourly
1 (No Trailing Zeroes) Read as 10 or 5 for 10 X
X.0 or .X
Such as
0.5 (Use a Leading Zero) overdose
1.0 or .5
Lead don’t follow
MS, MSO4
Morphine Sulfate
Read as Magnesium
MgSO4
Magnesium Sulfate
Read as Morphine
BT
Bedtime
Read as BID
Apothecary
Use metric dose in mg or
Obsolete usage
measure such ml
as dr or gr
HS
Half Strength or Bedtime
Confusion of meanings
per os
By mouth
OS read as left eye
ss
One-Half or Sliding Scale
Confusion of meanings
T.I.W.
Three Times A Week
TID or twice weekly

Do NOT use the following expressions:
Continue Medications
1.
Resume Medications
2.
Renew Medication
3.
Take Medications From Home

Spell Out What You Want!
15
National Patient Safety Goals
All JCAHO accredited health care organizations are surveyed for implementation of the
following Requirements – or acceptable alternatives – as appropriate to the services the
organization provides. Alternatives must be at least as effective as the published Requirements
in achieving the goals. Failure by an organization to implement any of the applicable
Requirements (or an acceptable alternative) for a National Patient Safety Goal will result in a
special Requirement for Improvement for that goal. Organizations are made aware of the
requirements to meet the NPSG-related Requirements in the Accreditation Participation
Requirements in the accreditation manual.
1) Improve the accuracy of patient identification.
a. Use at least two patient identifiers (neither to be the patient’s room number)
whenever taking blood samples or administering medications or blood products
[Scored at Standard PC.5.10, EP#4].
b. Prior to the start of any surgical or invasive procedure, conduct a final verification
process, such as a “time out” to confirm the correct patient, procedure and site,
using active – not passive – communication techniques [Scored at Standard
PC013.20, EP#9].
2) Improve the effectiveness of communication among caregivers.
a. Implement a process for taking verbal or telephone orders or critical test results
that require a verification “read back” of the completed order or test result by the
person receiving the order or test result [scored at Standard IM.6.50, EP #4].
b. Standardize the abbreviations, acronyms and symbols used throughout the
organization, including a list of abbreviations, acronyms and symbols not to use
[Scored at Standard IM.3.10, EP#2].
3) Improve the safety of using high-alert medications.
a. Remove concentrated electrolytes (including, but not limed to, potassium
chloride, potassium phosphate, sodium chloride >0.9%) from patient care units
[Scored at Standard MM.2.20, EP #9].
b. Standardize and limit the number of drug concentrations available in the
organization [Scored at Standard MM.2.20, EP #8].
4) Eliminate wrong-site, wrong-patient, wrong-procedure surgery.
a. Create and use a preoperative verification process, such as a checklist, to
confirm that appropriate documents (e.g., medical records, imaging studies) are
available.
b. Implement a process to mark the surgical site and involve the patient in the
marking process.
5) Improve the safety of using infusion pumps.
a. Ensure free-flow protection on all general-use and PCA (patient-controlled
analgesia) intravenous infusion pumps used in the organization.
6) Improve the effectiveness of clinical alarm systems.
a. Implement regular preventive mai9ntenance and testing of alarm systems.
b. Assure that alarms are activated with appropriate settings and are sufficiently
audible with respect to distances and competing noise within the unit.
7) Reduce the risk of health care-acquired infections.
a. Comply with current CDC hand hygiene guidelines.
b. Manage as sentinel events all identified cases of unanticipated death or major
permanent loss of function associated with a health care-acquainted infection.
16
Six Core Competencies
The important role GME Trainees play in hospital operations is aligned with pediatric general
competencies – the Graduate Medical Education training principles of the Accreditation Council on
Graduate Medical Education (ACGME). The ACGME is responsible for accreditation of post-medical
degree training programs within the United States. Accreditation is accomplished through a peer review
process and based on established standards and guidelines. Additionally, the evaluation standards to
which you became accustomed during your residency will continue to serve as guidelines for evaluation
of your performance as a medical staff member. Also of note, the American Board of Pediatrics uses
these competencies in the re-certification process.
So… The following Six Core Competencies are central throughout your entire
professional career.
1. Patient Care that is compassionate, appropriate, and effective for the treatment of
health problems and the promotion of health
2. Medical Knowledge about established and evolving biomedical, clinical, and
cognate (e.g. epidemiological and social-behavioral) sciences and the application of
this knowledge to patient care
3. Practice-Based Learning and Improvement that involves investigation and
evaluation of their own patient care, appraisal and assimilation of scientific evidence,
and improvements in patient care
4. Interpersonal and Communication Skills that result in effective information
exchange and teaming with patients, their families, and other health professionals
5. Professionalism, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population
6. Systems-Based Practice, as manifested by actions that demonstrate an awareness
of and responsiveness to the larger context and system of health care and the ability
to effectively call on system resources to provide care that is of optimal value1
1
http://www.acgme.org/outcome/comp/compMin.asp
17
Working in the
Hospital
18
Admission Criteria Recommendations
Bed Resource Management Sub-Committee
This Admission Criteria is designed for the most effective and efficient utilization of
resources while providing an environment that supports an appropriate level of care for
children. Consideration will be given to aggregation of patients with similar diagnosis,
continuity of care, and minimizing patient transfers.
Staffing on these units will be determined on a shift-to-shift basis and adjusted
based on patient acuity and clinical status. This adjustment may include
changing patient assignments, increasing staffing ration and/or transfer to a
higher level of care.
Exceptions to these criteria should be made at the discretion of the patient care team.
In all cases, decisions about patient placement will be made based on the following
values: Patient safety, staff safety, and Family Centered Care.
Medical Rose and Medical West (60 beds), 3 EAST and 4 EAST* (84
beds), Admission Criteria:
In general, patients admitted to these Units will include, but not limited to, those
with a predicted short length of stay or requiring comprehensive rehabilitation therapy
(see Rehabilitation patient criteria below). These would include routine pre- and postoperative patients, Trauma patients, and those patients with a medical diagnosis of an
acute or chronic illness, meeting the following criteria.
1. Respiratory Status
Patients on home apnea monitoring, or those requiring frequent oxygen saturation
checks, may be admitted to these units if the following criteria are met:
a. Patient maintains a patent airway without intervention.
b. Patient may require frequent assessments, short term, with expected
improvement.
c. Patients with a tracheostomy may be admitted to these units if they have
the ability to use the call light and to effectively clear their own secretions.
2 EAST (Hematology/Oncology Unit) Admission Criteria:
Inpatient and Outpatient Services, 38 inpatient rooms, infusion and procedure room
All patients with a Hematology and/or Oncology diagnosis, including stable post
operative patients, will be admitted to the Hem/Onc Unit, with the following exceptions:
a. Patients with a communicable illness (i.e. Chicken pox, Measles) may be
admitted to another unit per care team discretion.
b. Patients who require intervention to maintain a patent airway; complex
medications to maintain cardiac output and/or intravascular volume
support; complex telemetry; invasive monitoring; or those with *unstable
seizures, will be admitted to the Critical Care Unit.
* See Critical Care Admission Criteria #3 e. -- Unstable seizure
19
Critical Care Admission Criteria:
54 beds including 24 specifically designed to provide care to most critically ill child.
In general, patients admitted to the Critical Care Unit meet the following criteria:
1.
Respiratory Status
a. Any patient requiring mechanical ventilation via ETT or Tracheostomy.
b. Any patient requiring continuous monitoring and/or frequent assessments with
potential for deterioration in status.
c. Any patient requiring frequent interventions to maintain a patent airway, which
if not performed, intubation would result.
2.
Hemodynamic Status
a. Any patient unable to maintain adequate cardiac output without vasoactive
medications and/or on-going intravascular volume support.
b. Any patient requiring continuous ECG monitoring including arrhythmia
recognition. Any cardiac rhythm requiring medical intervention.
c. Any patient requiring frequent assessments, interventions, or at high risk of
deterioration in status.
d. Any patient requiring invasive monitoring including central venous pressure,
arterial blood pressure, pulmonary artery pressure, cardiac output calculation
and recordings.
3.
Neurological Status
a. Any patient with acute changes in neurological assessment.
b. Any patient requiring continuous monitoring or frequent assessments of
neurological status with high risk of deterioration.
c. Any patient requiring intracranial pressure monitoring.
d. Any patient requiring acute interventions or prophylactic therapy for increased
intracranial pressure.
e. Any patient with an unstable seizure disorder (i.e. new onset with associated
acute encephalopathy, recent history of status epilepticus, acute exacerbation
of seizures with associated loss of consciousness, or new onset convulsive
status epilepticus or suspected non-convulsive status epilepticus) should be
admitted to the Critical Care Unit.
4.
Renal and Hepatic Status
a. Any patient requiring intervention for acute renal failure (i.e. dialysis).
b. Any patient requiring frequent (i.e. every 6 hours), acute, IV diuretic therapy.
c. Any patient with signs of acute hepatic failure (i.e. changes in neuro-status, or
any suspected gastrointestinal bleeding).
Neonatal Critical Care Admission Criteria:49 beds designed to accommodate
infants requiring Level II and/or Level III care.
In general any infant under the age of 4 months may be admitted to this Unit with the
following exception:
Any infant from home suspected to have a communicable illness with upper
respiratory symptoms, diarrhea, or rash.
20
SBAR(N) Technique
SBAR(N) is an acronym used to facilitate communication between health care team
members regarding a patient’s condition. This memory aid helps to frame conversations
-- especially critical ones -- requiring a clinician’s immediate attention and action. Using
this technique to communicate with other members of the patient care team helps to
foster a culture of patient safety, and its use is encouraged at RCHSD. At RCHSD, we
have modified the standard “Situation-Background-Action-Recommendation” for
trainees to better fit roles and actions taken:
Situation
Background
Assessment
Action, Re-Check, Notify
Conversation examples:
Situation:
“I am calling about [patient name]. The problem I am calling about is [weakness /
altered mental status / etc]”
Background:
“The patient’s significant PMH is [CV / Resp / Renal / etc]. The patient’s significant
recent hx is [poor urine output / inc O2 need / etc].”
Assessment:
“I think the patient has [state the dx]”
- OR “I am unsure but am concerned with [abn lab / exam change / etc].”
Action, Re-Check & Notify
“I want to [state action needed, i.e.: transfer to critical care / have you or consultant to
see pt / start med / etc].”
“I will recheck in: [state time frame].”
“I will notify you of status in: [state time frame].”
“I will notify you of status if: [state change].”
21
Vascular Access Device Selection SBAR
Situation:
Severe infiltration injuries are recognized to be preventable hospital acquired conditions. Their
prevention requires a multidisciplinary approach in conjunction with the consistent use of
evidence based best practices.
Background:
Vein preservation, prevention of infiltration and extravasation injuries, and ensuring reliable
venous access is essential for hospitalized children. Selecting the best device to meet the child’s
IV therapy needs is critical in achieving the best patient outcomes possible.
Choose a Peripheral IV if:
The anticipated length of IV therapy is less than 5 days
No administration of vesicant medications is planned
The patient has at least three good PIV sites
The patient has no extremity limitations such as a cast or surgical site
Choose a PICC if:
The anticipated length of IV therapy is greater than 5 days
There are limited IV access sites or frequent infiltrations/IV restarts/frequent lab draws
Vesicant administration is planned e.g. TPN
Home infusion therapy
(may be used in critical care, for CVP monitoring, and up to a year or more as needed.
Vessel size in the extremity limits the size of PICC that can be placed)
Choose a centrally placed central venous acute care catheter (CVC) if:
The patient in the critical care or surgical setting needs multiple lumen large bore access
The anticipated length of use is less than 7 days
The patient needs emergent central access
Placement of a PICC is contraindicated or unsuccessful
Choose a Surgically implanted catheter or port if:
The patient requires long term IV access greater than 6 weeks
Patients have no other central access options
Assessment
Placement of a central venous access device, such as a PICC, early in the hospital stay provides
reliable IV access, reduces delays in therapy, reduces venipuncture, preserves vessels, reduces
peripheral IV extravasation injuries, improves the patient’s hospital experience, and is cost
effective.
The infection rate for Pediatric PICCs at RCHSD, FY 2013, was 0.28/1000 patient days.
Physicians are a critical member of the IV infiltration prevention team. IV infiltration prevention
begins with the appropriate selection of a vascular access device (algorithm on next page)
22
Recommendation:
Ensure provider familiarity regarding vascular access device selection as a key factor in
promoting best practices and optimizing patient outcomes.
23
The Clinical Social Worker at RCHSD
All staff Clinical Social Workers (CSW) at RCHSD have a Masters Degree in Social
Work (MSW), and most staff members have received their license (LCSW). Each
semester we do have CSW Interns (working with an LCSW supervisor) who are
completing their MSW at San Diego State University.
I. Psychosocial Clinical Services Available For Patients, Families, Staff:
1. Intervene with individual, family, and community services (CPS, Law
Enforcement, Regional Center, etc.).
2. Coordinate and case manage (CPS cases, Psychiatric Cases, Chronic
Patients, Risk Management Cases).Care Coordination services also provided
in Ambulatory Care setting.
3. Access hospital and community resources.
4. Enhance family coping skills.
5. Educate regarding safety, health system and available resources.
6. Provide individual and family counseling (Crisis Intervention, Supportive
Intervention, Problem Solving, Grief Counseling, etc.).
7. Facilitate support groups.
8. Advocate for patients and families.
9. Provide staff with psychosocial support.
II. When to Refer:
1. Child Protective Concerns:
suspected child abuse, suspected neglect/safety issues, lack of parenting skills
creating high risk concerns, ingestions with protective issues, near drowning,
Failure To Thrive with no organic basis, active CPS case with problem areas,
medical compliance issues, lacks adequate resources to meet pt. needs post
discharge.
2. Issues Related to Medical Diagnosis:
-potential death, discussion of Code Status, Bioethical concerns, quality of life
issues, chronic medical problem with acute complication, anticipated complex
discharge, sudden severe life threatening illness, difficulty with adjustment to
diagnosis, poor coping, case mgmt for chronically ill children (outpatient staff).
3. Social Situation Concerns:
-teen parent with limited or no resources, lack of support system, parent/infant
bonding concerns, notable family dysfunction interfering with patient care,
language or cultural barriers that impact medical care,
food/lodging/transportation needs, need for community resources, custody
issues affecting disposition.
4. Safety Concerns:
Suspected Domestic Violence, Temporary Restraining Orders, Families
upset/dissatisfied with care, destructive behavior (suicidal threats/attempts,
drug overdoses, violent family situations).
III. How to Refer:
For inpatient, referrals can be order as a consult in Epic; you can identify reason for
referral in Epic or/and progress notes. During "working hours", you can also give a
verbal referral to that unit's CSW. For outpatient, access assigned CSW for that clinic.
There is 24 hour CSW coverage; if "after hours", access this person through the
Nursing Supervisor.
24
Surgical Services
25
Surgical Services Department Orientation
Please have all required forms and supporting documentation turned into The Graduate
Medical Education Department Coordinator, Marian Toscano, prior to your clinical start in the
Operating Rooms, Warren Family Surgical Center (WFSC) and Outpatient Procedure Center
(OPC).
Our Department Philosophy is to be Kind, Caring and Compassionate with our Patients and
with One Another.
It’s truly “All About the Children”
1. Patient Safety is our #1 Consideration
There’s a great depth of knowledge to draw upon from our Attending Staff members,
Senior Residents and Fellows. Please ask questions if you don’t know or aren’t
clear about something.
We also have a seasoned staff of nurses and surgical technicians with extensive
experience. They are very willing to help you adapt to the department; maximizing
the safety and care of our patients. They will speak up if they have concerns.
Our Service Coordinators and Lead Surgical Technicians are considered our “Staff
Clinical Experts” and are there to support you. A procedure card/pick list exists for
most procedures and you are welcome to review them.
Fellows and Senior Residents: An attempt is made with the day shift daily staffing to
provide each service with their subspecialty team members. The downside occurs
when they are off and you are assigned to work with staff you’re not as familiar with.
(Please keep in mind they are also subspecialty “specialists” just from other
services.) Although it’s always a good idea to glance across the back table to look
for the presence of key equipment/instruments at the beginning of the case, please
make an effort to do so with staff you’re not familiar with. Help with tourniquet
placement and positioning is always appreciated.
26
2. Surgical Services Department Employees
It requires a huge team effort to meet the needs of our surgical patients:
Managers and Clinical Supervisors
Charge Nurses, Services Coordinators, Clinical Educators
Pre-Op RNs, Operating Room RNs, PACU RNs
Business Associates, Schedulers, Systems Analyst
Surgical Technicians (Specialty Lead Techs)
Anesthesia Technicians, Surgical Services Aides
Sterile Processing Technicians
Volunteers
3. Surgical Services Resource People
Title
Vice President & Director
for RCSSD
Director
Admin. Associate
Manager OR
Manager Pre-Op/PACU
Manager SPD
Supervisor PACU
Supervisor PACU
Supervisor OR
Supervisor OR
Supervisor SPD
Chief of Perfusionist
Management Person
Pager
E-Mail Address
Nicholas Holmes, MD
494-2983
[email protected]
Bruce Grendell, 5878
Cheryl Sosa, 5228
Mary Miller, 5376
Linda Sparks, 7806
Matt Parker, 3944
Shay Glevy, 4709
Toneya Jackson, 4770
Katheryn Kribbs, 6108
Deirdre Green, 4780
Danny Davis, 5612
John Allardyce
494-0377
493-7446
494-0764
493-6136
493-3046
494-9423
494-8571
494-1457
4944227
494-1648
494-9520
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Title
Service Coordinator
Cardiac
Endoscopy
ENT
Eye
Gloria Bagtas
Dorie Day
493-1226
493-3343
TBA
TBA
Alicia (Alice) Salinas
Leo Frutiz (interim Judy
Cross)
Dawn Overson
Anne Dizon
Kim Porter
Dawn Overson
Shari Mulligan
Courtney Horwat
K. Stuart (Stu) Mayo
Randy Nelson
Frances Ohira
Clinical Educators
Regina Faucette
Rebecca Reynolds, 8142
494-1099
[email protected]
494-7643
[email protected]
494-2666
493-2712
494-0118
494-2666
494-0638
494-7839
494-0329
493-8971
494-6573
Pager
494-5571
494-9301
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
E-Mail Address
[email protected]
[email protected]
Dental
Dermatology
General
GU
Laser Safety Officer
Neuro
Ortho
Plastic-Craniofacial
Spine
Sports Medicine
Education
OR
PACU
Pager
E-Mail Address
[email protected]
[email protected]
TBA
27
4. Important Surgical Services Phone Numbers
Main Hospital #858-576-1700 & then can access any extension
24/7 Operating Room #858-966-5856
Location/Person
Phone #
Scheduling
After Hours Scheduling
ACP Registration
After Hours Registration
5857
5856
858-966-4065
X5427
ACP Holding Room
ACP OR Charge
ACP PACU Charge
ACP Pre- Op
OPC Pre-Op
OPC OR Charge
OPC PACU Charge
3574
5184
5506
6392
5987
2366
5506
ACP Anesth Office
ACP Anesth Workroom
OCP Anesth Workroom
5580
2558
2270
Location
Anesth #
RN #
2376
2375
2374
2373
2372
2369
2368
2366
2272
2270
2269
2268
2267
2266
2265
2263
2581
2582
2583
2584
2585
2586
2587
2588
2589
2590
2591
2592
2593
2594
2595
4076
OR 1
OR 2
OR 3
OR 4
OR 5
OR 6
OR 7
OR 8
OR 9
OR 10
OR 11
OR 12
OR 13
OR 14
OR 15
OR 16
5. First Day Arrival and Check-In to the Operating Rooms
Routine start times are 0730, first patient in the room Monday through Thursday, every other
Friday 0830.
If you need any of the following first day services, please communicate your arrival date in
advance so that we are available for the following:
0645 to 0700 Meet with Cheryl Sosa, Administrative Associate for Director Bruce Grendell.
May reach Cheryl at hospital extension 5228 or e-mail at [email protected]
Facilitate any problems with the required paperwork for GME.
Provide Locker Assignment and Scrub Clothes Location
0800 If you would like a tour, ask for a Clinical Educators: Jocelyn (8717) or in their absence
the charge nurse will assist you.
Department Specific Tour Including OSHA Safety Items
WFSC and OPC Status Board Locations, Web Paging & Motherboard Usage and
Surgery Schedule Location.
6. Requesting/Scheduling Surgical Procedures
28
Scheduling during Monday-Friday Business Hours 0830-1630 (24 hours in advance)
Contact the Surgery Scheduling office at 858-966-5857, FAX at 858-966-7437.
FAX or verbally use the information on the “Surgery Scheduling Sheet” and either a
“Patient Demographics and Insurance Information” or face sheet from a patient
coming from another hospital.
Remember to request any special equipment or films needed, special patient needs:
latex allergy, IEDs such as pacemakers, transmission-based precautions, explant
hardware, etc.
ALWAYS indicate Right-Left-Bilateral or Levels (e.g. Cervical, Thoracic, Lumbar,
Sacral)
Clearly identify if the patient is a Sharp Share (SMBH) patient or from another
hospital and also clearly state the post-procedure plan: admitting here or returning to
Sharp Mary Birch.
An elective case on Saturday is limited to less than 2 hours in duration.
Scheduling the Day of Surgery or after Business Hours
Contact the Control Desk in the ACP at 858-966-5856 to schedule procedures. After
the phone call is made, an order must be placed in the EPIC system. The surgery
will not be scheduled until the order is placed.
You will be asked to supply the following information: Patient’s name, DOB, NPO
status, surgery date, surgeon, assistant, diagnosis, planned procedure with site/side,
amount of surgery time anticipated, intubation status, special equipment or
instrumentation including x-ray/c-arm, laser, microscope, special patient needs or
concerns, patient’s planned location post-op.
7. Patient Registration Process (if not already registered, e.g. patient
coming from another hospital or straight from clinic)
Registration during Monday-Friday Business Hours 0630-1700
Contact registration at 858-966-4065 to begin the registration process. May phone
in the information found on either the “Patient Demographics and Insurance
Information” or face sheet from another hospital. Outpatients must keep the exact
same name as that from the sending hospital.
May follow-up the initial phone call with a FAX.
The parent/legal guardian will need to complete the process with signatures.
Registration after Business Hours
Contact the Access Representative, pager number 858-494-5427 to begin the
registration process. Phone in the information found on either the “Patient
Demographics and Insurance Information” or face sheet from patient coming from
another hospital.
May follow-up the initial phone call with a FAX.
The parent/legal guardian will need to complete the process with signatures.
29
8. Accessing Forms for Scheduling/Registration from the Internet/Intranet
From Children’s Intranet
Click on Clinical Resources
Scroll down (on the right side) and click on Clinical Forms and will find:
“Patient Demographics and Insurance Information Forms”
“Surgery Scheduling Sheet”
“Surgical History & Physical Form”
From Internet Address: www.rchsd.org
Hover over Departments, then click Directory on top of the page
Scroll down and click on Surgical Services
Click onto forms for:
“Authorizations & Consents”
“Surgery Scheduling Sheet”
“Patient Education & Questionnaires”
9. Universal Protocol (Please read Clinical Care Manual Policy PM 2-17)
Section 3.2.10: “All residents and non-medical staff privileged fellows performing
surgical procedures or invasive procedures must have direct supervision from an
attending in their specialty field. A resident/non-privileged fellow may not start a
case without the supervising attending present. The resident/non-privileged fellow
may identify the patient and mark the surgical site, and the patient may be taken
back to the operating room. The attending surgeon must confirm patient
identification and surgical site prior to anesthetic induction and draping. The
attending physician must be immediately available during anesthetic induction. The
attending physician is to be present at the start of the case (skin incision, or
endoscope/trochar/cardiac catheter biopsy needle insertion etc.). The attending
surgeon must also be present for the majority of the case, including all key and
critical portions of the procedure.”
Time Outs are extremely important and the attending MUST be present. We must
always be 100% sure about the intended site and side. Elements actively confirmed
by the whole team:
o Correct Patient
o Correct Procedure with site/side marked when appropriate
o Correct Position
o Imaging studies available and right/left orientation confirm by surgeon (x 2
best)
o Implants, special equipment and medications available
o Blood products available as ordered/needed
30
10. Preventing Surgical Site Infections
CDC Wound Classification Utilized:
o 1-Clean
o 2-Clean-Contaminated
o 3-Contaminated
o 4-Infected Dirty
Statistics are collected on all cases with emphasis on data collection for:
o Spinal Procedures
o Cardiac Procedures
o VP Shunts (Observers Restricted to None)
Pre-Op Antibiotics – If applicable, please do your part to make sure they are ordered
and given at the appropriate time, including redosing.
Surgical Hand Prep Solutions: Iodine and CHG products available at all the scrub
sinks for a 2-3 minute scrub. Waterless Avagard is also available, but you must still
scrub for I minute and clean out your nails prior to first day’s use of the product. If
you are not familiar with Avagard’s 3 squirt protocol please ask one of the Clinical
Educators for a demonstration.
Surgical Attire (SSG 7-06) Summarized
o Hospital scrubs are provided, but personal scrubs are acceptable, clean set
daily.
o No cover gown needed, but if you contaminate during rounds with someone
on isolation precautions, please remember to change. Masks are required in
the OR whenever there is a sterile field open or the possibility of fluid splash
injury. Masks are not required in our Center Core area. Your hair must be
covered in the semi-restricted and restricted areas (inside the red line).
o Double gloving is highly recommended.
Traffic Patterns (SSG 7-07) Summarized
o The traditional unrestricted, semi-restricted and restricted areas are used.
NO FOOD or DRINK except in the unrestricted areas such as the lounge,
locker rooms and public hallways. The only exception is water bottles in
private offices and fruit juices for hypoglycemic incidents.
o When gowned and gloved you must not step into the center core, and should
not step out into the hallway.
o Doors in the operating rooms must be closed except during movement of
personnel and equipment.
o Observers are restricted to 1-2 per room.
o All visitors must be cleared through the Charge Nurse (Not referring to
Fellows, Residents on Surgical Rotations, Medical Students on Surgical
Rotations)
11. X-Ray Flow
We have a digital x-ray system: PACS.
For safety reasons, the OR Staff does NOT help place imaging studies on the
standard viewers. It is best practice to have two physicians confirm the right versus
left of the x-ray orientation.
If applicable, please help return x-rays post operatively to one of the x-ray racks:
o WSS: PACU, Holding Room, Hallway near Locker Rooms
o DSC: On Chart Rack, next to PACU entrance
31
12. Surgical Services Department Safety Items
(See “Preventing Surgical Fires” Handout)
Fire extinguishers in each OR and hallways
Code Button in each OR Room; Fire Pulls near all department exits.
Emergency Flashlights in each OR
Room gas shut off valves outside the double doors of each OR Room (Ask Room
Anesthesiologist first in an Emergency prior to shut-off)
Be familiar with the evacuation routes (all horizontal)
Four eyewash stations in WSS (Dirty Instrument Room, Center Core above each
Steris machine, endoscopy workroom (continuous flush) and one in DSC hallway
near rooms 3 and 4)
Showers in each locker room
In case of injury:
o Inform the charge nurse of the injury and ask for help in completing an
occurrence report with the online intranet Safety Reporting system.
o Seek care as needed. Occupational Health can assist with getting a patient
tested for HIV, hepatitis etc. if you suffered a sharps injury.
13. Preventing Foreign Body Retention
Intraoperative Count Policy SSG 9-19 Basics Summarized:
Your cooperation is greatly desired. Counts are time-consuming but must be
completed.
Performed by the RN Circulator and Scrub RN/Surgical Tech audibly, in a specific
order, with the results announced for the physicians.
Anyone can request a sponge or needle count at any time, if concerned.
Reminder: If you pull out a lap tape or raytex that was packed into a wound at any
time during the closing counts, & don’t hear an audible re-count, please request one.
Required Counts:
Sharps are counted on all cases.
Sponges are counted on all cases except procedures such as circumcisions and eye
cases.
Instruments counts, only when a major body cavity is involved, (abdominal, thoracic,
retroperitoneal) for patients weighing greater than 10 kilograms.
Unresolved Count Protocol:
The attending will be notified
A thorough search will be made and if not found an x-ray should be taken before the
patient leaves the room, unless:
o Item is too large to have been lost in wound.
o Item is too small to be seen on x-ray, e.g. 7-0 needle or smaller
o Patient too unstable
Occurrence report must be completed by the RN circulator, including x-ray
info/declined
14. Preventing Injuries
To prevent splash Injuries protective eyewear is required by OSHA
Please take care with the use of aseptos, pulse irrigator, syringes with loose
needles, etc.
32
Fall prevention – please be aware of wet floors near the scrub sinks
Sharps injury prevention (policy SSG 8-05) basics:
o Double gloving highly recommended
o General Principles – Treat sharps as if your life depends upon it. Take great
care to avoid sticking anyone!
o NEVER hand a loose suture (with needle) back to anyone. ALWAYS place it
back on the needle driver.
o Use a “Neutral Zone” when possible and practical. Avoid handing
contaminated sharps back to the scrub person. Instead lay the item down in
a prearranged spot (neutral zone).
o Avoid taking items directly from the scrub person’s mayo stand unless
absolutely necessary (e.g. they stepped away or they are holding retractors
with both hands).
o If injured, take the time to wash with soap and water immediately
15. Instrument Care
Instruments are very expensive and should be used for the designed purpose only,
e.g. Do not leverage bone with delicate instruments.
A request for outside instruments needs a minimum of 24 business hours.
Any instrument you wish to borrow, must be checked out through the Sterile
Processing Department (SPD) at 5612 and returned.
You should not bring in outside instrumentation, but if you must, the procedure is to
take the items to the Sterile Processing Department (next to the Cafeteria) and
check the items in per P & P SSG 11-23.
o There is a minimum of 90 minutes processing time required.
o You will need to stay for the initial inventory of all items, or you will be
responsible for any loss.
o At the end of the case, you must help identify the items and any missing items
will be addressed immediately. The items will be decontaminated in the
WSS/DSC SPD dirty instrument areas and you will be responsible for picking
them up and returning them.
16. PACU
Please assess and address the patient’s pain needs prior to leaving the PACU.
When placing an Epic order, please include your pager number, so that we can
contact you if we need clarification. Use hospital-approved abbreviations only.
When writing a STAT order, also verbalize it, to draw attention to it.
Prescriptions for narcotic may only be written on a Security prescription form if the
patient uses an outside pharmacy (State Law).
Post-Op orders must be placed in Epic. “Resume pre-op orders” is NOT allowed.
All medications, including home medications the child is to receive, must be
reconciled in Epic. “Resume home medications” is not allowed.
Again, welcome. Our hope is that you have a positive learning experience. You can count on
Surgical Services Management Team and Staff support. Please feel free to ask questions.
We’re here to help you!
~Surgical Services Operations Council and Staff
33
What You Can Do in the O.R.
TRAINEE TYPE
Fellow without Privileges
AUTHORIZED BY
GME Department
OBSERVER CONSENT
NO
Resident UCSD/Navy
GME Department
NO
RCHSD & Program ID
Sponsoring Physician
House-Wide
Visitor/Observation Full
Packet
YES
Visitor Sticker
GME Department
NO
But Needs to be
Processed through
GME
RCHSD & Program ID
Observe only, non scrubbed
until processed through GME.
Then may scrub in & may assist
as directed by attending
surgeon. Attending must be
present for beginning and all
key and critical elements.
Medical
Student/Observation
Data Packet
NO
Affiliated School
RCHSD & Program ID
May scrub in, under direct
supervision of surgeon.
Historically retracts & cuts
suture only, at most.
House-Wide
Visitor/Observation Full
Packet
YES
No Affiliation
Agreement
Visitor Sticker
Resident NOT UCSD/Navy
1-2 days maximum as a visitor
Resident NOT UCSD/Navy
>2 days needs to be processed through
GME
Medical Student UCSD
Medical Student NOT UCSD
1-2 days maximum as a visitor
ID BADGE
RCHSD
PRIVILEGE
May scrub in & may assist as
directed by attending surgeon.
Attending must be present for
beginning and all key and
critical elements.
May scrub in & may assist as
directed by attending surgeon.
Attending must be present for
beginning and all key and
critical elements.
Observe only, non scrubbed
Observe only, non scrubbed
34
Preventing Surgical Fires
Fire Triangle: Fuel, Oxidizer, Ignition/Heat Source
1. Fuel Sources in the OR
Linens: drapes, gowns, blankets, paper goods
Chemicals, solutions & ointments: prepping solutions with alcohol,
degreasers, tinctures, petroleum based products, methylmethacrylate
collodian, suture pack liquid, acetone
Plastics and rubber goods: anesthesia circuits, tubing
People and personnel: Lanugo and other hair, GI tract gases, hair sprays,
perfume
NOTE:
 Under the right circumstances, it all burns.
 Alcohol-based preps need a 3-5 minute dry time (Alcohol, Gel Prep,
Exiden-CHG)
2. Oxidizers in the OR
Oxygen
Nitrous Oxide
NOTE:
 Use lowest O2 concentration possible during MAC Cases.
 Touching an endotracheal tube that is supplying O2, with a hot
instrument, ESU or laser can cause great damage and fire.
 Opening a trachea with an ESU can create an airway fire
3. Ignition/Heat Sources in the OR
Electrosurgical units & argon beam coagulators
Lasers
Laparoscopic light cords left on the drapes (not on standby)
Sparks from:
 Defibrillator
 Frayed electrical cords
 Drills & burs
 Embers from cautery
 Fiberoptic light tips or fibers
 Static discharge
35
Fire Prevention Measures
NEVER, start a procedure that has an ignition source present without water or
saline on the back table, especially when a laser or ESU is used!
Allow alcohol-based prep solutions to dry prior to draping (3-5 Minutes)
Keep ESU pencils in holsters when not in use and only the operator of the
ESU or Laser should have access to the foot pedal
Place light cords on standby when not in use and protect the drape from a lit
cord.
Place Laser on standby when not in use, use wet towels or gauze 4 x 4s
around laser treatment area, beware of methane gas, packing the rectum with
a moist gauze if possible
Use a Laser ETT and non-reflective instruments when using the laser in the
airway
Fire Response Plan
Protect the patient. Non-scrubbed person in the room will push the code
button in the room.
Immediately remove burning material from patient (away from exit door) and
smother flames if possible
Be ready to use the fire extinguisher and able to locate the medical gas shut
off
Shut off medical gases 02 and N20 at the machine (Medical gas valves shut
off only as directed by the Anesthesiologist)
Disconnect patient from anesthesia machine and manually ventilate
Evaluate patient and need for evacuation to nearest area where O 2 may be
administered safely
Save all burned material and involved devices for investigation and document
fire events
Airway Fire Prevention Measures
Place drapes in a manner that allows for the venting of oxidant and to prevent
accumulation, fire retardant on drapes can conceal fire underneath
Place evacuation suction under drapes
MUST have a large asepto or 60 ml syringe of sterile water (or saline)
available
Water-soluble ointment applied to hair in surgical field, no pooled prep
solution nearby
Use lowest possible O2 level (Room Air - 21% if possible)
When using O2, without a cuffed ETT, turn off for 60 seconds prior to
activation of ESU or laser to prevent airway fire
What to do in Case of an Airway Fire:
To be performed in RAPID succession . . .
Disconnect O2 source: any breathing circuit, nasal cannula or mask delivering
O2
Attempt to extinguish the fire with water or saline
Remove the burning tube if applicable
36
Examine airway and remove any segment or burnt tube that may smolder
Mask ventilate, re-establish airway by re-intubation or by tracheostomy
Ventilate with 100% oxygen and prepare for a bronchoscopy to determine
extent of injury and necessary treatment
Prepare for administration of antibiotics and steroids
Post Fire/Incident Follow-Up
Save all burned material/equipment for investigation all fire materials
An Incident Report must be completed
Always investigate fully any question of the possibility of fire, excessive heat
Investigate fully any small occurrences because they can develop into a large
problem
De-brief, collect data, improve process for next time
37
Medical Staff Privileges
Medical Staff: Physicians (MD or DO), Dentists and Podiatrists
All must meet basic requirements of licensing, professional liability coverage, etc.
Categories of Medical Staff Membership:
 Patient contacts are defined as direct admissions, consultations, operative
procedures, surgical assists, and affiliated clinic service.
1. Senior – Completed a 12-month minimum as Associate. May admit
patients and exercise clinical (surgical) privileges. Ten or more patient
contacts over a two-year period. Protors others. Must serve on at least
one committee.
2. Associate – Completed a 12-month minimum as Provisional. May admit
patients and exercise clinical (surgical) privileges. Ten or more patient
contacts over a two-year period. Protors others. May serve on
committees. Two-year minimum prior to advancement to Senior.
3. Courtesy – Completed a 12-month minimum as Provisional. May admit
patients and exercise clinical (surgical) privileges. Cannot proctor. Only
2-8 patients contacts over two-year period. Exempt from meeting
attendance. Must be on the Med Staff (Senior or Associate) of another
California hospital.
4. Provisional – New to RCHSD. Twelve-month minimum. Must be
proctored, minimum of four cases. May admit patients and exercise
clinical (surgical) privileges.
5. Consultant – May not admit patients or schedule surgery. May assist in
surgery but not act as the managing surgeon.
6. Honorary – Do not actively practice at RCHSD. May only attend
educational programs and meetings of the Medical Staff.
7. Affiliate – (Completed minimum of 12 months as provisional and patient
activity is inadequate) May only attend meetings of the Medical Staff.
Other Medical Staff “Membership” Privileges:
1. Temporary Privileges – Application already submitted and license, training
etc, verified. Chair of Department may grant temporary privileges and is
responsible for supervising the performance. Good for 60 days plus one
renewal. Proctoring is still required.
2. Disaster Privileges – Member of Disaster Medical Assistance team
(DMAT). “In the event of an emergency, any member of the (RCHSD)
Medical Staff or Allied Health Professional Staff shall be permitted to do
38
everything reasonably possible, within the scope of their licensure, to save
the life of a patient or to save a patient from serious harm”.
Surgical Privileges:
Based on what the physician, dentist or podiatrist requested and then “evaluated
on the basis of their education, training, experience, demonstrated professional
competence and judgment, clinical performance, performance of a sufficient number of
procedures each year to develop and maintain the member’s new skills and knowledge,
and the documented results of patient care and other quality review and monitoring, and
the hospital’s programmatic resources.”
39
Job Descriptions
and Policies
40
CURRENT
EFFECTIVE
DATE
March
2007
REVISED
DATE
March
2007
MANUAL:
Medical Staff
TRACKING #
TITLE:
FELLOW JOB DESCRIPTION
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
PERFORMED BY:
Graduate Medical Education
Council
Review
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
ACCREDITATION/STANDARD
QIC 5/2/07
MSEC 5/17/07
RCHSD: Fellow Job Expectations
“Fellow” is a term used by the medical community to indicate a post graduate physician
in training who is in a second (or greater) residency training program specifically
targeted at subspecialty expertise in an area of studied during the first residency
program. “Pediatric Fellows” are training specifically for subspecialty in the care of
children. Examples include an individual trained in general otolaryngology, now in a
pediatric otolaryngology fellowship; an individual trained in general pediatrics now
training in pediatric hematology-oncology. Fellows rotating at RCHSD come from a
variety of parent institutions, or may be supported by Medical Staff members in good
standing within a particular specialty division or department. The following summarizes
oversight of fellows at RCHSD:
Rules and Regulations:
All fellows must follow the “Teaching Service: Housestaff and Medical Staff Rules and
Regulations”. For those obtaining RCHSD Medical Staff privileges, all medical staff
rules and regulations apply. As per contractual arrangement, while at RCHSD all
fellows will abide by the oversight restrictions placed upon them by the SOEP
(statement of educational purpose). All fellows must have signed an employment
contract with their parent institution/program/physician group which details the
employer-employee relationship. A copy of the institutional agreement and Statement
of Educational Purpose (SOEP)/MOU are available from the program director or the
RCHSD GME office.
Admissions:
Fellows may admit patients as an attending only if they met the qualifications for
Medical Staff membership and privileges in their specialty, have completed the
credentialing process for medical staff membership, and have been granted privileges
41
to practice independently. Fellows who will be supervised at all times function similarly
to a resident, and may not be the attending of record for any patients.
Patient care oversight, chart documentation, and licensure:
Fellows who are attendings of record for their own patients must follow the Medical Staff
Bylaws, Rules and Regulations and Policies for medical record documentation,
licensure requirements, and patient care responsibilities. Fellows without this status
must follow the requirements as stated in “Resident Job Description”.
Procedures and Surgery:
Each division is responsible for creating and maintaining a list of the non-operative
procedures appropriate for each year of fellowship. For non-medical staff privileged
fellows, surgical procedures must be performed with direct supervision of the
appropriate specialty attending physician. As each specialty is a distinct entity, this
information is kept by the Training Program Director (TPD) and Coordinator. Any staff
member may access this information by first accessing information on the RCHSD
intranet -> clinical resources -> GME. Any program without a unique job expectation
posting must follow the expectations as delineated in the “Resident Job Expectation”.
Orientation and Necessary Forms/Procedures:
The GME office is responsible for assuring all forms and orientation materials are given
to each fellow. The TPD and Coordinator are responsible for assuming their fellows are
appropriately oriented. In the minimum, it is the responsibility of all fellows to:
* Sign a confidentiality form and GME form yearly
* Obtain Meditech access code
* Obtain medical record dictation code
* Obtain and wear an RCHSD ID badge and either an RCSHD or parent
institution photo ID badge.
Work Hours: ACGME resident work hours mandate became effective July 1, 2003. Full
details are on the site www.acgme.org/new/residentHours602.asp. A summary is as
follows:
* 80 hours/week averaged over a 4 week period
* One in seven days off, averaged over a 4 week period
* Call no more than every third night
* 24 hours call limit, with 6 hours “transition time” for patient care
* 10 hour minimum rest period between duty periods
* Have a program to monitor the physical and emotional well-being of residents;
monitor effects of sleep loss and fatigue and intervene when necessary
* Educate faculty and residents on the signs of fatigue and countermeasures
All ACGME accredited programs are expected to adhere to the work hours rules above.
All non-ACGME accredited programs are strongly encouraged to adhere to the above
work hours rules.
Program Review:
All programs are responsible for their own review to assure educational content is
42
appropriate and meets all RRC requirements. The Director of GME is notified of all
audits and can facilitate such reviews as needed. All TPDs are responsible for assuring
ACGME mandated contract and SOEP are in place between RCHSD and the parent
program and responsible teaching staff. If the fellow is funded by RCHSD or an
independent physician or medical group, an additional employment contract must be
signed by the fellow, the program director and appropriate administrators.
Quality Improvement (QI) Involvement:
Involvement in focused or hospital-wide QI activities is an expectation. Fellows are
educated and involved in quality improvement activities as members of the Medical
Staff, and/or as designated by their TPDs.
M&M Process:
Fellows will participate in the M&M process of their respective section or department. All
occurrence reports involving fellows are reviewed and resolution provided by the
Director of GME, in conjunction with the TPD. The TPD has final responsibility for
action and filing of such information in the fellow’s educational file. The TPD is also
responsible for assuring communication with non-RCHSD based parent program
director or GME Director, as appropriate. Additionally, all fellows with Medical Staff
privileges must abide by the Medical Staff Bylaws, Rules and Regulations and policies.
Probation and Grievance Resolution:
Fellows with Medical Staff privileges must be reviewed according to the policies of the
RCHSD Medical Staff (RCHSD policy “Dealing with Disruptive Behavior Procedure”). All
other fellows are reviewed as per the “Resident Job Description “and must follow all
policies mandated by the GME office. All contracts and SOEP’s reference specific
policies for probation, disciplinary action, and grievance resolution, which may vary by
parent program institutional mandates. As previously noted, copies of these contracts
are available form the parent institution’s program office or the RCHSD GME office.
03/13/00
04/26/00 rev.
09/20/01 rev.
06/11/02 rev.
10/29/02 rev
06/01/04 ers rev
03/01/2007 ers rev
43
CURRENT
EFFECTIVE
DATE
3/15/07
REVISED
DATE
3/15/07
MANUAL:
Medical Staff
TRACKING #
TITLE:
RESIDENT JOB DESCRIPTION
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
PERFORMED BY:
Graduate Medical Education
Council
Review
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
ACCREDITATION/STANDARD
QIC 5/2/07
MSEC 5/17/07
Resident Job Description
All housestaff rotating at Rady Children’s Hospital San Diego (RCHSD) are the
responsibility of their respective parent institution, and must abide by all rules and
regulations set by those bodies. While on any of RCHSD campus or satellites, all
housestaff are also expected to adhere to RCHSD policies and procedures. A written
agreement or Statement of Education Purpose (SOEP) between RCHSD and each
parent institution is on file in the Rady Graduate Medical Education (GME) office. This
SOEP documents the general intent of the educational experience, lists key RCHSD
medical staff responsible for trainee oversight, and enforces the authority of the RCHSD
Director of Graduate Medical Education over all trainees at RCHSD. Specific
responsibilities and duties for each postgraduate level resident are defined below.
Definitions:
“Resident” or “housestaff” are interchangeable terms used for a person accepted to an
accredited residency program after successful completion of an accredited Medical
School program and having obtained a diploma in either doctorate of medicine (M.D.) or
the doctorate of osteopathy (D.O.). At RCHSD, the term “resident” is used to define
trainees in their first training program after Medical School. At RCHSD, the term “fellow”
is used to define trainees in their second (or greater) training program after medical
school where the training is specifically focused on pediatric subspecialty training
(Please see separate Fellow Job Description for details). Only non-medical staff
44
privileged fellows are discussed in both in the “Procedures” and “Surgeries” sections of
this job description and in the Fellows Job Description.
PL1 = postgraduate level one, the first year after medical school training
PL2 = postgraduate level two, the second year after medical school training
PL3 = postgraduate level three, the third year after medical school training
PL4 = postgraduate level four, the fourth year after medical school training
Subsequent years similarly defined. Residencies vary in number of years of training
from three to seven or more.
“Chief Resident” is a resident(s) chosen for particular skills and teaching ability, who
supervise and educate housestaff and medical students. A resident may be chosen to
perform Chief Resident duties either during a last year of traditional training or as an
additional year after traditional training.
Chart documentation:
All trainees must follow the Teaching Service: Housestaff and Medical Staff Rules and
Regulations Policy regarding order writing, progress note documentation, dictations,
and the need for co-signature.
Certification and Licensure:
As mandated by the State of California and Accreditation Council for Graduate Medical
Education (ACGME), all housestaff are required to maintain Pediatric Advanced Life
Support (PALS) certification or Advanced Cardiac Life Support (ACLS) for non-pediatric
residents. RCHSD follows the mandates of the California Medical Practice Act, which
permits medical and osteopathic school graduates to practice medicine within the scope
of their ACGME approved training program without a license in this State while they are
fully registered with the Medical Board of California as follows:
Licensure to practice medicine in the State of California is mandatory
by the end of the PL2 year OR when the house officer has completed
any prior graduate medical education training outside of the State of
California, a maximum of 12 months may be served in California, after
which time the house officer must be licensed in order to continue
training in this State. Please refer to “Special Requirements for House
Officers” for further information (Medical Board of California
Statement).
Licensure allows for residents to sign prescriptions and practice medicine as an
independent contractor if they so chose.
Patient care oversight:
Patients are assessed and treated by resident teams under the guidance of attending
physicians on staff at RCHSD. Attending physicians may elect to admit their own
patients without housestaff involvement. Any patient without a pre-existing primary care
provider or designated specialist attending is admitted to the Pediatric Hospital Medicine
service at RCHSD for attending level supervision. The attending physician (or his/her
45
partner) must see each of their patients every day, as required by the RCHSD Medical
Staff Bylaws. For each such visit, the resident note may be co-signed or a separate
attending note may be written, at the discretion of the attending and in keeping with
his/her practice standard. Patient care decisions will be discussed between attending
and trainee in person or by phone on at least a once daily basis. Responsibility for
patient care decisions, such as but not limited to order writing, telephone orders given,
consultations obtained, and procedures or treatments rendered ultimately lies with the
Attending physician for the patient (or his/her partner). The trainee is responsible for
notifying the attending of salient changes in patient status and for understanding patient
or specialty-specific notification standards. Please see Teaching Service: Housestaff
and Medical Staff Rules and Regulations Policy for further details regarding oversight.
Procedures and Interventions (Excludes outpatient and main Operating Room
surgeries):
Regardless of year of training, prior to performance of a given procedure without
supervision, the trainee must have observed and have been supervised in that
procedure according to specific individual program requirements. Hospital staff with
questions regarding trainee performance of procedures without supervision may obtain
this information from: trainee case log; supervising attending; program director; RCHSD
intranet under “clinical resources-GME”.
PL1: Each procedure will be observed once by the trainee, before first attempt at
performance under supervision. Each procedure must then be successfully performed
under supervision in the manner and frequency required by the trainee’s specific
program prior to being allowed to perform that procedure independently. Each PL1 will
carry a procedure card to be signed by a proctor. A proctor is defined as an attending,
fellow, senior resident or respiratory therapist who has demonstrated competence in
that procedure. In addition to the above, a PL1 must have supervision by a senior
resident or
Attending for the following: assessing unstable patients, responding to a Code Blue,
performing endotracheal intubation, decision-making to transfer to a higher level of care,
when specifically requested by a nurse, or in situations in which the senior resident or
Attending feel such supervision warranted.
PL2: All PL2’s should have completed their procedure logs. Any procedure not
signed to be performed independently will be supervised in the same manner as noted
above for the PL1 level resident.
PL3: All PL3’s will have completed procedure logs, and will provide the
supervision of such procedures for the PL1 and PL2 housestaff as necessary.
responsibility of review and education or additional proctoring for any procedure lies
with the Residency Program Director for that given house officer. The Director of GME
at RCHSD must be notified immediately of any house officer who has not met the above
requirements. The Program Director and house officer must be able to demonstrate
procedural competence at any time for any member of the hospital staff or other
appropriate administrative representative.
46
All Surgeries and Invasive Procedures (Main Operating Room, Day Surgery, Endoscopy
Suite, Cardiac Catheterization Lab, Interventional Radiology):
All residents and non-medical staff privileged fellows performing surgical procedures or
invasive procedures must have direct supervision from an attending in their specialty
field. A resident/non-privileged fellow may not start a case without the supervising
attending present. The resident/non-privileged fellow may identify the patient and mark
the surgical site, and the patient may be taken back to the operating room. The
attending surgeon must confirm patient identification and surgical site prior to anesthetic
induction and draping. The attending physician must be immediately available during
anesthetic induction. The attending physician is to be present at the start of the case
(skin incision, or endoscope / trochar / cardiac catheter / biopsy needle insertion etc.).
The attending surgeon must also be present for the majority of the case, including all
key and critical portions of the procedure.
Work Hours:
ACGME resident work hours mandate became effective July 1, 2003. Full details are on
the site www.acgme.org/new/residentHours602.asp. A summary is as follows:

80 hours/week averaged over a 4 week period

One in seven days off, averaged over a 4 week period

Call no more than every third night

24 hours call limit, with 6 hours “transition time” for patient care

10 hour minimum rest period between duty periods

Have a program to monitor the physical and emotional well-being of
residents; monitor effects of sleep loss and fatigue and intervene when
necessary
All ACGME accredited programs are expected to adhere to these ACGME work hours
guidelines. Non-accredited programs are strongly encouraged to follow these
guidelines.
Orientation:
All pediatric and family practice housestaff are offered RCHSD orientation in June of
each year. While this is focused on the incoming general pediatric and family practice
PL1 residents, all residents and fellows may attend. A separate “specialty resident and
fellows” RCHSD orientation is held for program coordinators and directors from May –
July yearly. The two orientations overlap but are distinct; details are in separate
manuals. Each manual is updated yearly and a copy sent to the Residency Program
Director for each parent institution. It is the responsibility of these administrators and
directors to review the orientation manual and RCHSD policies with each resident
trainee. Due to the frequency of rotations and inconsistent start dates for specialty
residents and fellows rotating at RCHSD, a single orientation date cannot meet the
needs of all of these trainees. Trainees are therefore expected to obtain, read, and ask
questions regarding the orientation manual and any RCHSD policies prior to the start of
a rotation. Copies of both manuals are on file at the RCHSD GME office. Specialty
residents may find benefit from both manuals. Included in the orientation are topics such
47
as clinical expectations, family centered care, fire safety and OSHA requirements,
confidentiality agreements and key contact name and numbers. Maintenance of these
manuals is the responsibility of the Director of GME at RCHSD.
Program Review/Quality Assurance:
Review: Individual programs at RCHSD are under the direction of division directors or
their designees. Review of the educational content and any appropriate materials or
contacts necessary are the responsibility of the division. The Director of Graduate
Medical Education at RCHSD is responsible for coordinating these efforts, assisting with
opportunities for improvements, and acting as a liaison to the Residency Program
Directors at each parent institution. For the general pediatric inpatient rotation at
RCHSD, the Associate Program Director is responsible also for the program content
and review, evaluations of housestaff, issues with hospital medical and nursing staff,
occurrence report resolution and M&M.
Morbidity &Mortality (M&M), Patient Safety, and Quality Improvement Education:
All housestaff should be involved in Department of Pediatric or Department of Surgery
M&M as part of the educational process. All programs should also include appropriate
education in patient safety and quality improvement. Opportunities for trainee
involvement in RCHSD safety and quality efforts can be obtained from the RCHSD
GME office. Individual divisions or departments have the additional responsibility to
educate and involve their residents and fellows in areas of quality assurance specific to
their subspecialty.
Occurrences and Grievances: Any occurrence report involving housestaff is reviewed
by the RCHSD Director of GME. Resolution and action plans are reviewed with the
appropriate Program Director.
Probation:
While the ultimate decision to place a given resident or fellow on probation lies with the
Program Director for that trainee, the RCHSD Director of GME has the responsibility to
provide input and recommendations for probation as necessary. Program Directors
must immediately notify the RCHSD Director of GME of any resident on probation.
RCHSD has the right to refuse rotation to any resident who, in best judgment of the
RCHSD Director of GME, would not be able to render appropriate patient care. Please
refer to other GME policies specifically for dismissal, sexual harassment, and similar
issues.
Ers
02/02/00
04/26/00 rev.
09/20/01 rev.
06/11/02 rev.
10/29/02 rev.
11/05/02 Approved QIC
48
11/07/02 Approved Surgery Department
12/12/02 Rev Peds Dept
06/01/04 ers rev
12/30/06 ers rev
49
CURRENT
EFFECTIVE
DATE
3/2009
REVISED
DATE
03/2009
MANUAL:
Medical Staff
TRACKING #
TITLE:
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
ACCEPTABLE USE OF THE INTERNET
(FOLLOW UP TO CPM 11-70)
PERFORMED BY:
Graduate Medical Education
Council
Review
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
ACCREDITATION/STANDARD
5/18/07 rev. sdp
3/25/2009 RCHSD added
TO: All Users of the RCHSD Information Network
FROM: Meg E. Norton
RE: Acceptable Use of the Internet - CPM No. 11-70
This is a follow-up to our ongoing communications regarding measures the organization has put
or is putting into place to promote zero tolerance, specifically as they relate to the policy
regarding Internet Acceptable Use - CPM No. 11-70.
As you know, we have technology in place that blocks access to certain Internet sites and
monitors Internet activity. We have enhanced and/or modified our processes as follows:

All user access, including BA1 access, requires specific user identification and
passwords.

All Internet activity is tracked to the individual user. As you know, a user must not
share his/her user identification or password with anyone else or use another's user
identification or password even for what the user might perceive as a legitimate
RCHSD purpose.

The following categories of Internet sites are blocked:
Hate
Dating/personals
Chat
Weapons
Glamour and Intimate Apparel
Games
Hacking
Adult/Sexually explicit
Gambling
iTunes
Violence
50
Our policy with respect to requests for access to blocked sites has been reviewed and exceptions
to access blocked sites are more limited.
We will continue to monitor and audit "attempted" access to blocked sites. Those who are using
the Internet inappropriately will receive disciplinary action.
Should a user receive an internal or external e-mail with inappropriate content or receive a pop-up
from a restricted site, the user should take the following immediate steps:
1. Report the incident, date and time, type of material and site to the CHAAT line (1-877-TOCHAAT/1-877-862-4228); and
2. Delete the material from your computer.
All GME policies are reviewed annually and as needed. Last review: 4/2012
51
CURRENT
EFFECTIVE
DATE
REVISED
DATE
5/2007
7/2004
MANUAL:
Medical Staff
TRACKING #
TITLE:
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
ADMISSION CRITERIA FOR SURGICAL
PATIENTS TO PEDIATRIC INPATIENT
SERVICE
PERFORMED BY:
Graduate Medical Education
Council Review
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
ACCREDITATION/STANDARD
QIC approved 7/7/04
Criteria for Admissions of Surgical Patients to the
Pediatric Housestaff Inpatient Service
Pediatric housestaff benefit from exposure to pediatric surgical training. However,
they are not surgical residents and their surgical experiences must be balanced
with their need for general medical pediatric training. Surgical admissions to the
general pediatric inpatient teaching service therefore must meet the criteria below.
This policy applies to all general and specialty surgical services. Please note the
criteria apply to the general pediatric inpatient teaching service, not specialty
residents or fellows.
Not appropriate for general pediatric inpatient teaching service:
1) New or established surgical patients with focused surgical problem(s) or
complication from the surgical procedure. Examples include bowel
obstruction from previous bowel surgery known to the surgeon, or CNS
shunt obstruction.
2) Care or coverage for a patient with anticipated problems that are related to
the surgical procedure or anticipated procedure.
Potentially appropriate for the general pediatric inpatient teaching service:
1) Patients with surgical problems, for whom the surgeon will act as the sole
attending of record, and for whom the surgeon feels there is educational
52
value to the general pediatric resident. All care must be within the surgeon’s
scope of practice. If the surgical attending requests general pediatric
teaching service coverage for patients for whom they will be the Attending,
the surgeon needs to discuss this directly with the senior resident. The
senior pediatric resident may accept or decline this educational opportunity.
An example is an appendicitis patient, where educational value may be
present discussing the presenting signs and symptoms and management
plans.
Potentially appropriate for the general pediatric inpatient teaching service as a
consult or for co-admission:
1) For any patient requiring co-admission or consult to the pediatric service, a
direct discussion between the specialty attending and the pediatric attending
on call must occur at the time of admission. Pediatric co-admission from the
time of admission, or consultation at any time after admission, are
appropriate for any patient with medical disease or concern out of the scope
of practice for the surgeon. Attending-to-attending communication should
include delineation of patient care decisions to be made by each service,
such as but not limited to order writing and involvement of trainees. The
surgeon must check to see if a private pediatrician is involved who would be
the pediatric attending of record, as not all patients are cared for by the
Pediatric Hospitalists.
Thank you for your cooperation with this. If you have any questions, please do not hesitate to call Dr. Sara
Marchese, Director of GME and Director of Pediatric Inpatient Teaching for UCSD Pediatrics at 966-5841 or email at [email protected].
All GME Policies are reviewed annually and as needed. Last Review: 4/2012.
53
CURRENT
EFFECTIVE
DATE
REVISED
DATE
5/2007
2012
MANUAL:
Medical Staff
TRACKING #
TITLE:
DISRUPTIVE BEHAVIOR
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
PERFORMED BY:
Graduate Medical Education
Council Review
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
ACCREDITATION/STANDARD
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
Disruptive Behavior Policy and Procedure
Background:
A cause for concern arises when a resident has practice patterns or behavioral traits that
could potentially compromise the quality of care provided patients or effective
communication with hospital and medical staff members. These issues may arise from a
variety of causes, such as substance abuse, psychiatric disorders, or significant personal
stressors. Training programs and training facilities such as Rady Children’s Hospital and
Health Center (RCHHC) have traditionally tolerated a wide range of personalities, as no
single set of personality attributes is perfect for all clinical circumstances. Despite this,
some behavior patterns are not acceptable and require intervention.
The GME office at RCHHC is prepared to assist with intervention necessary for such
events. As a trainee at RCHHC, common civility and dignified professionalism are
expected at all times. Written and verbal communication with all hospital staff, medical
staff members, families and visitors at RCHHC must support this. Physical and verbal
abuse is not acceptable. When a behavior demonstrated by a resident is perceived to be
disruptive, the following procedure will be followed:
*For trainees on the medical staff, please refer to Medical Staff Rules and Regulations
regarding disruptive physicians.
54
1. Disruptive behavior requiring immediate corrective action will be handled by the
RCHHC designated supervising physician/designee as noted in the Statement of
Educational Purpose for the program in question. The Director of GME at RCHHC and the
appropriate Program Director at the parent facility for the resident (UCSD, Balboa, etc) will
be notified immediately of all such significant interventions. Further actions will follow the
guidelines and policies of the parent program.
2. Disruptive behavior NOT requiring immediate corrective action will be documented by
the observer, who is to complete an occurrence report describing the occurrence related to
the disruptive behavior. The occurrence report will be forwarded to the RCHHC Director of
GME. The observer may also call the Director of GME at his/her discretion.
3. After reviewing the occurrence report, the Director of GME will confer with the resident,
the observer, and other involved parties as necessary. The Director of GME will
immediately notify the RCHHC responsible supervising physician and the resident’s
Program Director for any significant occurrences. For certain some cases, a “productive
interaction” (PI) will be scheduled with the resident, the RCHHC responsible supervising
physician, the resident’s Program Director, and others as needed. The “PI” format is
intended to elicit the problem at hand, and to work toward effective communication while
maintaining respect. The goal of PI is to allow for discussion of the event, provide support,
and to determine the factors that may have influenced the outcome of the event. PI offers
guidance on constructive behavior change and support systems that may be available at
RCHHC or the parent residency program. The PI process may be indicated for, but not
limited to, impaired physicians, physical or verbal abuse allegations, or perceived
harassment. PI general process guidelines are as follows:
Notification to Resident. After determining a PI is warranted, the parent Program
Director, RCHHC supervising physician or the RCHHC Director of GME will notify
the resident of the meeting, and of its confidential nature.
All interactions are confidential. The Program Director will have control over the
information, and the determination of resident’s ability to perform within the parent
program guidelines.
Timing and location. Every effort will be made for an expeditious meeting at a time
and location appropriate for all
Moderator. The Director of GME will moderate and assure issues are relayed in a
constructive manner.
Meeting responsibilities. All staff members are expected to bring relevant
information regarding the issue as well as program and support services which may
be offered to the resident.
Decisions and Follow-up. The Program Director will follow all program rules and
regulations regarding the final decision made during the PI, and any impact it may
have on the resident. Follow-up of this plan, as it pertains to function at RCHHC or
responsibilities for the RCHHC supervising physician, will be discussed
confidentially with the Director of GME and the RCHHC supervising physician.
Formal documentation will be kept confidentially only in the office Director of GME,
and the parent Program Directors office.
All GME Policies are reviewed annually and as needed. Last Review: 4/2012
55
CURRENT
EFFECTIVE
DATE
REVISED
DATE
5/2007
2012
MANUAL:
Medical Staff
TRACKING #
TITLE:
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
DISCIPLINE, DISMISSAL AND DUE
PROCESS
PERFORMED BY:
Graduate Medical Education
Council Review
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
ACCREDITATION/STANDARD
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
Discipline, Dismissal, Due Process Policy
RCHSD complies with Institution/entity-specific Discipline, Dismissal, and Due
Process policies. The RCHSD Director of GME is the liaison for all such issues,
and works in concert as needed to supply information or assist with the process
decisions. Formal review and appeal processes are the preview of each
sponsoring institution/entity. The RCHSD Director of GME must be notified in
writing of such processes if relevant to performance or ability to perform duties at
RCHSD. If an event triggering such an inquiry occurred on any RCHSD campus
facility, the RCHSD Director of GME should be involved in the review process.
All GME Policies are reviewed annually and as needed. Last Review: 4/2012
56
CURRENT
EFFECTIVE
DATE
REVISED
DATE
5/2007
2007
MANUAL:
Medical Staff
TRACKING #
TITLE:
MANAGING IMPAIRED RESIDENTS
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
PERFORMED BY:
Medical Staff Services
Council Review
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
ACCREDITATION/STANDARD
5/2007 rev sdp
3/2009 reviewed ers
4/2012 reviewed SM
Guidelines for Managing Impaired Residents Policy
Due to the extremely sensitive nature of the activities surrounding the identification
and management of an impaired post-graduate trainee, it is explicitly understood
that all participants in the process shall maintain a level of strict confidentiality. At
any time, the trainee may contact his/ her Institution/entity Physician Well Being
Committee to seek confidential assistance or to simply ask questions regarding
personal concerns. The following is a summary of the RCHSD general guidelines
for Managing Impaired Residents:
If any individual has a reasonable suspicion or concern about impairment of a
trainee, the following steps should be taken.
A complaint shall be made to the Training Program Director who will
be responsible for notifying other individuals as deemed appropriate
to include the RCHSD Director of GME and appropriate Dean/other
responsible party from the sponsoring institution/entity.
The Program Director will ascertain the medical nature of the
impairment and seek appropriate confidential consultation (as
indicated) regarding the impairment, following all guidelines of the
sponsoring institution/entity.
57
If it is found that sufficient evidence exists that the resident is
impaired, the Program Director, or designee, shall meet with the
trainee.
If after review of the complaint, the Program Director believes there is
sufficient information to warrant a more complete investigation, the
Program Director will initiate an investigation, and notify the RCHSD
Director of GME.
The investigation report will be confidential and the source not
revealed.
Depending upon the nature and severity of the impairment and the
problems presented, the Program Director has options which may
limit practice or impose mandatory various rehabilitation or treatment.
The RCHSD Director of GME must be informed in writing of: All
practice limitations and/or treatment Programs initiated placement on
disability, suspension, dismissal, or any other charge which may
impact the trainee’s ability to render care or participate in the usual
manner. Upon resolution of any of these listed charges in status, the
RCHSD GME Director must also be notified in writing. At any time, in
consultation with the program Director, the RCHSD Director of GME
may deny the access of the trainee in question to the RCHSD
programs, patients and facilities.
All GME Policies are reviewed in annually and as needed. Last Review: 4/2012
58
CURRENT
EFFECTIVE
DATE
REVISED
DATE
5/2007
3/2009
MANUAL:
Medical Staff
TRACKING #
TITLE:
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
TRAINEE USE OF NON-LICENSED
FACILITIES
PERFORMED BY:
Graduate Medical Education
Council Review
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
ACCREDITATION/STANDARD
3/24/09 – added “Rady”
Graduate Medical Trainee use of Non-Licensed Facilities Policy
Graduate medical and surgical trainees transporting and caring for any Rady
Children’s Hospital and Health Center patients requiring after hours or weekend
care in the non-licensed areas of the Medical Office Building (MOB) or any other
non-licensed areas within the Rady Children’s Hospital campus must be
accompanied by their supervising attending physician. As with all such use of
the MOB, all RCHHC policies and procedures regarding such transport must be
followed. This includes but is not limited to notification of the bedside nurse of the
procedure and plans; presence of the bedside nurse during transport as well as
during the procedure; hospital chart documentation of the transport with patient
status before, during, and after the procedure, and any special circumstances
relevant to the care of that patient. All appropriate consents must be obtained prior
to performance of any procedures.
While use of non-licensed facilities may be mandatory due to lack of operating
room time, the use of these facilities after hours or on weekends is strongly
discouraged unless all other options are exhausted.
This policy pertains only to Rady Children’s Hospital patients, and does not apply to
office-based patients for whom Rady Children’s Hospital bears no responsibility.
All GME Policies are reviewed annually and as needed. Last Review: 4/2012.
59
CURRENT
EFFECTIVE
DATE
03/15/07
REVISED
DATE
03/2009
MANUAL:
Medical Staff
TRACKING #
TITLE:
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
TEACHING SERVICE:
HOUSESTAFF AND MEDICAL
STAFF RULES AND REGULATIONS
PERFORMED BY:
Graduate Medical Education
Council Review
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
ACCREDITATION/STANDARD
3/23/09 – Added “Rady”
HOUSE STAFF RULES AND REGULATIONS
House Staff and the postgraduate medical education program (the "Program") at
Children's shall be governed by these rules and regulations:
1. Patients may be seen and treated by House Staff at the discretion of the
attending physician and under his/her supervision. Whenever reasonably
possible under the circumstances, the attending physician shall disclose to
the parents/guardians that the patient may be treated by House Staff under
the attending physician's supervision. In the event of an objection by the
parents/guardians, the attending physician shall not utilize House Staff in
treating the patient, except when necessary in an emergency or due to
unforeseen circumstances.
2. Members of the medical staff are encouraged to participate in the Program,
as teaching is part of the Hospital mission. Those members, however, who
choose not to participate in the Program shall not be subject to denial or
limitation of privileges for this reason alone.
3. Except to the extent they qualify for and are specifically granted independent
privileges, all House Staff are under the supervision of members of the
medical staff. The intensity and level of supervision provided by the
supervising member in each case shall be based upon the demonstrated
knowledge and proficiency of the House Officer, the clinical condition of the
60
patient, and the complexity of the circumstances under which the patient is
being treated. In addition, supervising medical staff members shall adhere to
such standards for the supervision of House staff as shall be necessary to
provide adequate supervision. These standards shall include, at a minimum,
the following:
a. House Staff admission notes, histories and physical exams must be
reviewed by the attending physician within 24 hours of the patient's
admission. The attending physician will enter an admitting progress
note on the medical record indicating this review has occurred and
will continue to review and enter notes on a daily basis (unless a
shorter interval is established by the relevant department) throughout
the patient's hospitalization.
b. The attending physician is responsible for co-signing the following
medical record entries by House Staff:
1) History and Physical Exams
2) Discharge Summaries
3) Consultation Reports
4) Operative Reports
5) Autopsies, Surgical Pathology and Radiology Reports
6) Resuscitation Limitation Orders (per Hospital Policy B-14)
c. Individuals providing entries (orders and/or notes) in the medical
record not requiring co-signing shall include residents and fellows in
approved programs. All orders regarding resuscitation limitations
and all entries by medical students must be co-signed by a
licensed physician member of the healthcare team. Orders not
signed by a member of the House Staff become the responsibility of
the attending physician.
d. The attending physician is ultimately responsible for the quality of
care delivered to the patient. The foregoing shall not apply with
respect to any practice privileges granted to a House Officer, which
are specifically designated as independent.
e. Prompt response to House Staff requests for assistance from medical
staff members if required.
f. No House Officer may admit or discharge a patient without the
approval of the attending medical staff member except in cases of
medical emergency.
4. Both House Staff and attending medical staff may write orders but should
follow usual courteous communication channels to optimize patient care.
5. House Staff must promptly notify the appropriate attending physician when
he patient's condition is deemed critical and under any other circumstances
where they require the input of the attending physician.
61
6. The Director of Pediatric Education, in cooperation with the respective
resident program directors, is responsible for the supervision of the
Program.
7. As specified in the Medical Staff Bylaws, the Program shall be under the
oversight of the Director of Pediatric Education, in conjunction with all
resident program directors, and all subspecialty directors. The Director of
Pediatric Education may call ad hoc meetings of these individuals and other
appropriate parties as necessary to address issues related to the GME
program. All recommendations and actions shall be subject to approval by
the MSEC. The Director of Pediatric Education shall oversee and monitor
the Program. The Director of Pediatric Education shall also review and
approve all policies and procedures governing the Program or conduct of
House Staff.
8. The rules and regulations governing House Staff function at Rady Children's
Hospital, as they apply specifically to House Staff from the University of
California, San Diego (UCSD) training programs are in concurrence with
bylaws stipulated by UCSD for House Staff.
HOUSE STAFF AS MEMBERS OF THE MEDICAL STAFF
All House Staff in a fellowship program at Rady Children's Hospital who will be
providing patient care services independently without supervision or direction will
be required to obtain membership on the attending medical staff.
Fellows joining the medical staff are not required to pay the application fee.
Additionally, based on the supervision they do receive, they do not have to
complete the proctoring requirements of medical staff membership as long as they
remain in the Fellowship program.
HOUSE STAFF LICENSURE REQUIREMENTS
All House Staff who rotate through Rady Children's Hospital will be required to
obtain a California license in accordance with the licensure laws of the State of
California. Specifically, the law states the following:
1) Those House Staff who intern in the State of California have two years into
their residency training to obtain a California license.
2) Those House Staff who intern outside the State of California have one year
into their residency training to obtain a California license.
3) Military personnel are not required to obtain a California license, but are
required to abide by the State of California Business and Professions Code,
Section 718. In accordance with that Section, there must be a contract
between Rady Children's and the appropriate branch of the armed forces
and the appropriate form required by the Division of Licensing of the Medical
Board of California has been completed.
62
4) The exception will be those House Staff who are fellows seeking medical
staff membership who will be required to obtain a California license in
compliance with medical staff Bylaw requirements.
5) Any House Staff from a foreign country will need to follow the procedures
defined in the State Business and Professions Code, Section 2111.
HOUSE STAFF REGISTRATION
All House Staff are required to register with the Office of Graduate Medical
Education. This will ensure that information required for annual Graduate Medical
Education Program audits is obtained and that all trainees are properly insured and
licensed in accordance with California state laws.
House Staff are required to complete the Office of Graduate Medical
Education Forms and provide copies of their Medical School Diploma, CV,
and Medical License. Military Trainees are required to provide copies of their
TAD orders for all rotations at RCHHC. All House Staff are required to sign a
Confidentiality Agreement as required by the Medical Staff Bylaws.
DRAFTED 5/10/93
REDRAFTED 7/8/93
MSEC 7/22/93
REVISED 7/96, 3/07
1/12/04 – mjs
3/15/07 – sdp
MEDICAL STAFF RULES AND REGULATIONS
Resident housestaff coverage is available for physicians admitting pediatric
patients to RCHHC. If an Attending staff member chooses to have patients covered
by housestaff the following is mandatory for all services:
Daily examination of each patient
Daily progress note must be written or revised by the Attending. The
statement “patient seen, examined, and agree with above (progress note)”
followed by the Attending’s signature written below a housestaff’s progress
note is acceptable.
Daily conversation with the housestaff to review plans and actions
Review of case-specific as well as service-specific criteria for
urgent/emergent notification of the attending of patient status/issues.
Availability at all times to answer questions (a partner may cover such calls)
this includes after hours and weekends.
All admissions must be accepted by the physician who will be the attending
of record for the patient, or their partner. Residents not on the RCHHC
medical staff cannot be the accepting physician for admissions to the
63
hospital. Residents must be informed of all admissions to their service prior
to arrival of the patient.
Understanding that the oversight and care of patients is the ultimate
responsibility of the Attending of record. This includes all regulations as put
forward in the Medical Staff bylaws Rules, Regulation, and Policies.
Examples of such responsibilities include signing of verbal orders and
dictation or documentation of notes if not done by housestaff members.
Attendings must have privileges in every treatment, procedure, or
intervention that they may ask the resident to perform on their behalf.
Resident competency for these treatments, procedures, or interventions
must follow program guidelines (GME Intranet Web page  Resources
http://intranet.rchsd.org/departments/directory/graduatemedicaleducation/res
ources/index.htm)
Every effort should be made for education on the thought process for
diagnosis and treatment for each patient. As a member of the medical staff
involved with the teaching service, attendance at morning report or other
educational sessions is strongly encouraged.
Use of the teaching service at RCHHC is NOT mandatory. Any issues or
comments should be addressed to the Director of Graduate Medical Education.
The number of patients that may be cared for by any single teaching service or
training program is limited. For pediatric and surgical specialty service
admissions, the decision for involvement of trainees is made by the responsible
teaching service attending for that specialty.
However, the final decision to accept patients into the general pediatric teaching
service is made by the Pediatric Chief Resident in coordination with the Director
of Graduate Medical Education.
Approved MSEC 03/20/03
Approved CHHC Board 03/26/03
All GME Policies are reviewed annually and/or as needed. Last Review: April 2012.
64
CURRENT
EFFECTIVE
DATE
5/2007
REVISED
DATE
12/19/07
MANUAL:
Medical Staff
TRACKING #
TITLE:
SEXUAL HARRASSMENT
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
PERFORMED BY:
Graduate Medical Education
Council Review
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
ACCREDITATION/STANDARD
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
Sexual Harassment Policy
Rady Children’s Hospital San Diego (RCHSD) is committed to creating and
maintaining a community in which all persons can work together in an atmosphere
free of all forms of harassment, exploitation, or intimidation, including sexual.
Specifically, every post graduate trainee and respective supervisors should be
aware that RCHSD is strongly opposed to sexual harassment and that such
behavior is prohibited both by law and by policy of each sponsoring
institution/entity. It is the intention of RCHSD to take whatever action may be
needed to prevent, correct, and if necessary, discipline behavior which violates this
policy. The RCHSD office of GME works collaboratively with each sponsoring
institution/entity adhering to the policies of each institution. The RCHSD Director of
GME is the liaison for any such inquiries or disputes, and may include other
RCHSD administrative staff as needed for smooth resolution.
All GME Policies are reviewed annually and as needed. Last Review: 4/2012.
65
66
CURRENT
EFFECTIVE
DATE
9/13/2004
REVISED
DATE
9/13/2004
MANUAL:
Medical Staff
TRACKING #
TITLE:
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
UCSD MODERATE SEDATION
POLICY
PERFORMED BY:
Graduate Medical Education
Council
Review
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
ACCREDITATION/STANDARD
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
September 13, 2004
To:
Department Chairs
Training Program Directors
From:
Wendi Rife
Director, Office of Graduate Medical Education
RE:
Moderate Sedation Policy
Attached please find the Moderate Sedation Policy approved by the Medical Staff
Executive Committee (MSEC) on June 15, 2004. This policy now allows moderate
sedation to be initiated by senior residents (PGY 3 or above) and fellows if they
meet the requirements stated in the policy and are deemed competent to do so.
For a description of the requirements to become competent to provide moderate
sedation by these trainees, please go to page 20 of the attached material.
The intent is to have moderate sedation performed by trainees under supervision
by an attending. A house officer (PGY 3 or above) resident or fellow may initiate
moderate sedation with the attending within the facility arriving to perform the
procedure; the attending will be in the room with the patient and the trainee
throughout the major portion of the procedure for which moderate sedation is
required.
Before a trainee is deemed competent to perform moderate sedation, the trainee
must complete an educational program and pass the required examination which
will be reviewed by the Training Program Director and the Medical Staff Executive
67
Committee (MSEC). The acquired competency for the trainee will then be listed
on the UCSD Medical Center Intranet “Resident Competencies” before the
individual will be allowed to initiate and perform moderate sedation.
The enclosed material is provided in the event you wish to have your trainees
perform moderate sedation. Please review the attached material and take the
following action:
Educational Packet
Material for Resident/Fellow Review:
1.
UCSDMC Clinical Competency Packet for Moderate Sedation – Page 1
2.
UCSDMC Moderate Sedation Competency Objectives – Page 2
3.
Clinical Approach to Moderate Sedation – Page 3 - 12
4.
UCSD Policy for Moderate Sedation MCP 370.1D – Page 13 - 26
5.
UCSD Moderate Sedation Competency Examination – Page 27 - 32
6.
UCSD Statement of Completion of Sedation Training/Competency Checklist –
Page 33
ACTION:
1.
Applicant - Review the attached Clinical Competency Packet
2.
Applicant - Complete the Moderate Sedation Competency Examination and
forward your completed exam to Wendi Rife, Director, Office of Graduate
Medical Education Mail Code 8829. Your exam will be scored. Please note,
the pass rate is 85% or greater. You will be contacted regarding the results.
3.
Applicant - Complete the Statement of Completion Sedation Training
Competency Checklist and forward this document to Wendi Rife, Director,
Office of Graduate Medical Education Mail Code 8829.
ACTION – OFFICE OF GRADUATE MEDICAL EDUCATION:
1.
Wendi Rife will forward the completed and scored exam and the Statement of
Completion Sedation Training Competency Checklist to the applicant’s Training
Program Director for TPD signature designating his/her approval status for
granting the clinical competency.
2.
Once the TPD returns the signed Checklist to Wendi Rife, the procedure will be
entered into the UCSD Housestaff Competency Intranet.
cc: Elaine Muchmore, M.D., Interim Associate Dean for Graduate Medical Education
Mary Middleton, RN, Associate Director, Patient Care Service
/moderate sedation policy
68
CURRENT
EFFECTIVE
DATE
REVISED
DATE
5/2007
3/2009
MANUAL:
Medical Staff
TRACKING #
TITLE:
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
TRAINEE OVERSIGHT AND GME
COMPLIANCE
PERFORMED BY:
Graduate Medical Education
Council Review
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
ACCREDITATION/STANDARD
3/24/09: added “Rady.”
TRAINEE OVERSIGHT AND RCHSD GME OFFICE COMPLIANCE
For all trainees rotating at RCHSD, regardless of primary institution, the following must
occur:
Compliance with all RCHSD rules, regulations, and policies.
Signature of all appropriate forms and review of the Orientation Manual (located on
the web or in the GME office) on or before the first day of rotation at RCHSD.
I.D. badge must be worn at all times.
Review of program-specific oversight or requirements with designated supervisor
for RCHSD rotation.
For all entering the operating areas, review of OR requirements as listed in the
manual. Contact is Bruce Grendell ext 5878, Surgical Education Administrative
Assistant ext. 5242.
Request for concurrent and end-of-rotation monitoring signatures for procedures or
any other specific competency as required by your program or primary institution.
For all Specialty Resident or Fellowship Program directors, the following must occur:
Assurance of understanding and compliance of trainees with all rules as listed
above.
A written Statement of Educational Purpose must be on file at the GME office.
A written Institutional Contract must be on file at the GME office.
Supervision for each level of trainee consistent with your program’s guidelines
Notification of the Director of GME of risk management issues including resident
educational or behavioral concerns, contractual changes, or any other change in
your program with an impact on RCHSD.
Immediate notification of the GME office of any addition or deletion of trainee to the
RCHSD campus or satellites.
69
Compliance with request made by the GME office for program or trainee
information.
Review and adherence to all RCHSD GME and appropriate RCHSD institutional
policies. RCHSD GME policies can be reviewed on the intranet at
http://intranet.rchsd.org/departments/directory/graduatemedicaleducation/policiespr
ocedures/index.htm. If you would like hard copies of these faxed to you, please
contact the GME office or Dr. Sara Marchese.
All GME Policies are reviewed in May of each year and as needed. Last Review: 4/2012
70
CURRENT
EFFECTIVE
DATE
REVISED
DATE
5/2007
4/2012
MANUAL:
Medical Staff
TRACKING #
TITLE:
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
RESIDENT WORK HOURS
(ACGME MANDATE)
PERFORMED BY:
Graduate Medical Education
Council Review
Specialty
Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
ACCREDITATION/STANDARD
3/24/09: added “Rady,” updated Work
Hours Link.
4/3/12: updated new ACGME rules
summary, updated link.
RCHHC Resident Work Hours: ACGME Mandate
For all ACGME accredited programs, RCHHC mandates and supports compliance with
ACGME work hours regulations. Each program is individually responsible for assuring
compliance and for meeting any other specific RRC expectations. As RCHHC is not the
sponsoring institution for any such training programs, oversight, concerns, or questions
should be addressed directly to the residency program director or institutional GME official.
Current ACGME resident work hours mandate became effective July 1, 2011. Full
details are on the websitesite, located at:
http://www.acgme.org/acWebsite/home/Common_Program_Requirements_07012011.pdf
A summary is as follows:
o Duty hours must be limited to 80 hours per week, averaged over a four
week period, inclusive of all in-house call activities and all moonlighting.
o Residents must be scheduled for a minimum of one day free of duty every
week (when averaged over four weeks). At-home call cannot be assigned
on these free days.
o Duty Periods of PGY-1 residents must not exceed 16 hours in duration
o Duty periods of PGY-2 residents and above may be scheduled to a
maximum of 24 hours of continuous duty in the hospital.
o Residents must not be assigned additional clinical responsibilities after 24
hours of continuous in-house duty.
o PGY-1 residents should have 10 hours, and must have 8 hours, free of duty
between scheduled duty periods.
o Residents must not be scheduled for more than six consecutive nights of
night float.
71
o
o
o
PGY-2 residents and obove must be scheduled for in-house call no more
frequently than every-third-night (when averaged over a four-week period).
Have a program to monitor the physical and emotional well-being of
residents; monitor effect of sleep loss and fatigue and intervene when
necessary.
Educate faculty and residents on the signs of fatigue and countermeasures.
For further information, please contact your program director or coordinator.
All GME Policies are reviewed in May of each year and as needed. Last Review: 4/2012.
72
CURRENT
EFFECTIVE
DATE
June
2012
REVISED
DATE
February
2007
MANUAL:
Center Policy
TRACKING #
CPM 12-22
TITLE:
MAINTAINING APPROPRIATE
BOUNDARIES
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty Review
Multidisciplinary
Nursing Council
RT Council
SW Council
Child Life
Human Resources
EOC/Safety
PERFORMED BY:
ALL STAFF, PHYSICIANS,VOLUNTEERS
& STUDENTS
Council Review
Information Services
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Forms
Med Staff
Specialty Review
ACCREDITATION/STANDARD
Back to Basics
Clinical Ops
Med Staff Executive
Center Ops
Board
I.
PURPOSE:
The purpose of this policy is to define appropriate boundaries and provide direction
regarding expected behavior of all employees, volunteers, medical staff members, and
others who have contact with patients and families. The delivery of care involves an
inherent vulnerability of the patient/family with respect to the care givers. It is the
responsibility of the care providers to maintain boundaries at all times in order to
maximize our ability to provide optimal care to the patients and families we serve.
II.
POLICY
It is the policy of Rady Children’s Hospital and Health Center, and its subsidiary and
affiliated corporations, to require all individuals who have patient contact, including
but not limited to, employees, volunteers, medical staff members and students, to
adhere to appropriate boundaries at all times during interactions with patients and
families.
III.
DEFINITIONS:
A. Boundaries: Boundaries separate therapeutic behavior from other behavior
(regardless of intent) which could lessen the benefit of care to the patients,
families, or community we serve.
Page 1 of 4
Center Policy Manual, CPM 12-22 “Maintaining Appropriate Boundaries”
73
B. - Clinical Touch: Touching that is necessary to provide direct patient care,
such as catheterizations, respiratory therapy, starting an intravenous line, or
changing a diaper.
C. - Therapeutic Touch: Touching of patients or families done for the
purpose of reducing anxiety, stress or to provide comfort. Examples
include:
1. Comforting a distressed or crying patient or family;
2. Helping a child cope with their anxiety surrounding a clinical
procedure (i.e., holding a child’s hand during an IV start,
holding a child’s hand while walking to a procedure room); or
3. Patting a child’s back or rubbing a child’s forehead in order to
provide comfort.
II.
BEHAVIORAL EXPECTATIONS
A. Verbal communications: All individuals are expected to adhere to appropriate
professional standards in all communications. Suggestive bantering, sexual
jokes, innuendoes or comments are not acceptable.
1. Staff should be aware that body language, tone, inflection and
facial expressions contribute to the intent of the communication.
B. Physical contact with patients should conform to the definitions for appropriate
clinical and/or therapeutic touch. In all cases consideration should be given to
the developmental stage and needs of the child.
1. Staff should be aware that one’s perception of touch is affected by
many variables, including the following (this list is not inclusive of
all possibilities):
a. the body part that is touched
b. the type of touch (an arm around the shoulder vs. a full frontal hug)
c. the length of time the touching occurs
d. who initiates the contact
e. the reaction of the person who is touched (whether the
touch is welcome or unwelcome)
f. the gender of the person who is touched and the gender of the
person performing the touch.
g. The age of the person who is touched
2. Any direct care that requires privacy curtains must be done with “two
sets of eyes.” There must be another adult, in addition to the health
care provider, present in the room whenever a privacy curtain is
pulled. This second adult may be another staff member, a physician,
or a parent/legal guardian.
74
C.- Physical contact between all staff, employees, volunteers, students and
others providing services shall be appropriate and respectful, and should
avoid any appearance of impropriety at all times.
1. For example, giving "shoulder massages" at a nursing station may seem
acceptable if both parties welcome the touching. However, this may
appear inappropriate to other individuals walking by, and therefore,
should not occur.
D. - Cultural Awareness: Respect for, and sensitivity toward, the cultural beliefs
of our patients/families should always be considered. For example, some
cultures prohibit touching between members of the opposite sex unless they are
married.
E. - Gifts in the context of professional boundaries:
2. Giving gifts: In a pediatric setting, small gifts (i.e., stickers, pins, crayons)
may be given to patients and/or siblings as a means of distraction or
anxiety-reduction.
a. In the event a staff member believes a small gift is appropriate, the gift
must be obtained from established hospital sources (i.e., unit or
department supplies, cafeteria for birthday cakes, Child Life or Social
Work).
b. The gifts should be given to meet the needs of the patient/sibling, and
they should be given from the organization.
c. At no time should an employee, volunteer, medical staff member or
student provide a gift on his/her own behalf to a patient or family
member.
d. Sensitivity should be maintained regarding the environment in which
the gift is given (e.g., are siblings present, are other patients present,
etc.)
3. Receiving gifts: Although families may bring in tokens of appreciation
(candy, coffee, etc.), we must be aware that if this occurs on a regular
basis it may impact professional boundaries. At no time, should staff
accept cash gifts from patients/families. (Please see RCPM 7-39 for
further details on gifts.)
F. - Unintended consequences: Maintain awareness that there may be unintended
consequences that result from boundary violations. . It is important to be aware
of the intent and frequency of receipt of even small gifts and assure the patient
and family that the quality of care is not dependent upon the relationship with the
caregiver.
75
G.- Developing personal relationships with patient/families: It is strongly
recommended that staff not develop personal relationships with patients/families that
blur professional boundaries.
1. For example, babysitting or providing care at the patient’s home during off-duty
hours, meeting parents for lunches, inviting families to your home, etc. These
activities can easily result in the blurring or elimination of boundaries.
2. It is understandable that staff may be invited to attend special events involving a
patient, especially when a patient has been in the hospital on a long-term basis,
for example, hematology-oncology patients. (For example, graduations, birthday
parties, etc.) In the event an invitation to such an event is extended and accepted,
you should make every effort to maintain appropriate boundaries and avoid
being seen as “part of the family.”
Date written: October 2006
Reviewed and approved by Operations Council: November 2, 2006
76
CURRENT
EFFECTIVE
DATE
January
2012
REVISED
DATE
September
2011
MANUAL:
Personnel
TRACKING #
PPM 826
TITLE:
P O L I C Y/PROCEDURE
STANDARDIZED PROCEDURE
PLAN
GUIDELINE
Specialty Review
Human Resources
EOC/Safety
Med Staff
Risk Management
Forms
RCHSD COMMITMENT TO
QUALITY, SAFETY, AND JUST
CULTURE GUIDELINES
PERFORMED BY:
All RCHSD Staff
Council Review
Information Management
Infection Control
Interdisciplinary Practice
Pharmacy & Therapeutics
Compliance
ACCREDITATION/STANDARD
Center Review
Med Staff Executive
Clinical Review
EOC/Safety
1.1 PURPOSE:
To provide a structured, consistent process for leaders to use when following up with
staff on safety concerns.
To foster a learning culture with increased reporting, transparency and accountability
2.1 PHILOSOPHY:
In order to support and deliver safe and effective care, RCHSD commits to the
following:
Accountability belongs to the individual and our system. People are accountable for
their own actions but should not carry the burden for system flaws.
Effective teamwork and open communication foster an environment that reduces
errors.
We strive to standardize and simplify information so that everyone shares a common
understanding.
We will use what we learn to make changes that improve safety.
We commit to looking for and correcting the causes of adverse events, assigning
responsibility for implementing actions to specific individuals or groups.
We promote open discussion within our organization to learn about adverse events
and potential causes of patient harm.
We commit to developing and maintaining easy and effective ways for caregivers and
patients to discuss adverse events and safety concerns.
Page 1 of 7
Personnel Policy Manual, PPM 826 “RCHSD Commitment to Quality,
Safety, and Just Culture Guidelines ”
77
We encourage sharing what we learn; this information helps lead us to actions that
improve the healthcare environment.
We promote interdisciplinary discussion to analyze adverse events and potential
patient harm.
We will seek different points of view to identify sources of patient harm.
We believe that patient/family input is indispensable to the delivery of safe care, and
we commit to promoting patient/family participation in our organizational decisions.
We commit to unbiased analysis of incidents of patient harm or potential harm,
looking at both the system and individual factors.
We will inform patients and families, caregivers, leadership, and trustees about
actions taken to improve patient safety.
We commit to fostering an environment that is concerned with safety through
ongoing education, reminders and dialogue.
We commit to ensuring that our leaders and caregivers understand the complexities of
delivering safe patient care and support our commitment to a safe and just culture.
We will measure our success in promoting an environment of patient safety.
3.0 DEFINITIONS
3.1 Human Error – Inadvertently doing other than what should have been done; a slip,
lapse, mistake
3.2 At-Risk Behavior – A behavior choice that increases risk where risk is not
recognized, or is mistakenly believed to be justified
3.3 Health Issue/Possible Reckless Behavior – A health condition that increases risk
where risk is not recognized or a conscious decision has been made to disregard
substantial and unjustifiable risk of causing harm
3.4 Reckless Behavior – Conscious decision to disregard substantial and unjustifiable
risk of causing harm
3.5 Red Rule – Requirements that are considered so important to an organization that
there is no tolerance for their being broken. Except in rare or urgent situations, Red
Rules are used to identify standards that should be undertaken every time a particular
event or process occurs. Because of their importance, when a Red Rule is broken, it is
considered Reckless Behavior, regardless of the intended consequences or outcome.
3.6 Systems Issues - Unintended organizational breakdown or failure of interacting
components (people, processes, equipment, environment) which contributes to
undesirable results
3.7 Support –A learning conversation discussing why an event happened and what, if
anything, can be done to prevent it from happening again. Also involves comforting
the employee in an attempt to alleviate the grief, sense of loss and/or anxiety they
may be feeling.
3.8 Coaching – A learning discussion in response to an at-risk behavior; often involves
raising awareness and/or changing the perception of risk and establishing an
understanding of the consequences. The purpose of coaching can be to improve
performance, often by eliminating, mitigating or reducing risk.
3.9 Corrective Action - Documented action plan designed to specifically address areas
of required improvement in performance. Corrective Action may be progressive in
78
nature or may lead to disciplinary action up to termination depending upon the
severity of the infraction.
3.10 Systems Analysis – A comprehensive and structured approach intended to
evaluate the interplay of an individual and the design of protocols, processes,
procedures, training, and environment for the purpose of improving reliability.
Correction of systems issues may include mitigating human errors, removing
opportunities for at risk behavior, creating incentives for healthy behaviors, and
increasing situational awareness.
4.1 PROCEDURE:
The Just Culture Algorithm is a guide to assist in event analysis and action planning by
the appropriate Manager/Director, in conjunction with Human Resources. This excludes
those incidents which involve violation of State and Federal law and RCHSD Standards
of Conduct.
EVENT ANALYSIS:
 After an incident involving a staff member occurs, follow the Just Culture algorithm
path by answering the specific algorithm question and moving to the next question
based on the answer arrow.
 Real world situations are rarely able to be answered with a simple yes/no. The
supplemental questions included below are designed to aid you in your analysis.
 If you are asking questions of a member of a collective bargaining unit work with
your Human Resource Partner to offer the employee the opportunity for union
representation.
 The analysis begins with the Deliberate Harm Test on the Just Culture Algorithm.
4.1 Deliberate Harm Test: Was it the employee’s deliberate intent to cause harm?
 Specific Intent: To identify if the employee made the choice to behave as he/she
did to cause or potentially cause a negative outcome.
 Supplemental Questions:
Were the actions purposeful/a choice?
What was the intent?
How do we know this was the intent?
Why would this person have this intent at this time?
Who else knew about this intent?
When/where was this intent expressed?
Why is this intent important?
Was the employee aware of the risks posed by their actions?
4.2 Incapacity Test: Does the person appear to be ill, under the influence, or unfit
for duty?
 Specific Intent: To identify if the employee has reported to work in a condition
that poses a safety risk to themselves or others or has engaged in conduct that
detracts from the effective and efficient operations of RCHSD.
79

Supplemental Questions:
What specific behaviors are being exhibited?
How often?
Who else has seen the behavior?
Are there multiple causal possibilities for the behaviors?
Are there performance issues?
Have the performance issues been addressed? When, by whom and how?
Has the person expressed a need for any ADA qualifying help?
4.3 Foresight Test: Did the person follow relevant policies, procedures, and
standards of care?
 Specific Intent: To identify whether protocols and safe working practices were
adhered to.
 Supplemental Questions:
What specific policy, procedure or standard of care was violated?
Why were the policies, procedures and standards of care not followed?
How do we know they were not followed?
4.4 Red Rules Test: Violation of RCHSD Red Rule?
 Current RCHSD Red Rules include:
1) Privacy policies
2) Child Safety-related policies
3) Patient Identification Verification
4.5 Substitution Test: Are other individuals (in the same peer group with similar
qualifications & experience) exhibiting or vulnerable to this same
behavior/action?
 Specific Intent: To identify issues that may exists amongst the group, unit,
department or organization. To assess how a peer may act with the same situation
to identify vulnerabilities beyond the individual.
 Supplemental Questions:
Were there any deficiencies in training, experience or supervision?
How prevalent is this behavior amongst the employee’s peers?
What normally happens? Could involve having other employees take you
through the steps they follow when performing same task.
Were there mitigating circumstances that lead to the individual’s action?
If not, why would they not?
If yes, why would this be true?
If yes, what are the circumstances that would make this true?
4.6 Foresight Test: Are the policies, procedures, AND systems: available, workable,
intelligible, up-to-date, routinely used, AND sufficient to manage risk?
 Specific Intent: To identify systems, policies, process, or procedural
vulnerabilities. To identify organization policies that are not feasible to adhere to.
 Supplemental Questions:
Was the employee aware of the policy/procedure?
Was the employee educated on the policy/procedure?
80
Did the individual have ready access to the policy/procedure?
Are there any conflicting policies/procedures?
Was it possible to follow the policy/procedure?
Policy/procedure technically accurate but not feasible for applying in the
work setting?
Did the policy/procedure promote correct and sensible action?
Was the policy/procedure recently changed?
Does the source of the series of human errors or at-risk behaviors
reside within the system?
Does the system rely on employee vigilance to not make a mistake?
How was the risk being managed before this event?
Are barriers in place to prevent this incident from reoccurring?
4.7 Repetitive Error Test: Is this a repetitive error?
 Specific Intent: To identify individuals who have a history of the same or
similar behavior/actions.
 Supplemental Questions:
Is the individual repetitively violating policy or involved in unsafe acts
Does the individual have a history of errors or mistakes?
Are there unidentified physical causes that are leading to these
repetitive actions or behaviors?
What types of mistakes or violations has this employee made in the
past? How often?
Has there been past support, education, or coaching? With whom and when?
Is there documentation of past support, education, or coaching with
this employee?
5.0 CROSS REFERENCES:
5.1 CPM 9-03: Safety Reporting System
5.2 CPM ####: Second Set of Eyes Policy
5.3 CPM 12-24: Privacy Violation Investigation, Sanction, and Corrective
Action Protocol
5.4 PPM 808: Corrective/Disciplinary Actions
5.5 CPM 12-21: Code of Conduct
81
UNIVERSITY OF CALIFORNIA, SAN DIEGO
Graduate Medical Education Academic Due Process and
Leave Guidelines
I.
INTRODUCTION
Definitions
Academic Deficiency: The terms “Academic Deficiency” or “Deficiencies” mean unacceptable
conduct or performance in the professional and/or academic judgment of the Chair or Program
Director, including failure to achieve, progress or maintain good standing in the Training Program,
or achieve and/or maintain professional standards of conduct as stated below.
Associate Dean: The term “Associate Dean” means the Associate Dean for Graduate Medical
Education.
Chair: The term “Chair” means the Chair of the Trainee’s specialty or subspecialty department, or
his/her designee.
Clinical Competence Committee: The term “Clinical Competence Committee” means a committee
of a School of Medicine department or division, and/or a committee specially selected by the
Associate Dean for Graduate Medical Education in conjunction with the Chair, Graduate Medical
Education Committee, that reviews the academic performance of Trainees.
Days: The term “days” means calendar days.
GME Training Program: The terms “graduate medical education training program” or “GME
training program” refer to the second stage of medical education during which medical school
graduates are prepared for independent practice in a medical specialty. The foremost
responsibility of the GME training program is to provide an organized education program with
guidance and supervision of the Trainee, facilitating the Trainee’s professional and personal
development while ensuring safe and appropriate care for patients. Graduate medical education
involves the development of clinical skills and professional competencies and the acquisition of
detailed factual knowledge in a medical specialty. These professional standards of conduct
include, but are not limited to, professionalism, honesty, punctuality, attendance, timeliness,
proper hygiene, compliance with all applicable ethical standards and UCSD policies and
procedures (including but not limited to the UCSD Medical Center Medical Staff Code of Conduct
Policy), an ability to work cooperatively and collegially with staff and other health care
professionals, and appropriate and professional interactions with patients and their families.
A Trainee, as part of his or her GME Training Program, may be in a hospital, other clinical setting
or research area. All such appointments, either initial or continuing, are dependent upon the
Trainee maintaining good standing in a GME training program. Dismissal from a GME training
program will result in the Trainee’s automatic dismissal from any and all related appointments
such as medical staff membership.
Medical Disciplinary Cause or Reason: The term “medical disciplinary cause or reason” applies to
a GME Trainee who holds a license from the State Medical Board of California and means that
aspect of a licentiate’s competence or professional conduct that is reasonably likely to be
detrimental to patient safety or to the delivery of patient care in accordance with Business and
Professions Code section 805.
Program Director: The term “Program Director” means the Training Program Director for the
Trainee’s specialty or subspecialty, or designee.
Trainee: The term “Trainee” includes all individuals appointed by UCSD’s School of Medicine to
the titles of Resident Physician I-IX (title codes 2709, 2723, 2708, 2724), Chief Resident
82
Physician (title code 2725, 2738), Resident Physician/Subspecialist IV-IX (title code 2726), Other
Post M.D. Trainee II-IX (title code 2732), where specified by UCSD guidelines, or any other GME
title assigned by UCSD.
Vice Chancellor: The term “Vice Chancellor” means UCSD Vice Chancellor Health Sciences or
his/her Designee.
Preamble
The procedures set forth below are designed to provide the University of California San Diego
(“UCSD”), UCSD resident physicians and other post-M.D. trainees (collectively referred to as
“Trainees”) an orderly means of resolving differences. These Guidelines apply to UCSD
sponsored programs of Graduate Medical Education (“Training Programs”). These Guidelines
shall be the exclusive remedy for appealing reviewable academic actions. Deviation from these
procedures that does not result in material prejudice to the Trainee will not be grounds for
invalidating the action taken.
Additional time for remediation, either within the Training Program appointment or beyond the
expiration of the Trainee’s current appointment, may be required to meet the educational
objectives and certification requirements of the department or specialty. The Trainee will be
notified in writing of any requirements for additional time. Funding for additional time extending
beyond the original period of appointment will be permitted only at the discretion of the Associate
Dean and upon written confirmation by the Associate Dean and the Program Director or Chair.
Academic credit will be given only for full participation in the regular program unless otherwise
approved by the Program Director or Chair.
At UCSD, the primary responsibility for remedial academic actions relating to Trainees and
Training Programs resides within the departments and the individual training programs.
Therefore, academic and performance standards and methods of training and evaluation are to
be determined by each department and/or program at UCSD School of Medicine and UCSD
Medical Center. There may be variances in these standards among the various departments and
Training Programs.
Trainees and their supervisors are encouraged to discuss their concerns with one another and, if
there are any disagreements or disputes, Trainees and their supervisors should make efforts to
resolve them. The action(s) taken should be those that in the professional and/or academic
judgment of the Program Director or Chair best address the deficiencies and needs of the Trainee
and/or the Training Program. These actions are at the discretion of UCSD and need not be
progressive. UCSD may select those action(s) described below that it deems appropriate.
A Trainee may request a correction or deletion of his/her academic file under this policy by
submitting a written request to the Program Director. Within thirty (30) days of receipt of a written
request to amend or delete a record, the Program Director will either make the amendment or
deletion or inform the individual in writing that the request has been denied. If the Program
Director refuses to amend or delete the record, the Trainee may enter into the record a statement
setting forth the reasons for the Trainee’s disagreement with the record. Removal of
documentation of action(s) from the Trainee’s file does not preclude the University from relying on
the removed documentation should any subsequent academic action be taken or from
communicating the information as required by law, upon receipt of a release from the Trainee, or
to any appropriate third party such as a hospital, hospital medical staff or professional licensing
board when such communication is intended to aid in the evaluation of the qualifications, fitness,
character or insurability of the Trainee.
II. ACADEMIC ACTIONS - NON-DISMISSAL
Administrative Actions
i.
Non Appealable Suspension
The Trainee may be suspended from the Training Program for any of the following reasons:
83
1. failure to complete and maintain medical records as required by the medical center or site
in accordance with the center’s/site’s medical staff bylaws and/or rules and regulations;
2. failure to comply with state licensing requirements of the California State Medical Board;
3. failure to obtain or maintain proper visa status;
4. unexcused absence from Training Program for three or more days;
5. the inability to complete a rotation at an Affiliate Institution that is deemed essential to
meeting the requirements of the Training Program.
The period of suspension should not exceed fourteen (14) days; however, other forms of
academic action may follow the period of suspension.
The Chair or Program Director will promptly notify the Trainee of his/her suspension. In
addition, for subsections b, c, d and e above, the Trainee will be provided the documentation
upon which the suspension is based and a written notice of the intent to consider the Trainee
to have automatically resigned at the end of the suspension period (see Part II.A.2. below).
The Trainee may utilize the suspension period to rectify (a) or to respond to the notice of
intent under (b), (c), (d) or (e) which can include correcting the problem identified in (b), (c) or
(e). If the Trainee is suspended under (a) and does not complete the medical records as
required within the 14 day suspension period, other academic action may be instituted.
The Trainee will not receive any academic credit during the period of suspension. The
Trainee’s stipend will continue to be paid while on suspension status.
ii.
Automatic Resignation
Automatic resignation from the Training Program will not entitle the Trainee to the procedures
contained in Part III.B. of these Guidelines. Reasons for automatic resignation include:
1. Failure to Provide Visa or License Verification.
Failure of the Trainee to provide verification of an appropriate and currently valid visa or
verification of current compliance with state licensing requirements of the state Medical
Board of California during the 14 day suspension period may result in the Trainee’s
automatic resignation from the Training Program.
2. Failure of trainee to achieve reversal of Affiliate’s decision to revoke the Trainee’s
privilege to rotate to the Affiliate Institution during the 14 day suspension period may
result in the Trainee’s automatic resignation or dismissal from the Training Program if the
rotation at the Affiliate is deemed essential by the Program to meeting the requirements
of the Training Program.
3. Absence without Granted Leave.
Trainees are expected to communicate directly with the Program Director in the event he
or she is unable to participate in the Training Program for a period of time in excess of 48
hours. The Program Director may grant a leave in times of exceptional circumstances. If
a Trainee is absent without leave for three (3) days or more, he or she may be
considered to have resigned voluntarily from the program unless he or she submits a
written explanation of any absence taken without granted leave. This explanation must be
received by the Program Director within five (5) days of the first day of absence without
leave.
The Program Director and Chair will review the explanation and any supporting
documentation submitted by the Trainee regarding the absence without leave and notify
the Trainee of their decision within five (5) days. Failure to adequately explain or
document the unexcused absence to the satisfaction of the Program Director and Chair
will result in the Trainee’s automatic resignation from the Training Program.
iii.
Leaves
84
Investigatory leave and conditional leave of absence are not intended to replace any leaves
that a Trainee may otherwise be entitled to under state or federal law or University policy.
1. Investigatory Leave
A Chair or Program Director may place a Trainee on investigatory leave in order to
review or investigate allegations of deficiencies or circumstances where the Trainee may
pose a threat to the health or safety of the public, patients or staff or in situations where
the Trainee’s own health or safety may be compromised. The leave will be confirmed in
writing, stating the reason(s) for and the expected duration of the leave. The alleged
deficiency should be of a nature that warrants removing the Trainee from the Training
Program. The Chair or Program Director should, as soon as practicable under the
circumstances, conclude the investigation and either return the Trainee to the program or
initiate action under these Guidelines. The Trainee will be paid for the period of
investigatory leave.
2. Conditional Leave
A conditional leave of absence from the Training Program may be provided only under
exceptional circumstances, at the Chair’s discretion and upon the Trainee’s request. At
the end of the conditional leave, the Chair will determine whether to re-admit the Trainee
conditionally, unconditionally, on probation or to seek the Trainee’s dismissal pursuant to
the procedures contained in these Guidelines. The Trainee will not be paid a stipend for
the period of the conditional leave.
Non-Reviewable Academic Actions
The following actions are non-reviewable and may or may not be used sequentially or in tandem
with one another:
i.

Counseling Letter

Notice of Concern

Probation
Counseling Letter
A counseling letter may be issued by the Program Director or Chair to a Trainee to address
an academic or professional deficiency that needs to be remedied or improved. The purpose
of a counseling letter is to describe a single instance of problematic behavior and to
recommend actions to rectify the behavior. The Program Director will review the counseling
letter with the Trainee. Failure to achieve immediate and/or sustained improvement, or a
repetition of the conduct may lead to other disciplinary actions. These actions are determined
by the professional and academic judgment of the Program Director and/or the Chair and
need not be sequential. For the purposes of this policy and for responses to any inquiries, a
counseling letter does not constitute a disciplinary action.
ii.
Notice of Concern
A notice of concern may be issued by the Program Director or Chair to a Trainee who is not
performing satisfactorily. Notices of concern should be in writing and should describe the
nature of the deficiency(ies) and any remedial actions required on the part of the Trainee. A
Letter of Concern is typically used when a pattern of problems emerges. The Program
Director or Chair will review the notice with the Trainee. Failure to achieve immediate and/or
sustained improvement, failure to meet any requirement(s) set forth in the letter, or repetition
of the conduct may lead to additional actions. This action need not follow a counseling letter
nor proceed other academic actions described later in these guidelines. A notice of concern
does not constitute disciplinary action for purposes of these guidelines or for responses to
inquiries.
iii.
Probation
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Trainees who are in jeopardy of not successfully completing the requirements of the Training
Program or who are not performing satisfactorily may be placed on probation by the Chair or
Program Director. Probation will be communicated to the Trainee in writing and should
include: a description of the reasons for the probation, any required remedial activity, and the
expected time frame for the required remedial activity. Failure to correct the deficiency(ies)
within the specified period of time may lead to an extension of the probationary period or to
other actions.
Academic Actions Appealable to the Clinical Competence Committee
Trainees may appeal the following actions to the Clinical Competence Committee:

Suspension

Adverse Annual Evaluation

i.
Non-renewal of appointment before four months prior to the end of the Trainee’s
current appointment

Repetition of an academic year

Denial of a UCSD Certificate of Completion of Training
Suspension
The Chair may suspend the Trainee from part or all of the Trainee’s usual and regular
assignments in the Training Program, including clinical and/or didactic duties, when the
removal of the Trainee from the clinical service is required for the best interests of the
Trainee, patients, staff and/or the Training Program. The suspension will be confirmed in
writing, stating the reason(s) for the suspension and its expected duration. Suspension
generally should not exceed sixty (60) days. Suspension may be coupled with or followed by
other academic actions and will continue unless and until overturned by the Clinical
Competency Committee after an appeal. The Trainee’s stipend will continue to be paid while
the Trainee is on suspension.
ii.
Adverse Annual Evaluation
Trainees will only be entitled to a review by the Clinical Competence Committee for annual
evaluations that are adverse (overall unsatisfactory or marginal) (“Adverse Annual
Evaluation”). Trainees will be notified by the Program Director of any Adverse Annual
Evaluation.
iii.
Non-Renewal of Appointment Before Four Months Prior to End of Appointment
The Trainee’s appointment is for a one-year duration, which is normally renewed annually.
Due to the increasing level of responsibilities and increasing complexity of clinical care over
the course of the Trainee’s training, satisfactory completion of prior academic year(s) or
rotation(s) does not ensure satisfactory proficiency in subsequent years or rotations. A
Trainee may have his/her appointment not renewed at any time there is a demonstrated
failure to meet programmatic standards.
The Program Director should provide each Trainee with a written evaluation at least twice per
year. The first evaluation should occur no later than sixth months following the beginning of
the appointment term. If the Program Director with the approval of the Chair concludes that
the Trainee’s appointment should not be renewed for the following year, the Program Director
will notify the Trainee of such. The Trainee will be permitted to conclude the remainder of the
current academic year unless further academic action is taken.
A Trainee who is notified of the non-renewal of his/her appointment for the following year,
before the four months prior to the end of his/her current appointment, will be entitled only to
the procedures contained in this Part II.D. of these Guidelines. (A Trainee who is notified of
the non-renewal of his/her appointment for the following year after this time will be entitled to
the procedures contained in Part III.B. of these Guidelines. See Part III.B.2.)
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iv.
Requirement that Trainee Must Repeat an Academic Year
A Trainee may be required to repeat an academic year in lieu of dismissal from the Training
Program due to unsatisfactory progress or other deficiencies at the discretion of the Program
Director and Department Chair provided there are sufficient funds. Funds for the additional
year must be identified with written confirmation by the Program Director or Chair to the
Associate Dean.
v.
Denial of University Certificate of Completion
If the Program Director, in consultation with the Chair, decides not to award the Trainee a
University Certificate, the Program Director will notify the Trainee as soon as reasonably
practicable of this intent.
Clinical Competence Committee Appeal Procedures
The Trainee will be notified as soon as reasonably possible that he/she has been suspended,
received an Adverse Annual Evaluation, that his/her appointment will not be renewed (notice
given more than four months before the end of his/her appointment), that he/she will be required
to repeat the current academic year, or that s/he will not be granted a UCSD Certificate of
Completion of Training. The Trainee will also be provided the name of and manner by which to
contact the appropriate Clinical Competence Committee Chair to appeal the Training Program’s
decision.
In order to appeal, the Trainee must, within ten (10) days from the date of the notification, provide
the Clinical Competence Committee Chair with a written statement detailing the reasons he/she
believes he/she should not have been suspended, should not have received an Adverse Annual
Evaluation, should have had his/her appointment renewed (for the Trainee notified of nonrenewal before four months prior to the end of his/her appointment), not be required to repeat the
academic year, or should not be granted a UCSD Certificate of Completion of Training. The
Clinical Competence Committee will review the Trainee’s statement within twenty (20) days of its
receipt. The Clinical Competence Committee, at its discretion, may permit or request the personal
attendance of the Trainee. While the Trainee has no right to representation by an attorney at the
Clinical Competence Committee meeting, another person of his/her choice may accompany the
Trainee.
The Clinical Competence Committee will orally notify the Trainee of its decision within three (3)
days of its meeting and provide the Trainee a written decision within ten (10) days of the oral
notification. The decision of the Clinical Competence Committee will be final. Failure by the
Trainee to timely request a review before the Clinical Competence Committee will be deemed an
acceptance by the Trainee of the academic action.
III. ACADEMIC ACTIONS - NON-RENEWAL OF APPOINTMENT WITHIN FOUR MONTHS OF END
OF CURRENT APPOINTMENT AND/OR DISMISSAL
Grounds for Action
The following actions, if appealed, are reviewable by the Vice Chancellor:
i.

Dismissal from the Training Program including non-renewal of appointment at
any time for a medical disciplinary cause or reason;

Non-renewal of appointment within four months of the end of the current
appointment.
Dismissal From Training Program
Based on the Program Director’s discretion as approved by the Chair, a Trainee may be
dismissed from the Training Program for academic deficiencies, including any of the following
reasons:
1. Failure to achieve or maintain programmatic standards in the Training Program;
87
2. Serious or repeated act or omission compromising acceptable standards of patient care,
including an act which constitutes a medical disciplinary cause or reason;
3. Unprofessional, unethical or other behavior that is otherwise considered unacceptable by
the Training Program;
4. Material omission or falsification of Training Program application, medical record or other
University document, including billing records;
5. Confirmation of findings in a criminal background check which could be considered a
potential risk to patients and/or other individuals or considered unprofessional or
unethical.
ii.
Non-Renewal of Appointment Within Four Months of End of Current Appointment
See Section II, C.3. of these guidelines for discussion of non-renewal of appointment.
Dismissal Procedures
The procedures contained in this Part III.B of these Guidelines apply only to those actions
reviewable by the Vice Chancellor listed in Part III.A. of these Guidelines. Failure to appeal within
thirty (30) days will be deemed a waiver of any appeal rights and acceptance by the Trainee of
the academic action.
The Ad Hoc Formal Review Committee, see below, will handle all procedural matters during the
actual hearing. At all other times, before and after the actual hearing, including up to the Vice
Chancellor’s final decision, the Associate Dean will make all such decisions.
i.
Level One - Informal Review
When the Program Director, with the approval of the Chair, determines that grounds exist to
dismiss a Trainee or to not renew his/her appointment (notice given within four months of the
end of the appointment date), the Program Director will provide the Trainee with written
notice of the intent to dismiss or non-reappointment. This notice will include a statement of
the reason(s) for the intended dismissal or non reappointment, a copy of the materials upon
which the intended dismissal or non-renewal is based, and a statement that the Trainee has
a right to respond in writing to the Chair within ten (10) calendar days of receipt of the notice.
If the Trainee does not respond, the intended action shall become final eleven (11) calendar
days after receipt of the notice or as otherwise noted by the Program Director. If the Trainee
submits a written response within the ten-day period, the Chair will review it. After reviewing
the Trainee’s written response (if any), the Chair will decide whether non reappointment or
dismissal is appropriate. Within ten (10) days thereafter, the Chair will notify the Trainee of
the Chair’s decision by letter, which shall also be copied to the Program Director and
Associate Dean. If the decision is to uphold the intended non-renewal or dismissal, the letter
should include the reasons for upholding the proposed action, provide the effective date of
the non reappointment or dismissal if the Complainant does not appeal the Chair’s decision,
and include a copy of these guidelines. Attempts at informal resolution do not extend the time
limits for filing a formal appeal unless the Trainee and the Program Director so agree, or upon
the approval of the Associate Dean. The Trainee will continue to receive regular stipends until
the effective date of the dismissal or appointment end date.
ii.
Level Two - Formal Review
If the Trainee wishes to appeal the Chair’s decision to dismiss or not reappoint, the Trainee
(“Complainant”) must file a written complaint with the Associate Dean no later than thirty (30)
days after the Trainee receives the Chair’s decision. The written complaint should concisely
explain why the Complainant believes the Chair’s decision was arbitrary and capricious and
should address the specific reasons for the dismissal or non-reappointment set forth in the
Program Director’s notice of intent to dismiss or to not reappoint.
The Complainant may be assisted or represented by another person at his or her own
expense. UCSD may also be represented. If the Complainant is represented by an attorney,
88
he/she shall notify the other party fifteen (15) days prior to the pre-hearing conference or
thirty (30) days prior to the hearing, whichever occurs first. The University will not be
represented by an attorney if the Complainant is not so represented. The Complainant must
appear in person at the hearing, even when represented. The failure of the Trainee to appear
in person for the full duration of the hearing will be deemed a voluntary dismissal of his/her
complaint.
Within ten (10) days of receipt of the appeal, or as soon thereafter as is practicable, the
Associate Dean will appoint an Ad Hoc Formal Review Committee to hear the complaint. The
Committee will consist of either three or five members, at least one of which shall be a
member of the full-time faculty, one senior trainee (PGYIII or higher), and one faculty member
of the Graduate Medical Education Committee. The Associate Dean will designate one of the
Committee members to be the Committee Chair. If possible, one of the Committee members
should be from the same department as the Complainant; however, individuals who were
substantially involved in any earlier review of the issues raised in the complaint, or who were
substantially involved in any incident underlying the complaint generally should not sit as a
member of the Committee. The Committee may, at its discretion, request that an attorney
from the Office of the General Counsel be appointed to provide independent legal counsel to
the Committee. This attorney shall not vote in the Committee’s deliberation process. Until the
appointment of a Committee Chair, the Associate Dean will resolve all issues related to these
procedures.
The Hearing will ordinarily be held within forty-five (45) days of receipt of the appeal by the
Associate Dean. Unless otherwise agreed by the Parties and the Chair, the Complainant and
his/her advocate, if any, will meet at least fifteen (15) days prior to the Hearing at a prehearing conference with the Committee Chair, the University representative and the
University advocate (if any) to agree upon the specific issues to be decided by the
Committee. If the parties are unable to reach an agreement on the issues to be decided, the
Committee Chair will determine the issues to be reviewed. Issues that were not raised in the
notice of intent to dismiss or to not reappoint, the Trainee’s written and timely response
thereto, or the notice of the Chair’s decision, may not be raised in the Hearing absent a
showing of good cause. At this conference, the parties may raise other procedural and
substantive issues for decision by the Chair.
At least ten (10) days prior to the Hearing or at another date agreed to by the Parties and the
Chair, all documents to be introduced as evidence at the hearing and names of all witnesses
shall be exchanged. With the exception of rebuttal witnesses and documents used in rebuttal,
any witnesses not named and documents not exchanged seven (7) days before the hearing
may, at the Committee Chair’s discretion, be excluded from the Hearing.
The Hearing will provide an opportunity for each party to present evidence and crossexamine witnesses. The Committee Chair has broad discretion regarding the admissibility
and weight of evidence and is not bound by federal or state rules of evidence. If requested by
either party, the Committee will take judicial notice of (i.e., recognize as a fact the existence
of) any University policies. The Committee Chair will rule on all questions of procedure and
evidence. The hearing will be recorded on audio tape by the University unless both parties
agree to share the cost of a court reporter, or one party elects to pay the entire cost for the
reporter in order to have a transcript for its own use, in which case the other side may
purchase a copy of the transcript for half the cost of the court reporter and transcription plus
any copy costs. The Complainant may listen to any audio tape and may purchase a copy of
the audio tape. The Associate Dean, or designee, will be the custodian of the audio tape and
any stenographic record, and will retain the recording for five (5) years from the time the Vice
Chancellor’s decision becomes final.
Unless both the Complainant and the University agree to an open hearing, the hearing will be
closed. All materials, reports and other evidence introduced and recorded during the course
of a closed proceeding may not be disclosed until the final resolution of the appeal under
these procedures except as may be required by applicable law. At the request of either party
89
or the Committee Chair, only the witness testifying may be present and other potential
witnesses will be excluded. However, the Complainant, his/her advocate and the University’s
representative and its advocate will at all times have the right to attend the hearing.
The University has the responsibility to establish that the dismissal or non-renewal was
neither arbitrary nor capricious. The University will initially come forward with evidence in
support of the Chair’s decision. Thereafter, the Complainant will present his/her evidence.
The parties shall have the opportunity to present rebuttal evidence. The Committee Chair has
the right to limit rebuttal evidence at his/her discretion.
At the discretion of the Committee, briefs may be submitted. The Committee Chair will
determine the appropriate briefing schedule, if any. If briefs are not requested, each party
shall have the opportunity to present a closing statement. In any event, the Complainant may
submit a written statement at the close of the hearing. Following the close of the Hearing,
including receipt of any briefs, the Committee will present its written recommendation(s) to
the Complainant, the Chair, Program Director and Associate Dean. This recommendation(s)
should occur, absent unusual circumstances, within fifteen (15) days of the Hearing’s
conclusion, or if briefs are submitted, within fifteen (15) days of the date the briefs are
submitted.
The Committee will evaluate the evidence presented and prepare a recommended decision
that shall contain written findings of fact and conclusions. The decision of the Chair will be
upheld if the Committee finds that the University has met its burden and established by a
preponderance of the evidence that the Chair’s decision was not arbitrary and capricious.
The recommended decision shall become final after fifteen (15) days unless an appeal is filed
pursuant to III.C.
Decision By Vice Chancellor
Within fifteen (15) days of receipt of the Committee’s recommendation(s), either party may submit
a final written response to the Committee’s recommendation(s) to the Vice Chancellor. Any such
response submitted to the Vice Chancellor must be limited to:
i.
Evidence to support the Committee’s recommendation; or
ii.
Whether there is new evidence that could not reasonably have been introduced at the
hearing and would be likely to change the result.
After receipt of the Committee’s recommendation, the parties’ written response (if any), and
the record, the Vice Chancellor within sixty (60) days, or as soon as practically reasonable
thereafter, will take any action deemed appropriate, including upholding the Committee’s
Recommended Decision, rejecting the Committee’s recommendation or remanding the
matter back to the Committee with instruction for further review and recommendation. The
Vice Chancellor’s ultimate decision will be final and will be in writing and sent to the Program
Director, the Chair, the Complainant, the Associate Dean and the Ad Hoc Formal Review
Hearing Committee Chair.
Remedy
If the Complainant appeals and the Chair’s decision is not upheld, the remedy will not exceed
restoring the Complainant’s stipend payment, benefits or any rights lost as a result of the action,
less any mitigating income earned from other sources. The Trainee will also receive his/her
stipend for any time that they remain in the Training Program unless further action is taken.
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Fatigue and Stress
Management
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Getting a Better Night’s Sleep
from the UCSD Sleep Medicine Center (http://health.ucsd.edu/specialties/sleep/tips.htm)
SLEEP TIPS
These tips from the American Academy of Sleep Medicine may help you get a better night's sleep:
Get up at approximately the same time every day, including weekends
Go to bed only when sleepy
Establish relaxing pre-sleep rituals, such as a warm bath, light bedtime
snack or 10 minutes of reading
Exercise regularly, but avoid strenuous workouts within six hours of
bedtime, and mild exercise, such as simple stretching or walking, at
least four hours prior to bedtime
Maintain a regular schedule-our inner clocks run most efficiently when
eating meals, taking medications, performing chores and other activities
at regular intervals
Avoid caffeine within six hours of bedtime, and don’t drink alcohol,
especially when you are sleepy
While a light snack before bedtime can promote sound sleep, avoid
large meals
Minimize light, noise and extremes in temperature in the bedroom
Avoid smoking as bedtime approaches
Avoid daytime naps, or limit nap time to a single nap of less than an hour
no later than 3 p.m.
Avoid using your bedroom for activities such as work, watching
television, etc.
Manage stress by relieving your worries through therapy, relaxation
techniques, hypnosis, biofeedback, or by simply talking to a trusted
companion or designating some personal problem solving time.
Sleeping pills should be used only as prescribed by your personal
physician (most doctors avoid prescribing sleeping pills for periods
longer than three weeks)
If sleep eludes you, leave your bedroom and engage in a quiet activity elsewhere. Do not permit yourself
to fall asleep outside the bedroom. Return to bed only when you are sleepy. Repeat this process as often
as necessary throughout the night.
Read more about How to set up a healthy sleep environment
Think you might have sleep apnea? Read the article Should I have a
sleep study to diagnose obstructive sleep apnea
To make an appointment at the Sleep Center, call (619) 543-5713, or request an appointment online. A
referral from you primary care doctor is needed in most cases.
Sleep Medicine Center
200 West Arbor Drive
San Diego, CA 92103
(619) 543-5713
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Stress Management
What is Stress?
Stress is the "wear and tear" our bodies experience as we adjust to our continually
changing environment; it has physical and emotional effects on us and can create
positive or negative feelings. As a positive influence, stress can help compel us to
action; it can result in a new awareness and an exciting new perspective. As a negative
influence, it can result in feelings of distrust, rejection, anger, and depression, which in
turn can lead to health problems such as headaches, upset stomach, rashes, insomnia,
ulcers, high blood pressure, heart disease, and stroke. With the death of a loved one,
the birth of a child, a job promotion, or a new relationship, we experience stress as we
readjust our lives. In so adjusting to different circumstances, stress will help or hinder us
depending on how we react to it.
How Can I Eliminate Stress from My Life?
As we have seen, positive stress adds anticipation and excitement to life, and we all
thrive under a certain amount of stress. Deadlines, competitions, confrontations, and
even our frustrations and sorrows add depth and enrichment to our lives. Our goal is not
to eliminate stress but to learn how to manage it and how to use it to help us.
Insufficient stress acts as a depressant and may leave us feeling bored or dejected; on
the other hand, excessive stress may leave us feeling "tied up in knots." What we need
to do is find the optimal level of stress which will individually motivate but not overwhelm
each of us.
How Can I Tell What is Optimal Stress for Me?
There is no single level of stress that is optimal for all people. We are all individual
creatures with unique requirements. As such, what is distressing to one may be a joy to
another. And even when we agree that a particular event is distressing, we are likely to
differ in our physiological and psychological responses to it.
The person who loves to arbitrate disputes and moves from job site to job site would be
stressed in a job which was stable and routine, whereas the person who thrives under
stable conditions would very likely be stressed on a job where duties were highly varied.
Also, our personal stress requirements and the amount which we can tolerate before we
become distressed changes with our ages.
It has been found that most illness is related to unrelieved stress. If you are
experiencing stress symptoms, you have gone beyond your optimal stress level; you
need to reduce the stress in your life and/or improve your ability to manage it.
How Can I Manage Stress Better?
Identifying unrelieved stress and being aware of its effect on our lives is not sufficient for
reducing its harmful effects. Just as there are many sources of stress, there are many
possibilities for its management. However, all require work toward change: changing the
source of stress and/or changing your reaction to it. How do you proceed?
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1. Become aware of your stressors and your emotional and physical reactions.
Notice your distress. Don't ignore it. Don't gloss over your problems.
Determine what events distress you. What are you telling yourself about meaning of
these events?
Determine how your body responds to the stress. Do you become nervous or physically
upset? If so, in what specific ways?
2. Recognize what you can change.
Can you change your stressors by avoiding or eliminating them completely?
Can you reduce their intensity (manage them over a period of time instead of on a daily
or weekly basis)?
Can you shorten your exposure to stress (take a break, leave the physical premises)?
Can you devote the time and energy necessary to making a change (goal setting, time
management techniques, and delayed gratification strategies may be helpful here)?
3. Reduce the intensity of your emotional reactions to stress.
The stress reaction is triggered by your perception of danger...physical danger and/or
emotional danger. Are you viewing your stressors in exaggerated terms and/or taking a
difficult situation and making it a disaster?
Are you expecting to please everyone?
Are you overreacting and viewing things as absolutely critical and urgent? Do you feel
you must always prevail in every situation?
Work at adopting more moderate views; try to see the stress as something you can cope
with rather than something that overpowers you.
Try to temper your excess emotions. Put the situation in perspective. Do not labor on the
negative aspects and the "what if's."
4. Learn to moderate your physical reactions to stress.
Slow, deep breathing will bring your heart rate and respiration back to normal.
Relaxation techniques can reduce muscle tension. Electronic biofeedback can help you
gain voluntary control over such things as muscle tension, heart rate, and blood
pressure.
Medications, when prescribed by a physician, can help in the short term in moderating
your physical reactions. However, they alone are not the answer. Learning to moderate
these reactions on your own is a preferable long-term solution.
5. Build your physical reserves.
Exercise for cardiovascular fitness three to four times a week (moderate, prolonged
rhythmic exercise is best, such as walking, swimming, cycling, or jogging).
Eat well-balanced, nutritious meals.
Maintain your ideal weight.
Avoid nicotine, excessive caffeine, and other stimulants.
Mix leisure with work. Take breaks and get away when you can.
Get enough sleep. Be as consistent with your sleep schedule as possible.
6. Maintain your emotional reserves.
Develop some mutually supportive friendships/relationships.
Pursue realistic goals that are meaningful to you, rather than goals others have for you
that you do not share.
Expect some frustrations, failures, and sorrows.
Always be kind and gentle with yourself -- be a friend to yourself.
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Academics
Evaluations
ACGME mandates and other suggestions
The evaluation process for each specialty residency or fellowship is unique to that program,
and is the responsibility of the program directors. There are, however, ACGME mandates
evaluations based on the Six Core Competencies:
Patient Care
Medical Knowledge
Practice-Based Learning and Improvement
Interpersonal/Communication
Professionalism
Systems-based Practice
There are many tools to use to in these evaluations, such as oral exam, check lists, live or
recorded performances, procedure/operative logs, patient surveys, portfolios, record review,
simulations and models, written exams, and a ‘360’ multi-discipline evaluation.
A sample of a checklist review is included.
Written evaluations of subspecialty resident must be performed and reviewed with the trainee
at least semi-annually. A written evaluation must also be done at completion of the training
program. Teaching faculty must be evaluated at least annually. Evaluation should include
teaching ability, commitment to teaching, clinical knowledge, and active participation in
scholarly activity. Periodic and annual review of the program must include participation of at
least one subspecialty resident.
RCHSD Offers a Noon Conference series inclusive of topics mandated by the ACGME, such
as politics, ethics and more The monthly calendar is available on the RCHSD GME Intranet
page.
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Noon Conference Core Topics for Inpatient Rotation
Allergy / Immunology
Allergic Rhinitis
Asthma Care
Cases
Immunodeficiencies
Infections in
Immunodeficient Patients
Dermatology
Blistering Disorder
Eczema
Rashes and Bumps
Skin Signs of Systemic
Diseases
Vascular Anomalies
Cardiology
Cardiac Case Studies
Cardiac Catheterization
Cardiac Congenital
Anomalies
Cardiac Interventions
Cardiomyopathy
Coarctation of Aorta
Fetal Cardiology
Genetics of Cardiac
Arrhythmia
Genetics of CHD
Heart Murmurs &
Echocardiography
Hypoplastic Left Heart
Syndrome
Interventional Cardiology
Pediatric Cardiac
Emergencies
Pulmonary Stenosis &
Aortic Stenosis
Rheumatic Fever
Rhythm Disturbances
Sudden Cardiac Death
Supraventicular
Tachycardia
Syncope & the Long QT
Syn
Tetralogy of Fallot
Total Anom. Pulm
Venous Return
Transposition of Great
Arteries
Cyanotic Heart Disease
in the newborn
Doctors Black Bag
(see p. 95)
Emergency Medicine
Cases
Line, Access
Mock Codes
Pediatric Trauma
Endocrinology
DKA
Adrenal Disorders
Ambiguous Genitalia
Congenital Adrenal
Hyperplasia
Congenital
Hypothyroidism
Diabetes Outpatient
Management
Hypercalcemia
Hypocalcemia
Pubertal Delay
Rickets
Short Stature
Thyroid Disorders
Evidence-Based Medicine
Various - resident case
dependent
Gastroenterology
Approach to Feeding
Problems
Childhood Obesity
Evaluation & Treatment
of Constipation
Evaluation of
Upper/Lower GI Bleeds
Functional Abdominal
Pain
Gastrointestinal Motility
Disorders
GERD
GI Decontamination
Feeding Tubes and
Complications
Chronic Diarrhea
Intractable Vomiting
Lactation / Formula /
Nutrition
Liver Failure &
Transplantation
Pancreatitis
Pediatric Gallbladder
Disease
Pediatric Inflammatory
Bowel Disease
Pediatric TPN
Polyposis Syndromes of
the GI Tract
ENT
Airway Disturbances
Otitis Media and
Otoscopy
Stridor (by Age)
Hearing Loss
Foreign Body Aspiration
Neck Masses
Sinusitis
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General
AAP Community Access
to Child Health
Abdominal Pain (by age)
Acute Life Threatening
Event
Altered Mental Status
Bronchiolitis
Child & Adolescent Trial
for Cardio
o Health
Child Life Services
Community Pediatrics Advocacy
CP/DD patients Common
Problems/complications
Diarrhea & Dehydration
Do Movies Influence
Adolescents toSmoke?
Down Syndrome
Evaluation of Child with
Petechiae, Purpura
Evaluation of the Febrile
Infant
Failure to Thrive
FEN
FUO (by Age)
Ingestions
Intussusception
Kawasaki Syndrome
Limp (by Age)
Nutrition - Diabetes
Nutrition - Formulas
Nutrition - Lactation
Pharmacy Updates
Sports Medicine
TPN
UTI's
Vomiting (by Age)
Genetics/Dysmorph
Cleft Palate
Evaluation of Tall Stature
Genetic Testing
Novel Genetic
Mechanisms
Structural Defeects
Syndromes
Teratogens
Hematology/Oncology
Abdominal Masses
AIDS
ALL
Approach to Coagulation
Brain Tumors
CBC Interpretation
Evaluation of Anemia
Hemoglobinopathies
Hemophilia
Infections in Oncology
Patients
ITP
Leukemia
Neutropenia
Sickle Cell Disease
Stemcell Transplant
ICU
When to Transfer:
Resp/CNS/CV
Shock Syndromes
Infectious Disease
AIDS in Children
Antibiotic Resistance
Antibiotic Therapy
Antiviral Therapy
CNS Infections
Facial and Periorbital
Cellulitis
GI Tract Infections
Infectious Rashes
Meningitis-Bacterial &
Aseptic
Ostemyelitis & Septic
Arthritis
Pneumonia
Rapid Diagnosis of
Infections
Respiratory Tract
Infections
Streptococcal Infections
Travel Medicine
Tuberculosis
Urinary Tract Infection
Nephrology
UTI
Glomerulonephritis
Hemolytic Uremic
Syndrome
Hypertension
Nephrotic Syndrome
Renal Tubular Acidosis
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Neurological
Ataxia
Autism
CSF Exam
Floppy Infant
Headaches, Pain
Management
Language Delay
Movement Disorders
Neonatal Brain Injury
Neurocutaneous Disorder
Seizures - Febrile,
Afebrile
Status Epilepticus
Weakness
Pathology
Blood Banking
Body Fluids
Pharmacy
Practical Approach to
Drug Interactions
ADR's
What's New: Med Errors
and You
Physiatry
Approach to Rehab
Chronic Pain
Management
Pulmonary
Cystic Fibrosis
BPD
Case Conferences
Inpatient Management of
Asthma
Tracheostomies
Rheumatology
JRA
Eval of Autoimmune
Disorders
Surgical
Abdominal Pain
Acute Surgical
Obstruction
Approach Toward
Feeding Tubes
Appendicitis
Biliary Atresia
Congenital Malformations
Congenital Pulmonary
Anomalies
Esophageal Problems
Gastroesophageal Reflux
Disease
GERD
Hirschprung's
Interesting Surgical
Cases
Pyloric Stenosis
Seat-belt injuries
Surgical Emergencies
Tumors
Vomiting – bilious
Toxicology
APAP, ASA
Antidotes
Arthropod Envenomation
Botulism
Cardiovascular Agents
Case Studies
General Management of
Poisoning
Greatest Myths of Med
Toxicology
Household Hazards
Inhalation Toxins
Iron
Marine Envenomations
Multi-Drug Ingestions
Mushrooms
New Drugs of Abuse
Opioid Poisoning &
Toxicity
Over the Counter
Anagesic Poisoning
Poisonous Plants
Snakebites
Toxic Alcohols
Toxidromes
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Research
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RCHSD Research Approval Process/IRB
Research performed on Rady Children’s campus requires review by RCHSD, and for
many, UCSD. For further information on research operations and IRB process, access:
RCHSD IRB webpage: http://irb.rchsd.org/
and/or
UCSD Human Research Protection Program (HRPP) http://irb.ucsd.edu/
e-IRB Services
The Office of Human Subjects Protection provides online services for CHHC
researchers and IRB committee members:
Currently available:
Login for e-IRB services - including:
o My Protocols at a Glance - a summary of the current status of protocols
(for registered CHHC researchers and staff)
Register to create a user ID and password for using secure e-IRB project review
services
Online Human Subjects Protection training - a web based tutorial2
2
from www.irb.rchsd.org
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RCHSD IRB Forms and Submission Information
How do you know what form to use?
Each form serves to:
Let the IRB know what action you wish to take
Provide the necessary information to allow the IRB to decide if they may approve
that action
Document that an action took place
If you have more than just one action taking place (renewing your study approval AND
changing the study protocol) you will need to address the actions separately:
Use the correct form for each action.
Submit the materials for each action separately. DO NOT attach a study
change to your study renewal. These are different processes and must
stay separate.
For each action, submit 3 full set of copies which will be distributed to the
IRB sub-committee reviewing that action.
If you have looked over the list of forms and are still not sure which form to use, contact
Hope He in the RCHSD Office for Human Subject Protection.3
Forms On the Web
The RCHSD IRB Forms List is located at:
http://www.rchsd.org/professionals/officeofhumansubjectsprotection/applicationsandfor
ms/
For dual tracking (UCSD/RCHSD) review, please refer to the UCSD Web site:
http://irb.ucsd.edu/forms.shtml
3
http://www.chsd.org/body.cfm?id=505
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