Graduate Medical Education
MSC11 6093
1 University of New Mexico
Albuquerque, NM 87131-5156

Phone: (505) 272-6225
Fax: (505) 272-5184

email

Graduate Medical Education

Resident Handbook

Procedures

ACCESS TO FILES

Houseofficers shall have the right to access and review all documents in their academic, departmental, and employment files during the term of their appointment, excluding pre-employment references. Request for copies of files must be made to the Office of the Associate Dean for Graduate Medical Education. Copies of files will be provided within three (3) days of written request by the Houseofficer where reasonable need has been established.
Houseofficers shall have the right to review all materials placed in his or her file at any time, both by appointment and at a regularly or specifically scheduled evaluation or counseling session with program faculty. The Houseofficer may place in his or her file a response to any file entries or report any may withdraw his or her response at any time. Any adverse documents not made available to the Houseofficer may not be considered in any disciplinary or arbitration hearing during employment at UNM. In addition, any adverse documents not made available to the Houseofficer shall not in any way be considered in any form of evaluation or communication by UNM during employment at UNM or regarding any other employment, including but not limited to future employment following training at UNM.
Written evaluations of Houseofficers shall be performed regularly after each rotation, by an attending physician who has direct, continuous contact with the Houseofficer. Evaluations shall be conducted in a timeframe and format acceptable to the Residency Review Committee, specialty board, or other accredited/accreditating body and disclosure in advance to the Houseofficer. A copy of any evaluations shall be accessible to the Houseofficer on line and place in his or her file within a reasonable time after completion or after rotation.

ATTORNEY CONTACT (by Outside Attorneys Not Representing UNM)

If you are served with a summons and complaint or a subpoena regarding medical malpractice, employment issues or other issues that are within the scope and duty of your responsibilities as a Houseofficer at UNM, notify your Program Director, GME Office, Division Chief, and Department Chair and the Office of University Counsel (“OUC”) immediately. Your supervisors will make the necessary contacts with the appropriate Dean, or Vice President to approve the involvement of the OUC in the matter. All requests for information made by attorneys or investigators outside of UNM should be directed to Office of University Counsel at 272-2377.

COMPLAINTS/RESPONSIBILITY OF ASSOCIATE DEAN/GME

In the event a complaint is logged by a patient or staff regarding a Houseofficer, the GME Office is charged with the obligation to investigate and report back to the appropriate authority (UNMH, VAMC, SOM, Department) the findings and recommendations. This responsibility may be delegated to Program Directors, Chief Residents, or designees.

DISASTER PLAN FOR GME

In case of a devastating disaster, UNMHSC has developed a partnership with the University of Arizona to provide information, support, and communications in case such resources were unavailable due to the disaster. Although our institutional disaster plan specifies the steps for recognition, responses, and command structure, we previously had not developed a GME communications and remote administrative disaster plan. Since the recent Hurricane Katrina disaster, the need for such a plan has become apparent.

In the case of a disaster requiring evacuation of the UNM HSC, but in which services and communication are intact, we would communicate with residents through our website with up-to-date postings of information and resources, as well as responses to specific questions via our e-mail network.

In the case of loss of our communication system and evacuation, we will partner with the University of Arizona to post information on their GME website and work together to find accommodations for our residents. We should also set up a connected administrative structure in Tuscan at the University of Arizona. WE would simply help to provide accommodations to the University of Arizona should a disaster requiring evacuation befall them.

Rebecca Potter, MD from the University of Arizona will be coordinator of the GME communications plan with the help of her staff.

http://www.gme.medicine.arizona.edu - 520-626-7878

David Sklar, MD from the University of New Mexico will be coordinate of UNM GME communications plans with the help of his staff.

http://hsc.unm.edu/som/gme/prog_admin.shtml - 505-272-6225

Thus, our GME Disaster Plan is the following:

Notification – The UNM HSC Executive Vice President will declare a disaster and begin                the implementation of the HSC Disaster Plan, including activities of the Emergency Operations Center.  The Public Information Officer will provide updates concerning the nature and level of the disaster.  Residents will be expected to respond as part of their appropriate departmental response per the HSC Disaster Plan.

Communication – The HSC website will be used to communicate with all Housestaff, students and faculty.  The HSC website will be responsible for providing timely updates and will communicate with the HSC Vice President, or designee, for specific  information.  In case the HSC website becomes inoperable, the University of Arizona GME website will be utilized to provide information to all UNM residents and students.  Residents and students will be instructed concerning this backup mechanism at orientation.  As soon as possible the UNM website will be reactivated for communications.  UNM will provide a similar back-up system for University of Arizona Health Sciences Center in case of a disaster at that campus.

Relocation – Residents will initially be accommodated in Tucson at the University of Arizona.  After assessment of the extent of the disaster, other long-term accommodations may be necessary.  The Associate Dean for Graduate Medical Education and staff will accompany residents to Tucson.  Similarly, UNM will accommodate University of Arizona residents and students in the case of a disaster in Tucson.

FALSE CLAIMS ACT (Deficit Reduction Act)

Training of the Federal False Claims Act and the NM Medicaid False Claims Act is required pursuant to the Deficit Reduction Act of 2005 (DRA). Both Statues cover fraud involving federally funded contracts or programs (i.e., Medicare and/or Medicaid) and establish liability for any person who knowingly present or causes to be presented a false or fraudulent claim for payment. The Qui Tam ("whistleblower") provisions encourage people, with actual knowledge of allegedly false claims, to come forward and report the misconduct. Whistleblowers are protected from retaliation by both statues, as well as, by UNM Business Policy 2200, Reporting Misconduct and Retaliation. You may anonymously report internally using the toll-free 24/7 contracted HSC Compliance Hotline at 1-888-899-6092.
For more information on the DRA, please review the PowerPoint presentation entitled "Deficit Reduction Act of 2005 (DRA)" on the HSC Compliance web page at http://hsc.unm.edu/admin/compliance/index.shtml.

GRIEVANCE PROCEDURE

This procedure pertains to disciplinary action including suspension, termination, or non-renewal of contract based on academic, professional, or clinical performance or competency. Please see the CIR/SEIU Collective Bargaining Agreement, Articles 25 and 26 for additional information on grievances other than academic, clinical, or professional matters.

1. Purpose: The purpose of this procedure is to secure, at the lowest possible level, equitable solutions to individual grievances which may arise regarding terms and conditions of employment.
2. Definitions:
   1. A grievance shall mean a complaint by a Houseofficer, and/or Houseofficer and the CIR/SEIU, that action or inaction by the University has, in a substantial way, adversely affected his or her progress in the educational program threatened their intended career development, wrongfully deprived him or her and of the compensation owed by the University under this Agreement, is work environment related, or related to the program or faculty.
   2. The term “grievance” shall not be construed to apply in the following instances:
   1. Questions about whether or not a University policy or practice is good, bad, wise, unwise, etc. Concerns about such matters must be pursued by other means.
   2. Matters beyond the authority or control of the University, or beyond the University’s ability to provide a remedy.
   3. Termination or suspension due to the exhaustion of funds as determined by the Dean of the School of Medicine (see section on Resident Reduction/Closure).
3. Preliminary Procedure: No matter shall be submitted for the grievance procedure unless informal resolution has been attempted between the Houseofficer and his/her Program Director. If the Program Director is personally involved in the matter, then the Associate Dean for Graduate Medical Education, or his authorized representative, shall be substituted for the Program Director. The parties shall make a good faith effort to resolve the grievance in an informal manner. If the grievance is not resolved, the Houseofficer may proceed to Step 1 of the grievance procedure.
4. Step 1.
1. The grievance shall be submitted within ten (10) calendar days following the grievable event, or within ten (10) calendar days after the Houseofficer becomes aware of such event, whichever is longer.
2. The grievance shall be in writing and must contain a statement of the grievance, the facts upon which it is based, information describing the attempt to resolve the matter in accordance with Section 3 of this policy, and the remedy sought.
3. The grievance shall be filed with the Associate Dean for Graduate Medical Education or his designee.
4. The grievance shall be heard by a committee (voting members) consisting of
   1. an uninvolved Houseofficer appointed by the Resident Council,
   2. two training Program Directors from other programs who have not been involved in the dispute, or, if Program Directors are not available, a faculty member involved in medical education shall be appointed as an alternate. Committee members must be mutually acceptable to the other members of the committee, but such person must be a SOM faculty in the field of clinical medical practice.
      The Associate Dean for Graduate Medical Education shall be the Chairman of the committee, shall attend to the administrative matters and may participate in the deliberations but shall not have a vote. The grievant's Program Director, or, the Program Director shall appoint an alternate to serve in his/her place, will be present at the committee hearing, but shall not vote. The committee may be advised by a faculty member who specialized in medical ethics, psychiatry, or other fields which would be of assistance to voting members. Those providing advice are non voting members. If the committee has not been formed within ten (10) days of the filing of the grievance, the Dean of the School of Medicine shall make the necessary appointments as soon as possible.
5. The committee shall hear the case as promptly as is practicable with due notice to all parties. The parties are required to exert their best efforts to commence the hearing within twenty-one (21) calendar days after the grievance is filed. Evidence and argument may be submitted in writing, in person, or both. Either party may employ attorneys or other advisers to assist them in the presentation of the case. The purpose of the meeting will be to obtain factual information from the Houseofficer. Any attorney representing a Houseofficer shall act in an advisory capacity only. The grievant Houseofficer shall present his/her case, and stand for questioning. The committee shall keep a record of the case and may tape record any oral presentation.
6. The committee shall decide whether the subject is grievable pursuant to the terms of his policy. At such time as the committee decides that the matter is not grievable, the Houseofficer shall be so notified and the proceedings stopped. The decision of the committee in this regard is final.
7. The committee is authorized to decide the grievance and to provide for a remedy to carry out its decision.
8. The grievance shall be decided by a majority vote of the voting members of the committee. The decision shall be rendered in writing and shall be delivered immediately to the Houseofficer in person or if he or she is not immediately available, a copy of the decision shall be sent by Certified Mail to the Houseofficer’s address of record kept at the School of Medicine.
5. Step 2.
1. If the Houseofficer or the Program Director is dissatisfied with the decision of the committee in Step 1, he or she may appeal the decision to the Dean of the School of Medicine. Appeals are limited to 1) alleged violations in the Houseofficers right to due process or 2) new information potentially applicable to the decision that was not available to the Houseofficer at the time the committee rendered the decision.
2. The notice of appeal to the Dean, and a copy provided to the Office of GME, shall be submitted in writing within five (5) calendar days following the decision in Step 1. That written notice shall state the basis for the requested appeal.
3. The Dean shall review the record of the case as presented to the committee in Step 1. In his decision, the Dean will render the Houseofficer’s basis for the appeal. The Dean may call for further evidence or argument at his/her discretion.
4. The Dean may affirm, reverse or modify the decision. The decision of the Dean is final.

HEPATITIS B VACCINE/VARICELLA/MEASLES

These vaccines are offered at no cost to Houseofficers. All Houseofficers must have had proof of being offered Hepatitis B vaccine. Employee Occupational Health Services will perform serologic titers for hepatitis B on Houseofficers uncertain of their immune status and vaccinate as needed.

 Houseofficers must have proof of immunity to measles, mumps and rubella before working per local law. Houseofficers must also be immune to varicella through a clinical history of chickenpox or history of vaccination (two doses for adults) with serology performed after vaccination. Employee Occupational Health Services will test for immunity to varicella. Susceptible Houseofficers are referred to their primary care providers to receive the vaccine. Varicella vaccine is also available through the Infectious Diseases Consult Clinic at Truman Street 272-1312.

HIPAA

HIPAA training and certification is required annually of all Houseofficers Physicians for each location they are assigned in accordance with the institutional policy. UMNH HIPAA training is online at https://edcscai.unm.edu/m3webbin/ VAMC HIPAA training is online at http://www.vhaprivacytraining.net/frame.htm

HIV/HEPATITIS C/HEPATITIS B

Houseofficers should be aware that state law governs the practice of physicians with HIV and varies from state to state. CDC recommendations concerning the practice of physicians with chronic Hepatitis B and C must be followed. As yet, no state has elected to regulate the practice of physicians with Hepatitis C. The Centers for Disease Control and Prevention recommend strict adherence to Standard Precautions as outlined in the OSHA Bloodborne Pathogen Standards as the best way to prevent transmission of bloodborne pathogens from infected health care workers to patients as well as the infected patient to providers.

In New Mexico, HIV-seropostive physicians who perform “exposure-prone procedures” must report their HIV status to the New Mexico Board of Medical Examiners. Consultants from the Department of Health, the physician’s speciality, and Infectious Diseases will then review the physician’s practice and clinical status and determine whether he/she may continue practicing as before or should be restricted in the scope of his/her practice. “Exposure-prone procedures” are defined as procedures which create a risk of the provider sustaining an injury and bleeding into the patient, such as palpation of a needle tip in a body cavity. Such procedures may occur in, but are not limited to, surgical and dental fields.

Houseofficers who are HIV-positive should seek advice from their HIV physician as to whether it is appropriate for them to disclose their HIV sero-status to their program director based on their clinical status, training program, and need for practice modification under State Law. Houseofficers with chronic Hepatitis B and C who perform invasive procedures should seek expert consultation with Hospital Epidemiology pager 951-1067, coordinated through their residency Program Director, on how to prevent the transmission of disease to patients.

In the event of an acknowledgment of an infection such as HIV and Hepatitis C, the Houseofficers should be expected to be counseled as to career effects; limitations, precaution, options, expectations, liabilities and position of the Department and Institution. This counseling will be provided by a committee that is to include the Program Director, a mentor/advocate (selected by the Houseofficers) and the Infection Control Physician for the Institution. The Chair of the Committee will be the Associate Dean of GME or his delegate.

HSC IDENTIFICATION

HSC Identification badges are the official photo identification for all Houseofficers. UNM HSC ID badges must be worn at all times when training or when representing UNM HSC. Houseofficers are expected to display appropriate photo ID when on duty.UNM Hospital Security will assess a replacement fee of $15 for all lost cards. Stolen cards should be reported to Hospital Security (272-2160) immediately.

HSC ID Cards with a Lobo card code allows Houseofficers to take advantage of the following at a discounted rate:

• University tennis courts
• Medical Library — North Campus
• Zimmerman Library and satellite libraries
• Johnson Gymnasium facilities (spouse and dependent cards are available from Leisure Services at the gym and a minimal charge per semester)
• North Golf Course
• HSC Lockshop Key Service

 

INCIDENT REPORTS/BLOODBORNE PATHOGEN EXPOSURES

( See Workers Compensation)

All exposure to blood or other potentially infectious materials (needlesticks, splash to mucous membranes or exposure to non-intact skin) must be evaluated and treated as soon as possible, preferably within two hours of exposure. Trainees must be released immediately to seek treatment. Houseofficers should fill out an incident reporting form with their supervisor’s signature and a Workmen’s Compensation form (available on all floors or on the GME website) and then report to the appropriate clinic or Emergency Department.

INCIDENT REPORTS/BODY FLUID EXPOSURE

(Also see Worker’s Compensation, Blood Borne Pathogens)

All injuries or infectious disease contacts by disease of human blood or prevention exposure of Houseofficers while on duty must be reported to the Workers Compensation Office, 277-9793 and the Employee Occupational Health Services, 272-8043 on the appropriate incident report forms. Accidents must be reported to the Program Director and Program Coordinator as well as the above two listed departments.Forms are available in the clinics, nursing stations, emergency room, operating rooms, and online at www.unm.edu/~sheaweb. Houseofficers with puncture wounds must follow appropriate procedures for UNM HSC, VAMC, or Lovelace Medical Center. For additional information contact your Program Director and see the UNM HSC policy on Blood & Body Fluid Exposure (Needlestick) at https://hyper2.unm.edu/policies/main.cfm

 INFECTION CONTROL

All Houseofficers receive training on basic infection control at new Houseofficer orientation, including the principles of Standard Precautions, patient isolation, and hand hygiene. Houseofficers temporarily unable to perform routine hand hygiene in the course of patient care should be reassigned to non-patient care duties.

Houseofficers may be contacted by Infection Control regarding the potential exposures from patients and are expected to comply with prompt follow-up and treatment at Employee Occupational Health Services. Houseofficers are encouraged to report potential exposures to Infection Control/Hospital Epidemiology.

Questions or concerns regarding isolation, nosocomial infections, exposure, or diseases reportable to the State Department of Health may be addressed to Infection Control staff at UH at 272-0131 or VAMC ext 4945, as well as Hospital Epidemiologist at pager 951-3000.

MANDATED BEHAVORIAL EVALUATION COUNSELING

1. If a UNM GME Program Director identifies the need for a mandatory behavioral evaluation of a Houseofficer’s fitness for duty, the Program Director will notify the Houseofficer, make an emergent referral of the Houseofficer to the designated psychiatrist(s) in the UNM Department of Psychiatry, and will remove the Houseofficer from clinical responsibilities until the initial behavioral evaluation has been completed and a report has been received of that evaluation.
2. The Houseofficer will be seen within 48 hours (work week hours) by the designated psychiatrist(s) in the UNM Department of Psychiatry. For Houseofficers in the UNM Department of Psychiatry, referral will be made to designated community.
3. The psychiatrist(s) performing such evaluations will
   1. Meet with the Houseofficer
   2. Clarify the dual reporting responsibility of the psychiatrist to the Houseofficer (i.e., reporting both to the Houseofficer and to the referring Program Director)
   3. Provide an initial psychiatric assessment, focused upon the fitness for duty of the Houseofficer.
   1. If the Houseofficer is determined to be fit to return to duty,
   1. The psychiatrist will notify the Program Director what, if any, reasonable accommodations will be required for the Houseofficer to return to duty, including, as appropriate, recommended time limitations for these accommodations.
   2. If the Program Director feels such accommodations are not reasonable and cannot be provided, the matter should be referred to the Associate Dean for GME for resolution.
   3. The psychiatrist performing the initial evaluation may recommend additional evaluations/treatment to the Houseofficer, will help identify available resources for such evaluations or treatment, and will assist with those referral(s).
   4. Ongoing psychiatric care is not to be provided by this psychiatrist.
   5. As necessary, the psychiatrist performing a fitness for duty evaluation will develop a “behavioral contract”, with input from the referring Program Director, which the Houseofficer must sign as a condition for returning to duty.
   2. If the Houseofficer is determined not to be fit for duty, the psychiatrist
   1. Will notify the Program Director and the Office of GME of the need for medical leave, and estimate the duration of leave, if possible;
   2. May recommend additional evaluations/treatment to the Houseofficer, will help identify available resources for such evaluations or treatment, and will assist with those referrals;
   3. Will provide re-evaluations of fitness-for-duty.
   4. Will document all evaluations on standardized templates developed by the UNM Department of Psychiatry
   5. Will, if substance abuse is suspected, refer the Houseofficer for testing, as outlined in the current GME policy, “Physician Impairment and Substance Abuse”.
4. The Houseofficer will not be subject to any out of pocket cost for such mandated behavioral evaluations of fitness for duty. Such evaluations will be provided by UNM Department of Psychiatry, or in the case of a Psychiatry Resident a mutually agreeable designated community psychiatrists, and the UNM Office of GME. Any additional evaluations or treatment recommended as a result of mandated behavioral evaluations of fitness for duty will be the financial responsibility of the Houseofficer. The Office of GME will be available to assist the Houseofficer with processing medical insurance claims and with identifying other available resources (including financial resources) for such additional evaluations or treatment.
5. Individuals or agencies providing additional evaluations or treatment, including ongoing behavioral care, to Houseofficers as a consequence of a mandated behavioral evaluation, will be required to notify, as appropriate, the designated psychiatrist(s) in the UNM Department of Psychiatry, or their designated subcontractor(s), that the Houseofficer is ready for re-evaluation of their fitness for duty.
6. Housestaff whose medical leave extends beyond 12 months will be required to reapply for admission to their UNM residency or fellowship program, should they wish to resume their GME training at UNM.

OSHA TRAINING

The Federal Government requires annual training of all personnel who may be exposed to blood borne diseases. New Houseofficers receive this training as part of their orientation day activities. All Houseofficers must complete annual certification. Web based OSHA training is available at both UNM and VA sites. The UNM on-line training resides under Learning Central on the main UNM HSCL website https://learningcentral.health.unm.edu/elms/learner/login.jsp The VA on line training resides on the VA Internet under "Clinical", then under "Computer Based Training" as "Physician OSHA Bloodborne pathogens (with test)". Upon completion of the Web-based training, Houseofficers may print out a certificate of completion and forward it to the GME Office. Houseofficers taking the refresher training should log in after the third week in July to ensure that they are entered in the on-line training system. Houseofficers who are not in compliance may be suspended from duty without pay until they provide documentation of having taken the training.
N-95 respirator training and fit-testing is provided at new Houseofficer orientation for all first and second year Houseofficers, as well as first year fellows. Thereafter, respirator fit testing is required yearly. Program Coordinators will be responsible for ensuring all Houseofficers comply with yearly fit-testing. Yearly respirator fit-testing will be provided through group sessions or individual appointments arranged by the residency coordinators. New Houseofficers not medically cleared or fit-tested at orientation may contact Employee Occupational Health at 272-8043.

TUBERCULOSIS TESTING/TST

The State of New Mexico requires annual tuberculosis testing for all health care personnel. New Houseofficers will receive this test during their orientation day activities. All Houseofficers will be sent reminders for annual tuberculin skin testing, which is performed at Employee Occupation Health Services. Only Housestaff with proof of prior positive TST’s are excluded from this requirement, but they will be required to complete an annual symptoms survey from EOHS.

WORKERS COMPENSATION

(See Workers Compensation under Insurance)