Policies

Resident Moonlighting

Advocate Aurora Health Surgery

Date: May 2022

Goal: To ensure that each resident has sufficient opportunity to participate fully in the educational activities of the residency program.

Policy: The AAH Surgery Residency is committed to the education and training of the residents as they achieve competency and proficiency. Therefore, it is essential to ensure external activities do not interfere with the ability of the resident to achieve the goals and objectives of the educational program.

It is the opinion of the program that moonlighting or other employment outside the residency-training program would substantially increase the number of hours a resident is working per week and therefore interfere with the ability of the resident to participate fully in the educational activities and could adversely affect their well-being.

As such moonlighting is strictly prohibited.

Policy for Resident Supervision

Advocate Aurora Health Surgery

Date: May 2022

Goal: To ensure a safe patient care environment.

Mandatory Reasons to Contact Attending Immediately

The foundational element of the Advocate Surgical Residency is to provide safe, reliable, and value-based patient care. Effective and timely communication is critically important in meeting those goals. All residents and all members of the healthcare team will ensure that patient care needs are communicated whenever appropriate.

It is recognized that there are critical, time-sensitive aspects of care that must be communicated to the supervising faculty member immediately. These include, but may not be limited to:

1. Patient Death

2. Code / rapid response / unexpected intubation

3. Complication / significant unexpected finding during a procedure

4. Unexpected clinical deterioration necessitating transfer to ICU or higher level of care

5. Post-operative hemorrhage

6. Consult for patient with an acute surgical emergency (i.e., acute abdomen)

7. Intra-operative consult by another surgical service

8. Resident illness or personal emergency that prevents or significantly interferes with performance of clinical responsibilities

POLICY ON SUPERVISION OF PGY 1 RESIDENTS

Goal: To ensure a safe patient care environment while developing skills in the novice trainee.

Policy: All patient care provided by General Surgery residents will be supervised by appropriately qualified faculty attending physicians. The AAH Surgery Residency provides additional guidance for supervision of PGY-1 residents due to ensure their ability to achieve the educational goals and objectives necessary for them to progress.

PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available; there will always be a more senior resident in the hospital immediately available for supervision. As with all residents, a graduated level of responsibility for PGY 1 residents is commensurate with their acquisition of knowledge and development of compassion, judgment, and skill, in a manner consistent with safe and effective patient care. It is expected that the entering PGY 1 possesses knowledge and skill will allow for indirect supervision with direct supervision immediately available from a more senior level resident or attending physician for the following:

1. Evaluation and management of a patient admitted to hospital, including initial history and physical examination, formulation of a plan of therapy, and necessary orders for therapy and tests

2. Pre-operative evaluation including history and physical examination, formulation of a plan of therapy, and specification of necessary tests

3. Evaluation and management of post-operative patients

4. Writing transfer orders for patients between hospital units and hospitals

5. Discharge of patients from the hospital

6. Interpretation of laboratory results

7. Performance of basic venous access procedures, including establishing intravenous access

8. Placement and removal of nasogastric tubes and Foley catheters

9. Arterial puncture for blood gases

As closer supervision is required for more advanced patient management and procedural competencies, PGY 1 residents must have direct supervision (until competency is demonstrated) by a more senior level resident or an attending faculty for the following:

1. Initial evaluation and management of patients in the urgent or emergent situation, including urgent consultations, trauma, and emergency department consultations (ATLS required)

2. Evaluation and management of post-operative complications, including hypotension, hypertension, oliguria, anuria, cardiac arrythmias, hypoxemia, change in respiratory rate, change in neurologic status, and compartment syndromes

3. Evaluation and management of critically ill patients, either immediately post-operatively or in the intensive care unit, including the conduct of monitoring, and orders for medications, testing, and other treatments

4. Management of patients in cardiac or respiratory arrest (ACLS required)

PGY-1 Residents require direct supervision for the following procedures:

1. Advanced vascular access procedures, including central venous catheterization and arterial cannulation

2. Repair of surgical incisions of the skin and soft tissues

3. Repair of skin and soft tissue lacerations

4. Excision of lesions of the skin and subcutaneous tissues

5. Tube thoracostomy

6. Paracentesis

7. Endotracheal intubation

8. Bedside debridement

Once competency has been demonstrated, the PGY 1 resident can perform these skills under indirect supervision with direct supervision from a more senior resident or attending faculty member immediately available. A PGY 1 resident shall be considered competent in the patient management skills after completing ATLS, ACLS, the Intern Boot Camp/ Fundamentals of Surgery curriculum and direct observation of these skills performed on five patients by a more senior member of the team. A PGY 1 resident shall be considered competent in the procedural skills after completing the departments simulator based PGY 1 skills curriculum and direct observation of these skills performed on five patients by a more senior member of the team. The simulator-based curriculum is a proficiency-based curriculum modeled in part on the ACS/APDS skills curriculum and consists of basic suture technique, central line insertion, arterial line insertion, airway management to include endotracheal intubation and cricothyroidotomy, tube thoracostomy and paracentesis.

POLICY ON SUPERVISION OF RESIDENTS (PGY 2 AND ABOVE)

Date: May 2021

Goal: Documentation of supervision for resident clinical rotations.

Policy: It is the policy of the AAH Surgery Residency that all residents are given the required level of supervision, whether direct, indirect with supervision immediately available, or indirect with supervision available, throughout their training and that this supervision will be documented in the medical record.

The Program Director, site directors and faculty will:

• Periodically assess the teaching faculty’s discharge of supervisory responsibilities from evaluations and interviews with residents, other practitioners, and other members of the health care team.

• Ensure that resident supervision is consistent with the requirements of the RRC and the teaching site requirements.

• Ensure that residents attend required rounds, lectures, seminars, core curriculum and other educational venues and scholarly activities required to fulfill the curriculum goals and objectives of the residency program.

• Provide for all residents entering their first rotation to participate in an orientation to institutional policies, procedures, and the role of residents within the health care system.

• Provide residents the opportunity to participate on committees where decisions are made that affect resident activities (Quality Assurance, Utilization Review, Ethics, GME Program Committees, and Medical Staff Activities). These activities will provide the program feedback on supervision of residents.

Proper supervision of residents is expected to assure consistently high standards of patient care.

The overall responsibility for the treatment of each patient lies with the teaching faculty or staff practitioner to whom the patient is assigned and who supervises the resident physician. All inpatients and outpatients will have one staff practitioner as the physician in charge of the patient’s medical treatment. The name of this staff practitioner will be clearly designated on each patient's medical record.

Each faculty member is expected to:

• Direct the care of the patient and provide the appropriate level of direct supervision based on the nature of the patient's condition, the likelihood of major changes in the management plan, the complexity of care, the experience and judgment of the resident being supervised and within the scope of the approved clinical privileges of the staff practitioner. Documentation of this supervision will be via progress note, or attestation statement and countersignature of the resident’s progress notes daily.

• Meet the patient early during care and document, in a progress note, concurrence with the resident's initial diagnosis and treatment plan. At a minimum, the progress note must state such concurrence and be properly signed and dated.

• Participate in daily attending rounds. Participation in rounds provides the direct supervision to residents.

• Assure that all technically complex diagnostic and therapeutic procedures which carry a significant risk to the patient are: medically indicated, fully explained to, and understood by the patient to meet informed consent criteria, properly executed, correctly interpreted, and evaluated for appropriateness, effectiveness and required follow-up Evidence of faculty supervision shall be documented.

• Assure that a high-risk or technically complex treatment modality (such as the withholding/withdrawal of life-sustaining treatment) is the appropriate therapy, properly prescribed/ordered, properly initiated, or executed, and monitored as appropriate. Evidence of faculty supervision shall be documented.

• Direct appropriate modifications of care as indicated in response to significant changes in diagnosis or patient status. Evidence of faculty supervision shall be documented.

Graduated Levels of Responsibility:

The AAH Surgery Residency will ensure a personal program for each resident which assures continued growth and guidance from teaching faculty. As part of their training program, residents will be given progressive responsibility for the care of the patient. A senior resident may act as a teacher assistant to less experienced residents. Assignment of the level of responsibility must be commensurate with their acquisition of knowledge and development of compassion, judgment, and skill, and consistent with safe and effective patient care and with the requirements of accrediting agencies.

The determination of a resident's ability to accept responsibility for performing procedures or activities without a supervisor directly present and/or act as a teaching assistant will be based on the staff practitioner’s direct observation and knowledge of each resident’s skill and ability.

Supervision of Residents Performing Invasive Procedures or Surgical Operations:

The inherent risks associated with all types of surgery and invasive procedures require that teaching faculty provide an appropriate level of direct supervision of all residents performing such procedures. Teaching faculty supervising residents will review the indications for the performance of each procedure which shall be documented by a written notation in the patient’s medical record stating their concurrence with both the performance and with the interpretation of the results and complications, if any. It is expected that teaching faculty will always be directly involved in obtaining informed consent, except in emergent situations for which documentation in the medical record shall be provided.

Teaching faculty will supervise the work-up of patients, scheduling of cases, assignment of case priorities, the preoperative preparation, and the intra-operative and postoperative care of surgical patients and patients undergoing invasive procedures. This supervision must be reflected in progress notes made by teaching faculty at appropriate times during each patient’s hospitalization. As residents advance in their education and training, they may be given progressively increasing levels of responsibility. The degree of responsibility will depend upon the individual's general aptitude, demonstrated competence, prior experience with similar procedures, the complexity and degree of the risks involved in the anticipated surgical/invasive procedure. This will be based on direct observation by the teaching faculty and knowledge of each resident’s skills and ability.

An important aspect of a resident’s learning experience is the opportunity of a senior resident to supervise more junior residents. As a rule, senior residents, when acting in the role of a teaching assistant to less experienced residents, may supervise the performance of surgical/invasive procedures of lesser or more routine complexity. This, however, does not release the teaching faculty from having ultimate responsibility for the oversight of the patient's care. When a resident is acting as a teaching assistant, the staff practitioner remains responsible for the quality of care of the patient, providing supervision and meeting medical recorded documentation requirements as defined within this policy.

Surgery faculty call schedules ensure that attending physicians are always readily available to residents for consultation and support. Each faculty member, or a faculty member taking his/her call, can always be reached through PerfectServe. Faculty members are typically also available through various communication devices (e.g., pager, mobile phone). Faculty members will keep their service residents apprised of all device contact numbers. Faculty members will keep the support staff and service residents informed about any transfer of patient care coverage to other faculty members.

The Program Director monitors the systems in place for prompt, reliable communication, and interaction of residents with supervisory physicians in all participating institutions of the residency. Resident concerns about adequate supervision and communication will be conveyed to and promptly addressed by the Program Director.

General Surgery Residency Policies

Subject: Vacation

Date: June 2022

Goal: To ensure that each resident can schedule vacation time in the most fair and equitable way, as well as to maintain a balanced life.

Policy:

Residents will have 4 one-week vacations per year. The expectation is for vacations to be distributed throughout the academic year; 2 between August 1 and December 31, and 2 in the second 6 months. This is to help ensure wellbeing.

Vacation requests and approval will be managed in MedHub during the academic year. For requests placed prior to the start of an academic year, communication will be in writing by email, and must include the program coordinator and program director. Vacation requests should be submitted no later than July 15th.

Vacation requests will be prioritized by the timing of request and by level of training, with the most senior residents having priority for requests submitted within the same time.

A week vacation is 7 days, Monday through Sunday. Accommodations for specific requests deviating from these guidelines will be considered by the PD when requested.

No vacations are allowed during June or July of the academic year, except that PGY 5 residents may request vacation during June.

Residents may take vacations during any rotation except Trauma at CMC, but no more than one resident on a service may be on vacation at the same time.

Residents will notify the supervising faculty of any rotation during which they have an approved vacation prior to starting that rotation.

Three-day weekend requests will be considered individually by the PD and must first be approved by the appropriate rotation supervising faculty.


Policy for Resident and Faculty Member Well-Being

Advocate Aurora Health Surgery

Updated: May 2022

Resident and Faculty Member Well-Bein

Goal: To monitor and provide support for resident and faculty member well-being.

Policy: The AHC Surgery Residency recognizes that there is an increasing incidence of burnout and depression, including risk for substance abuse, in the current healthcare practice environment and that this affects all members of the healthcare team, including faculty and residents. Furthermore, the program believes that the physical, emotional, psychological, and social well-being of all department members is essential to maintaining compassion, competency, and proficiency in providing patient care and in providing an effective learning environment. To help ensure the goals of this policy, the residency partners with the Advocate aurora System and the hospitals to address well-being on an ongoing basis.

Procedure:

1. The Program Director and faculty work together to support each other and to support residents and team members in having time to meaningfully interact with patients, minimizing non-productive obligations, providing adequate administrative support, and enhancing professional relationships.

2. Effective communication is critically important in preventing harassment, a disruptive workplace, and understanding the personal and professional desires and needs of everyone, including a sensitivity to the diversity each person brings with them into the group. All residents will receive training in education, including CRM. The program will monitor and embrace effective communication. There is zero tolerance for disruptive communication or behavior.

3. Attention to scheduling and encouraging open dialog regarding personal / family demands is a core element of the program. The Program Director maintains open lines of communication with residents and faculty to monitor and verify that scheduling, work intensity, and work hours are appropriate.

4. Attention to burnout, depression, and substance abuse:

a. The program provides education annually on these topics, including recognition of symptoms and how to seek appropriate care, including information on resources available through the AAH Academic Affairs and site GME office.

b. Residents and faculty are encouraged to alert the Program Director or other designated personnel when they are concerned that a resident or faculty member may be displaying signs of burnout, depression, substance abuse, suicidal ideation, or potential for violence.

5. The program will provide tools for self-screening, such as the Mini-Z Burnout Inventory.

6. The program, in collaboration with AHC teaching sites and the Academic Affairs office, will ensure that residents, and faculty have access to affordable mental health assessment, counseling and treatment.

7. The program director will ensure that resident work hour limits, including adequate rest and time off, are adhered to.

8. The program will provide residents appropriately structured leave for important life events, including family emergencies, bereavement, important family events, time for healthcare. The program ensures frequent communication with residents that includes assessment of well-being including the following:

a. Annual program retreat

b. Monthly meeting with PD

c. Regular meetings with individual faculty mentors

d. Discussions of the semi-annual review of residents

e. Interaction with peers and faculty during didactics

f. Team building activities

Employee Assistance Program (EAP)

Employee Assistance Program (EAP) - A Benefit Available to You

What is the EAP? The Employee Assistance Program (EAP) is a confidential service for you. It is a voluntary and confidential source of help for all types of issues, such as:

· Depression/Anxiety

· Suicidal ideation / Behavioral health concerns

· Stress management

· Work issues

· Parenting skills

· Loss/Death/Grieving

· Anger management

· Coping skills

· Alcohol/Substance abuse/Addictions

How do I use the EAP? You can place a confidential call directly to the program by calling 1-800-775-0304. Emergencies are handled 24 hours a day/7days a week. Once you discuss your concern, the EAP Counselor will assist you in developing a plan. Information will not be shared with anyone without your written consent except if required by law.

Residents can also schedule well-being sessions with counselors (through the Employee Assistance Program - EAP) in MedHub, which maintains the confidentiality of these appointments. The counselors will then work with the fellow to set up a mutually convenient time for any follow-up sessions based on any areas of wellness that need to be further addressed.

Additional Wellbeing Initiatives/Resource

Dedicated time is set aside on the last Friday of every month for Residents to meet with their faculty mentor.

Institutionally sponsored wellness activities are organized quarterly by the departmental wellness committee. These activities are designed to enhance peer and social support networks.

The program will facilitate medical/dental appointments for the Residents by facilitating access to providers across the health system and offers protected time from clinical responsibilities for their health care needs.

Access to a site dedicated to Wellbeing resources for all AHC/AAH team members. https://advocatehealth.sharepoint.com/sites/AAHWellbeing

ACGME has several resources available to residents and faculty.

https://dl.acgme.org/pages/well-being-tools-resources

Policy for Clinical and Educational Work Hours

Advocate Aurora Health Surgery

Subject: Resident Work Hours

Date: April 2022

Goal: To ensure that each resident has adequate ability to participate fully in the educational activities of the residency program, as well as to maintain a balanced life.

Policy: Resident work hours are first and foremost designed to ensure primacy of the educational process. The program is committed that residents have adequate ability to achieve the educational goals and objectives, as well as to maintain a balanced life with adequate periods for rest and personal needs.

The AAH Surgery Program adheres to limitations and guidelines set forth by the RRC and ACGME. In specific:

1. Duty hour assignments recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. The structuring of duty hours and on-call schedules must be inclusive of the needs of the patient, continuity of care, and the educational needs of the resident.

2. Didactic and clinical education have priority in the allotment of residents’ time.

3. The PD and faculty ensure that the learning objectives of the program are not be compromised by excessive reliance upon residents to fulfill non-physician service obligations.

All residents are expected and required to adhere to these regulations as set forth below.

1. Duty hours consist of all clinical and academic activities related to the residency program. These hours include patient care and administrative duties related to patient care, time spent in-house during call activities, and scheduled activities such as conferences.

a. Duty hours do not include reading and preparation time spent away from the hospital or medical school site.

2. Total duty hours will be limited to 80 hours per week averaged over a four-week period inclusive of all in-house call activities.

a. Clinical work from home, such as answering calls and accessing the electronic health record will be monitored and will be included in the 80-hour work week limit.

3. Continuous on-site duty, including in-house call, will not exceed 24 consecutive hours. After 24 consecutive hours of call, residents may remain on duty for up to four additional hours to participate in didactic activities and clinical care necessary to ensure patient safety.

4. No new patients may be accepted after 24 hours of continuous duty, with a new patient defined as a patient not previously cared for by the surgery department.

5. Residents will have one 24-hour day in seven free from all educational and clinical responsibilities when averaged over a four-week period, inclusive of call.

6. Each resident will have an adequate time for rest and personal activities during the work week. A 10-hour duty-free period is appropriate between all daily duty periods but at a minimum an 8-hour duty free period is required, and residents must have 14 hours free of responsibility after any 24 period of in-house call, prior to resuming the next day’s duties.

7. In-house call may not occur more frequently than every third night averaged over a 4-week period.

8. For those residents on home call:

The frequency of at-home call is not subject to the 24+4 limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident.

a. PGY 1 residents will not be primarily responsible for patient care while taking home call because of the inability to be directly supervised, until necessary competency achieved.

c. Residents taking at-home call must be provided with one day in seven completely free from all educational and clinical responsibilities, averaged over a four-week period.

d. Clinical work from home, such as answering calls and accessing the electronic health record will be monitored and will be included in the 80-hour work week limit.

e. When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit.

The Program Director and Site Directors will be actively involved in ensuring that resident work hours guidelines are met by monitoring work hours reports weekly. Monthly work hours will be reviewed at the quarterly meeting of the Surgical Education and Clinical Competency Committee.

There are no exceptions to the duty hours as listed above.