GME : Winthrop Policies

• Annual Program Evaluation Checklist. All program directors must submit to the GMEC, on an annual basis, a completed Annual Program Evaluation.
• Annual Review of House Staff Benefits. The Accreditation Council for Graduate Medical Education (ACGME) requires that, on an annual basis, there be a review of house staff stipends, benefits and position allocations.
• Certification in Cardiac Life Support. The policy defines the requirement for certification and recertification in cardiac life support for WUH residents.
• Disabilities (Accommodation for). The purpose of this policy is to assure appropriate accommodations for residents with disabilities who meet the academic and technical standards for admission to, and participation in, training programs.
• Disaster (Administrative Support for Residents in Event of). To define the process and procedure for WUH GME programs in the event of disruption by emergencies, catastrophic events or natural disasters.
• Dress Code. House Staff are to dress and appear in a professional manner at all times when on duty.
• Duty Hours (Exceptions to). There are no exceptions to the hospital’s resident duty hours policy.
• External Elective Rotation. This policy stipulates the conditions under which House Staff may request approval for outside elective rotations that are not part of an on-going training agreement.
• Fatigue, Rest and Transportation.
• Fourth Year Medical Student Rotations. Policy outlines eligibility requirements for fourth year medical student to do rotations at WUH.
• GMEC Application for Increase in Size of Program. To ensure consistency in presenting requests to the GMEC for increase in program size.
• GMEC Application for New Program. To ensure consistency in presenting requests to the GMEC for new programs.
• GMEC Review and Approval of Requests and Materials Submitted to ACGME. Selected submissions/communications with the ACGME must be reviewed and approved by the GMEC prior to submission, and counter-signed by the Designated Institutional Official (DIO).
• Health-Related Industry Guidelines for House Staff and Faculty. Principles and guidelines for WUH House Staff and faculty governing interaction with health-related industry.
• House Staff Academic Probation and Due Process Policy. Procedures for probation and dismissal of a resident from a WUH training program based on academic or other deficiencies. Residents who believe they are being unfairly disciplined or dismissed may appeal to the GMEC.
• House Staff Educational Allowance Policy for all ACGME post-graduate training programs sponsored by WUH, defining eligible expenses to be covered under the House Staff Educational Allowance, the process for prior approval and the process for submission of approved expenses for reimbursement.
• Internal Review Protocol. The policy outlines the ACGME requirements for Internal Reviews, and the role of the Internal Review Subcommittee.
• Interview Days. The policy establishes the WUH policy re: interview days for House Staff, which applies equitably to all GME programs at WUH.
• Invasive Procedures in the Dying or Recently Deceased. The policy sets forth guidelines for House Staff training in invasive procedures in this patient population.
• Licensure. WUH policy re: licensure for house staff. (IN PROCESS)
• Medical Degree and Hospital Identification. Use of medical degrees on WUH GME diplomas and other hospital identification.
• Moonlighting. WUH House Staff who choose to moonlight must obtain pre-approval from their Program Director for moonlighting activities internal or external to WUH.
• Program Accreditation Status (Full Disclosure of). As per ACGME requirements, all residents, incoming residents and applicants to a program must be made aware of the accreditation status of the residency or subspecialty residency program in question.
• Record Retention. Outlines hospital policy re: maintenance of personnel and education of residents and fellows consistent with ACGME guidelines, institutional policy and legal requirements.
• Reporting of Other Learners. It is the Program Director’s responsibility to ensure that the presence of other learners does not interfere with the appointed residents’ education.
• Requirements and Responsibilities of Residency Program Director. Outlines the requirements and responsibilities of WUH Program Directors.
• Residency Reduction in Size, Residency Closure, or Closure of Institution. WUH, as the Sponsoring Institution of ACGME-accredited programs, will notify residents as soon as possible of any adverse action taken by the ACGME with respect to their programs.
• Resident Educational and Work Environment. WUH and the residency/fellowship programs must provide an educational and work environment in which residents may raise and resolve issues without fear of intimidation or retaliation.
• Resident Eligibility and Selection. All residents who are selected into residency programs at WUH are required to meet the eligibility and selection requirements in accordance with the Essentials of the Accreditation Council for Graduate Medical Education.
• Resident Participation on Committees and Councils. The ACGME Institutional Requirements stipulate that a GME sponsoring institution must ensure that residents participate on committees and councils whose actions affect their education and/or patient care.
• Resident Promotion and Renewal Policy . The ACGME requires that there be an institutional policy regarding conditions for reappointment, non-renewal, or non-promotion of residents.
• Resident Supervision. Post-graduate trainees in the graduate medical education programs at WUH engage in patient care activities under the supervision of the Medical Staff.
• Resident Visas. Policy for all ACGME post-graduate training programs at WUH related to requirements for appropriate visa for graduate medical education.
• Restrictive Covenants. ACGME accredited residencies may not require residents to sign a non-competition guarantee.
• Scholarship and Research Productivity. The purpose of this policy is to set a recommended minimum level of scholarship for WUH House Staff, consistent with ACGME requirements, and with WUH’s institutional commitment to scholarship and research as part of its core mission.
• Time Off, Leave of Absence and Completion of Training. (IN PROCESS)
• Transfer Residents. Policy for all ACGME post-graduate training programs sponsored by WUH consistent with ACGME Common Program Requirements regarding resident transfer.
• WUH Statement of Commitment to GME. Statement of WUH commitment to providing the educational, financial and human resources necessary to support all graduate medical education training programs at WUH.