Residents & Fellows Policies and Procedures Manual

1. Introduction

This manual establishes the policies and procedures that apply to all residents and fellows training within the institution. It is intended to promote a safe, educational, and professional environment that meets accreditation standards, complies with federal and state regulations, and supports the development of competent physicians.

All trainees are required to read, understand, and acknowledge this manual upon commencing their program. Updates will be communicated annually or as needed.

2. Governance & Oversight

2.1. Leadership Structure

• Program Director: Overall responsibility for curriculum, recruitment, and compliance.
• Associate Program Director(s): Assist with daytoday operations and serve as liaisons for specific subspecialties.
• Clinical Education Committee (CEC): Reviews curriculum, evaluates outcomes, and recommends improvements.
• Graduate Medical Education (GME) Office: Provides institutional oversight, policy guidance, and accreditation liaison.

2.2. Reporting Lines

Residents and fellows report clinical concerns to their supervising attending physician, then to the Program Director if unresolved. Nonclinical concerns (e.g., harassment) follow the Institutional Reporting Pathway outlined in the Employee Handbook.

3. Roles, Duties, & Expectations

All trainees are expected to demonstrate professionalism, commitment to learning, and adherence to institutional policies.

• Provide patientcentered care under supervision.
• Participate actively in conferences, rounds, and scholarly activities.
• Maintain confidentiality and comply with HIPAA regulations.
• Complete required documentation promptly and accurately.
• Engage in continuous selfassessment and seek feedback.

4. Clinical Education & Supervision

Education is delivered through a blended curriculum of bedside teaching, didactics, simulation, and scholarly projects.

4.1. Supervision Levels

• Direct Supervision: Attending present in the room for all patient interactions.
• Indirect Supervision: Attending immediately available; trainee may act independently for lowcomplexity tasks.
• Autonomous Practice: Senior fellows may manage patients with indirect oversight after meeting competency milestones.

4.2. Curriculum Components

• Core rotations (e.g., Internal Medicine, Surgery, Pediatrics).
• Subspecialty electives tailored to career interests.
• Quarterly scholarly project updates.
• Annual competency assessments.

5. Work Hours, Duty Hours, & Rest

The institution adheres to ACGME dutyhour regulations:

• Maximum 80 hours per week, averaged over four weeks.
• Minimum one day free of duty every seven days, averaged over four weeks.
• Maximum shift length: 24 hours of continuous duty, plus up to 4 hours for transition of care.
• At least 8 hours off between scheduled shifts; 14 hours after a 24hour shift.

Any perceived violations should be reported to the Program Director or the GME Compliance Office.

6. Evaluation & Feedback

Formative and summative assessments are integral to trainee development.

• Quarterly InTraining Exams (ITE): Benchmark knowledge against peers.
• Direct Observation Tools (DOTs): Assess procedural competence.
• MultiSource Feedback (MSF): 360degree input from peers, nurses, and patients.
• Annual Review: Comprehensive performance summary, determination of readiness for advancement.

7. Remediation & Disciplinary Process

7.1. Identifying Deficiencies

When a trainee fails to meet defined milestones, the Program Director initiates a remediation plan within 30 days of identification.

7.2. Remediation Plan Elements

• Specific performance gaps.
• Targeted educational interventions (e.g., workshops, mentored clinics).
• Timeline for reassessment (typically 48 weeks).
• Documentation of progress.

7.3. Disciplinary Actions

If remediation fails, graduated steps include formal warning, probation, and possible termination of the training appointment, following dueprocess guidelines.

8. Wellness, Support, & Resources

Resident and fellow wellbeing is a priority. The institution provides:

• Confidential counseling services (24hour hotline).
• Wellness workshops focusing on stress management, mindfulness, and resiliency.
• Access to peersupport groups.
• Flexible scheduling for personal or family emergencies.

Any concerns about burnout, mental health, or harassment should be directed to the Wellness Coordinator or the Office of Human Resources.

9. Conflict of Interest & Professionalism

All trainees must disclose any financial relationships, research funding, or personal interests that could influence clinical decisions.

• Complete an annual Conflict of Interest (COI) statement.
• Adhere to institutional policies on gifts, industry interactions, and prescribing practices.
• Maintain professional conduct at all times, with zero tolerance for discrimination, harassment, or unprofessional behavior.

10. Documentation & Record Keeping

Accurate documentation is essential for patient care, accreditation, and legal compliance.

• All progress notes, orders, and procedural reports must be entered into the EMR within 24 hours.
• Maintain an uptodate resident/fellow portfolio containing case logs, scholarly work, and evaluation forms.
• Submit required logs (e.g., surgical case numbers) quarterly to the GME Office.

11. Appendices

Appendix A Sample DutyHour Log

Residents must complete a weekly electronic dutyhour log, capturing start time, end time, and type of activity for each shift.

Appendix B Contact List

• Program Director: Dr. Jane Smith jsmith@hospital.org
• GME Office: 5551234567
• Wellness Coordinator: Maria Lopez mlopez@hospital.org
• Human Resources (Harassment Reporting): 5559876543

Appendix C Frequently Asked Questions

Q: How do I request an exemption from a scheduled rotation?
A: Submit a written request to the Program Director with supporting documentation; approval is at the Directors discretion.

Q: What is the process for reporting a patient safety concern?
A: Use the institutions safety reporting system or notify your attending immediately; all reports are investigated confidentially.