Graduate Medical Education: House and Staff Policies and Procedures

Graduate Medical Education Administration

• John C. DeToledo, MD
  Dean
  Texas Tech University Health Sciences Center
  School of Medicine

 

Campus GME Directors

• Amarillo (806) 414-9666
  Kristin Stutz, MS, Assistant Regional Academic Dean and DIO
  Janet Abbott, Unit Manager
• Lubbock (806) 743-2978
  J.Edward Bates, PhD, M.Ed., Assistant Dean for GME and DIO
  Stormy Daniels, PhD, MBA, Assistant Managing Director
• Permian Basin (432) 703-5089
  Isabel Erives, M.Ed., Senior Director and DIO
  Susie Thiessen, MS, Manager

01.01 PGY Level. A Post Graduate Year (PGY) level is assigned to each resident.

01.02 PGY Training Requirements. Post Graduate training at TTUHSC requires that each resident be eligible to be licensed in Texas and to take national board exams for board certification.

01.03 USMLE/COMLEX. Prior to accepting an applicant, the Program Director shall ensure that the applicant has passed USMLE/COMLEX, Step 1, within the number of attempts provided by the Texas Medical Board (TMB) for Texas licensure.

01.04 Criminal Background Check. In accordance with HSC OP 10.20, Criminal Background Checks for Students, Trainees, and Residents, a resident entering training will not be placed on the payroll nor be assigned any clinical duties until s/he has undergone a Criminal Background Check (CBC) and the results establish that the resident is eligible for clinical training. (See HSC OP 10.20, Attachment A, "Notice to Students and Trainees" and Attachment B, "Consent for Release of Information.")

01.05 Discrimination. TTUHSC does not discriminate based on race, color, national origin, sex, disability, religion, age or veteran status in admission, employment, access to, or treatment in its programs or activities, in accordance with state and federal laws and Regents' Rules, Section 03.01.8

01.06 ERAS. Each applicant submitting an ERAS application shall be required, at the time of the interview, to complete a TTUHSC ERAS Addendum.

01.07 Approved Medical School. Each applicant must be a graduate of a medical school that is approved by TMB or a medical school whose curriculum is accepted by the Texas Higher Education Coordinating Board as equivalent to that of a Texas medical school. A graduate of the latter must:

• 01.07.1 Valid Certificate. Possess a valid certificate issued by the Education Commission for Foreign Medical Graduates (ECFMG); and
• 01.07.2 Eligibility Requirements. Meet the same eligibility requirements as persons employed at TTUHSC.
• 01.07.3 Appointment as a Resident. A resident's appointment is recommended by the department and is subject to review and approval by the TTUHSC GME Office, as well as the Dean of the TTUHSC School of Medicine or designee. No resident may begin or continue in a residency without the approvals referenced above and an official appointment.

02.01 Salaries. Salaries are appropriate to the training level of the resident, and are reviewed annually. Each resident is paid by TTUHSC on a monthly basis. Payment is inclusive from the first to the last day of the current month; checks are issued on the first regular business day of the following month, and direct deposits are made on the last day of the pay period. A GME representative may be consulted regarding distribution of paychecks at each campus. Direct deposit may be set up or updated on the TTUHSC web portal (https://portal.texastech.edu/web/hsc/payroll-tax). You may also find contact information on the TTU Payroll & Tax Services website (https://www.depts.ttu.edu/payroll/). For tax purposes, remuneration to a resident is considered salary by the Internal Revenue Service.

02.02 Insurance. TTUHSC provides insurance coverage for the following:

• 02.02.1 Professional Liability. Professional liability (malpractice) coverage for each resident is $100,000 per incident and $300,000 annual aggregate while participating in TTUHSC-authorized training. Coverage is on an occurrence basis, i.e., the insurance covers incidents that occur while the coverage is in force, regardless of when the claim is made or reported. This insurance covers any activity that is a part of the resident's training program, but does not assume liability for activity beyond the scope of the residency training program, including outside remunerative medical activity, i.e., "moonlighting." Any resident who suspects the possibility of an "incident" shall immediately notify the campus Risk Management Office.
• 02.02.2 Group Health Insurance. Group health insurance is provided by TTUHSC for each resident and his/her eligible dependents, if applicable. If a resident elects to enroll in a health plan other than the group plan provided, the entire cost shall be borne by the resident. A resident should not assume that professional courtesy discounts will be extended for oneself and family members. If a resident is on approved leave, premiums will be paid in accordance with state and federal guidelines not to exceed 12 weeks, e.g., FMLA, parental leave, etc. Upon completion of training or leaving the program before completion, a resident may elect, at his/her expense, to continue insurance coverage in accordance with federal COBRA regulations.
• 02.02.3 Other Medical Services. In addition to health insurance, each resident is provided coverage for dental and eye exams. A resident is able to select his/her own providers from lists provided at the beginning of each year's residency.
• 02.02.4 Workers' Compensation. Workers' Compensation coverage is provided for each resident. Any on-the-job injury must be reported to the resident's supervisor as soon as possible, at which time the supervisor shall have the duty to complete applicable paperwork and forward same to the TTUHSC Department of Human Resources. Further, reimbursement for an on-the-job injury cannot be considered unless an appropriate report has been filed with the institution's Health and Safety Office. Each resident shall be provided access by either website or written copy to the School of Medicine Ambulatory Care Clinic Policy No. 7.07: Management of Blood and Body Fluid Exposures (https://hscweb.ttuhsc.edu/provost/documents/policies/ACPolicy7.07.pdf) and shall comply with the respective campus procedure relative to needle sticks.
• 02.02.5 Disability Income and Term Life Insurance. Disability income and term life insurance are provided by TTUHSC for each resident and eligible dependent(s), where applicable.

 

02.03 Leave.

• 02.03.01 General. Leave is integrally conditioned upon each program's participation requirements for board eligibility in terms of minimum time spent in the training program. TTUHSC GME provides leave benefits as outlined below and GME Offices manage considerations for paid versus unpaid leave status. However, professional board requirements for each resident shall take precedence on considerations of extensions of training or reductions in required time spent in the training program related to any period of leave, discretion resting with the Program Director and the ABMS-specific board policies.
  • 02.03.01.1 Each program must have a leave policy that describes the process for requesting leave, and tracking of leave, including the definition of a “work week” for each rotation, specifically through a document to be completed by the resident for all leave types, executed by the program’s coordinator and approved by the Program Director. Any variance from this policy must be recommended by the Program Director/Chair to the campus DIO for review and approval.
• 02.03.02 Extended Period of Leave. Each resident acknowledges that an extended period of leave, regardless of the type, may necessitate an extension of his/her training program in order to meet the minimum training requirements of each respective professional board in order to qualify to sit for the board examination. Where applicable, a resident shall review this matter with the Program Director well in advance to ensure s/he will be able to utilize such leave and timely complete the program as anticipated. Alternatively, the resident shall coordinate with the Program Director an acceptable plan for extension of the training program in each specific situation so the resident will have met all specialty board-training requirements in a timely manner. All paid leave must be exhausted before a resident may be on unpaid leave.
• 02.03.03 Paid Leave. Paid leave shall be approved for not more than four work weeks for PGY-1 level, and not more than five work weeks for the PGY-2 level and above, subject to each respective residency program requirements and policies. Except as provided in Section 02.03.04 below, paid leave is inclusive of all leave types, including but not limited to vacation, sick, educational leave, and funeral leave. Paid leave benefits must be taken within the current contract agreement year. Any unused paid leave benefits are not carried forward from year to year and are not paid upon completion or termination of the GME Program Agreement.
  • 02.03.03.1 Vacation Leave. Timing and scheduling of vacation leave is at the discretion of each Program Director in accordance with the established program-specific policy. Vacation leave may be limited to specific rotations or in length.
  • 02.03.03.2 Sick Leave. A resident who must be absent from duty because of illness shall notify the Program Director at the earliest practicable time. To be eligible for ongoing paid leave benefits during a continuous period of more than three days due to illness, the resident must provide a doctor’s certificate or other written statement that is acceptable to the Program Director.
  • 02.03.03.3 Educational Leave. All educational leave must be approved by the resident's Program Director. Subject to residency program requirements and approval, when defined and allowed by ABMS-specific board policy, educational leave is granted with pay and will not be counted toward paid leave time. When not defined or allowed by ABMS-specific board policy, educational leave will be counted toward paid leave time.
  • 02.03.03.4 Funeral Leave. Funeral leave may be granted with pay upon the death of an immediate family member or immediate family member of the resident's spouse. The total time allowed shall normally not exceed 3 days.
• 02.03.04 Parental, Caregiver and Medical Paid Leave. In alignment with ACGME policies effective July 1, 2022, a single six-week (42 days) period of paid parental, caregiver and medical leave will be afforded to residents once during their training program. For the purposes of this Section 02.03.04, leave is counted continuously, with every calendar day included from first day of absence through date of return to duty. Definitions of each leave type include: birth and care of a newborn, adopted, or foster child (“parental leave”); care of an immediate family member (child, spouse or parent) with a serious health condition (“caregiver leave”); or the trainee’s own serious health condition (“medical leave”). Paid leave under this Section 02.03.04 is in place of, not in addition to, the paid leave defined in Section 02.03.03. Paid leave under this Section 02.03.04 must be utilized in a single contract year, for only one leave type, and cannot be shared across leave types. Leave under this Section 02.03.04 for an approved, qualified event exceeding six weeks will be unpaid, but health insurance will be maintained by the institution during the unpaid status. An additional week (7 days) of paid leave is reserved for use during the same contract year that an approved parental, caregiver or medical leave occurs. Extended leaves of absence may necessitate an extension of training, dependent on minimum training time defined by relevant specialty boards (ABMS).
• 02.03.05 Family and Medical Leave/Parental Leave. The Family and Medical Leave Act (FMLA) requires covered employers to provide up to 12 workweeks of unpaid, job-protected leave to an eligible employee for certain family and medical reasons. A resident is eligible if s/he has worked at TTUHSC at least 12 months and a minimum of 1,250 hours over the previous 12 months. A copy of the TTUHSC FMLA policy may be obtained from the GME Office or the Office of Human Resources. Parental leave of absence, not to exceed 12 weeks, is available for a resident with less than one year of service or who has worked less than 1250 hours in the 12-month period immediately preceding the commencement of leave. This parental leave of absences is limited to, and begins with, the date of the birth of a natural child, or the adoption or foster care placement, of a child under three years of age. Paid leave defined in 02.03.04 is inclusive of paid time under FMLA and parental leave. Leave beyond paid leave will be an unpaid leave of absence; health benefits will be maintained by the institution. Extended leaves of absence may necessitate an extension of training, depending on allowances defined by relevant specialty boards (ABMS).
• 02.03.06 Unpaid Leave of Absence. An unpaid leave of absence is defined as the interval when all paid leave time has been exhausted, but the resident maintains an active status in the residency program under a leave designation with ACGME. The Campus GME Committee must approve an unpaid leave of absence longer than 30 days, exclusive of FMLA or parental leave. Any issues related to required ABMS-specific minimum training time defined by specialty certification boards will be resolved by the Program Director. All available paid leave must be utilized prior to being under an unpaid leave of absence, except as otherwise required by ACGME.
  • 02.03.06.1 An extended unpaid leave of absence not approved by the Campus GME Committee may result in termination of the leave and require that the resident resign from the program, reapply for residency training, and be reappointed, if applicable. Reappointment is not guaranteed, but will be considered only on the same basis as any other applicant seeking appointment. Granting of the leave of absence, along with any reappointment, if applicable, is at the discretion of the Program Director and approval by the campus GMEC.
• 02.03.07 Other Leave Types Outside Paid Leave.
  • Jury Leave. When a resident receives a summons to serve as a juror, his/her attendance is required. The resident must notify the Program Director immediately regarding receipt of a summons in order that training and patient care responsibilities may be accommodated. On occasion, a judge may, at his/her discretion, excuse a resident called to serve as a juror by virtue of the resident's being a physician in training. However, since the resident receives a salary, the judge may determine that no exemption is permitted. Unless the judge grants an exemption, a resident is required to perform jury duty and must be released from the department to respond to the summons. Such jury leave shall be without loss of salary and will not count toward paid leave time.
  • Military Leave. Military leave requires that a resident provide immediate written verification to the Program Director of any and all applicable military orders, which order the resident to duty. A resident who is a member of the state’s military forces or member of any reserve component of the United States armed forces who is called to active duty or authorized training is entitled to a leave of absence from resident duties not to exceed fifteen (15) workdays per academic year. Such military leave shall be without loss of salary and will not count toward paid leave time. After exhausting the fifteen (15) workdays of paid military leave, the resident may use paid leave or be placed on leave without pay for the remainder of the active-duty period.
• 02.03.08 Educational Leave. Educational leave must be approved by the resident's Program Director. An official travel form must be completed by the resident, executed by the department's administrative officer and approved in writing by the Program Director. Failure to comply with this requirement may jeopardize certain benefits, including those for dependents, which may be forfeited if the resident is not on official leave of absence. Subject to residency program requirements and approval, educational leave is granted with pay and not charged to vacation time.
• 02.03.09 Funeral Leave. Funeral leave may be granted with pay upon the death of an immediate family member or immediate family member of the resident's spouse. The total time allowed shall normally not exceed 3 days.
• 02.03.10 Court Leave. When a resident receives either a summons to serve as a juror or a subpoena to appear as a witness, his/her attendance is required. The resident must notify the Program Director immediately regarding receipt of a summons or subpoena in order that training and patient care responsibilities may be accommodated. On occasion, a judge may, at his/her discretion, excuse a resident called to serve as a juror by virtue of the resident's being a physician in training. However, since the resident receives a salary, the judge may determine that no exemption is permitted. Unless the judge grants an exemption, a resident is required to perform jury duty and must be released from the department to respond to the summons.
• 02.03.11 Military Leave. Military leave requires that a resident provide immediate written verification to the Program Director of any and all applicable military orders, which order the resident to duty. A resident who is a member of the National Guard, or a member of any non-activated reserve unit of the Armed Forces, will be entitled to a leave of absence from resident duties not to exceed fifteen (15) work days per academic year for those days with troops on field exercise or for instruction when ordered to duty by the proper authority. Such military leave shall be without loss of salary or vacation time.
• 02.03.12 Compensation for Leave. Residents shall not be entitled to pay or other compensation for holidays, unused vacation or sick leave.

03.01 Responsibility of Resident. Licensure is the personal and financial responsibility of each resident. TTUHSC requires that each resident pass the medical licensure exam as follows:

• 03.01.01 USMLE/COMLEX.
  • A. PGY-1 Level. Prior to an applicant's commencement of residency or training at the PGY-1 level, the Program Director shall verify that the applicant has passed USMLE, Step 1, or its equivalent, within the number of attempts permitted for Texas licensure, i.e., a maximum of 3 attempts for Step 1.
  • B. PGY-3 Level or Above. If a resident from another training program applies for a transfer into a TTUHSC residency program at the PGY-3 level or above, or if a fellow applies to a TTUHSC fellowship, the Program Director shall verify that prior to beginning orientation or commencement of training, the applicant has passed all three steps of USMLE or COMLEX within the number of attempts permitted by TMB for a physician to be licensed in Texas, i.e., a maximum of 3 attempts for Step 1; a maximum of 3 attempts, respectively, for Step 2 Clinical Skills (CS) and Clinical Knowledge (CK); and a maximum of 3 attempts for Step 3.
• 03.01.02 Deadlines for USMLE/COMLEX.
  • A. PGY-1 Level. No later than end date of the PGY-1 year contract, each resident must provide written verification to the Program Director and the campus GME Office of having passed USMLE Step 2, both CK and CS, or their equivalents, within the number of attempts permitted for Texas licensure AND having taken USMLE Step 3 at least one time.
  • B. PGY-2 Level. No later than March 1 of the PGY-2 year, or 4 months before the end of a resident's PGY-2 year, each resident shall be required to provide verification to the Program Director and campus GME Office of having passed USMLE, Step 3, or its equivalent, within the number of attempts permitted for Texas licensure.
  • C. Program Agreement Void. If the applicant has not met the requirements with regard to passing USMLE or COMLEX as outlined herein, the applicant is not eligible to begin a TTUHSC graduate medical education program. Therefore, the previously executed program agreement, if applicable, will be deemed null and void.
  • D. Failure to Pass USMLE/COMLEX Steps 3. If a resident fails to pass Steps 3 of the USMLE or the COMLEX no later than March 1, or 4 months before the end of the PGY-2 year, a new TTUHSC GME Program Agreement will NOT be offered to the resident. However, the resident will be required to complete his/her obligation under the current Program Agreement, i.e., serve as a resident through June 30 of the year, or until the resident has completed his/her then current year of training, unless specific facts or conditions indicate that an exception should be granted. Such exception must be approved by the Program Director.
  • E. Passing USMLE Step 3 after the Deadline. If a resident passes Step 3 of the USMLE subsequent to March 1 of the PGY-2 year, but prior to June 30 of that year, or before the end of the PGY-2 year, the Program Director, at his discretion, may offer a new TTUHSC GME Program Agreement if the program has not already filled the position. However, a resident who passes USMLE Step 3 after the deadline of March 1, or 4 months before the end of the PGY-2 year, is NOT guaranteed a residency position under this circumstance.

04.01 Current or Former Medical License. Each resident shall timely provide copies of all medical licensure information to the GME Office. A resident having either a current or former license from any state must provide a copy of same to the GME Office prior to the beginning of the residency. If any license has been canceled, limited, or removed for any reason, certified copies of that information must be provided in advance of appointment to establish eligibility for appointment. If, or when, discovery of licensure problems is made after appointment, failure on the part of the resident to provide this information at the earliest time possible to the Program Director, as outlined above, constitutes failure to comply with terms of the GME Program Agreement, renders the agreement null and void and results in immediate termination of the resident's appointment.

04.02 Texas License or PIT Permit.

• 04.02.01 Patient Care. No resident or fellow will be allowed to participate in clinical or patient care duties unless a current, valid Texas medical license or a Physician in Training permit (PIT) is on file in the Campus GME Office and the residency program department.
• 04.02.02Physician in Training Permit. A Physician in Training permit is required for any resident not independently licensed as a practitioner in the State of Texas. The permit, obtained from TMB, does not authorize a resident to practice clinical activity outside his/her training program. Notification from TMB that the resident's application for a Physician in Training permit is denied for any reason will void the GME Program Agreement and any applicable provisions therein
• 04.02.03Texas License. Subject to program requirements, an eligible resident may be required to obtain a Texas license after the first year of training. If this is not a departmental requirement, the Physician in Training, formerly referred to as basic postgraduate permit, is renewed as applicable in accordance with current TMB rules. Expiration of one's license or permit will result in suspension of privileges by the affiliated hospital and/or dismissal from the residency program.
• 04.02.04 Reporting Requirements to TMB. TMB requires that within 7 days of occurrence, the Program Director of each approved postgraduate training program report in writing to the TMB Executive Director the following occurrences:
  • A. If an applicant did not begin the training program due to failure to graduate from medical school as scheduled, or for any other reason(s).
  • B. If a permit holder has been terminated or has resigned from the program and the reasons(s) why.
  • C. If a permit holder has been or will be, absent from the program for more than 21 consecutive days (excluding vacation, family, or military leave) and the reason(s) why.
  • D. If the program has information that a permit holder has been arrested after the permit holder begins training in the program.
  • E. If the program has information that a permit holder, while in postgraduate training:
    • (1) Engaged in alcohol or chemical substance abuse, dependency or addiction
    • (2) Engaged in sexual contact with a patient, or sexually inappropriate behavior or comments directed towards a patient
    • (3) Behaved in a disruptive manner toward physicians, hospital personnel, other medical personnel, patients, patient's family members or others that interferes with patient care or could be reasonably expected to adversely impact the quality of care rendered to a patient; is known or suspected to have a medical disorder and has exhibited behavior that is likely to have resulted from the disorder and that could reasonably be expected to adversely affect the quality of care rendered to patients
    • (4) Is known or suspected to have a sexual disorder including, but not limited to, pedophilia, exhibitionism, voyeurism, frotteurism, or sexual sadism
    • (5) Was named in a professional liability claim or suit in which the permit holder was named that involved death or serious bodily injury and in which funds were paid on behalf of the permit holder
    • (6) Failed to practice medicine in an acceptable professional manner consistent with public health and welfare where such failure indicates the permit holder is unable to practice medicine in a competent manner and the permit holder has been unable to correct his or her deficiencies through the remedial measures, if any, offered by the program.
  • F. If the program has determined that a permit holder has committed unprofessional or dishonorable conduct within the meaning of the Texas Medical Practice Act, or as further addressed in the Texas Administrative Code, Section 190.8, Violation Guidelines, relating to, and the reason(s) why;
  • G. If the program has, in relation to academic or non-academic reasons, made a final determination and taken disciplinary or adverse action to include:
    • (1) Limited, reduced, suspended, revoked or denied privileges.
    • (2) Formally warned, censured, reprimanded, or admonished in writing.
    • (3) Monitored admissions and/or treatment plans in a manner that exceeds standard educational practices.
    • (4) Placed the permit holder on academic or disciplinary probation.
    • (5) Requested termination or terminated the permit holder from the program, requested or accepted withdrawal of the permit holder from the program, or requested or accepted resignation of the permit holder from the program.
    • (6) Any such similar action and the reason(s) why.

 

04.03 Drug Enforcement Administration (DEA)

• 04.03.01 Institutional DEA Numbers. Institutional DEA numbers are assigned by the GME Office or affiliated hospital. The institutional DEA number allows prescription-writing privileges for only those activities that are a part of the training program.
• 04.03.02 Individual DEA. Institutional DEA numbers are not valid for outside remunerative employment, i.e., "moonlighting." Once a resident obtains a full, unrestricted Texas medical license, the institutional DEA number is invalid for use by the resident, who must then obtain an individual DEA. Each eligible resident is responsible for obtaining, as well as maintaining current, his/her individual DEA numbers and must keep the program and campus GME Office informed of his/her status.

05.01 Billing Compliance. Within the first 30 days of beginning residency training at TTUHSC, each resident shall undergo Billing Compliance training, and then annually thereafter.

05.02 Medical Records. Dictation, timely completion of charts, signing patient orders and compliance with the rules and regulations of the Medical Records Departments of TTUHSC and affiliated hospitals are considered integral to graduate medical education and professional development. Each resident shall complete all medical records in a timely manner and shall be responsible for familiarizing himself/herself with hospital medical records policies. Failure to complete medical records as prescribed by applicable hospital bylaws, rules and regulations, clinic rules and regulations, and/or departmental policy will result in corrective action, which may include, but is not limited to, disciplinary action at the department/campus level. A resident will not be permitted to advance to the next PGY level, and will be subject to dismissal, if any medical records are outstanding at the end of the training year. A Certificate of Completion or Verification of Training letter shall not be issued by the Program Director until all medical records are completed.

05.03 Disaster Plans. Disaster plans of TTUHSC clinics and respective affiliated hospitals vary. Each Resident should receive an assignment to a disaster station and must be familiar with his/her applicable role and responsibilities relative to the situation.

05.04 Sexual Misconduct. Sexual harassment is a violation of state and federal law. The TTUHSC Graduate Medical Education program prohibits sexual harassment. Each resident will be provided access to TTUHSC OP 51.03, Sexual Misconduct and shall be responsible for understanding its contents and complying with this policy. OP 51.03 is available in the TTUHSC Department of Human Resources, the campus GME office and the TTU System EEO office. In addition, each resident is responsible for attending and participating in any training programs required by TTUHSC.

05.05 Violence and Workplace Threats. Violence and workplace threats are addressed in TTUHSC OP 76.08, which prohibits violent, threatening or intimidating conduct by TTUHSC personnel, including residents. A copy of this policy is provided and reviewed at orientation and is available in the Department of Human Resources, each campus GME office and any TTU Police Department office.

05.06 Immunizations. Each resident is responsible for understanding and complying with the TTUHSC Immunization Policy, which is distributed at orientation and is available in each campus GME Office. TTUHSC provides immunizations at no cost to a resident.

05.07 Physician Impairment. Each resident is responsible for knowing the contents of and complying with the TTUHSC evaluation and Treatment of Impaired Physicians or House Staff, which is distributed at orientation and is available in the GME Office (see Appendix A).

06.01 Educational Goals. The Program Director, with the assistance of the faculty, is responsible for developing and implementing the academic and clinical program that includes, but is not limited to, a written compilation of the program's educational goals with respect to the knowledge, skills and other ACGME competencies required of each resident as s/he relates to each major assignment and level of the training program. The document will be distributed to and reviewed with each resident prior to the assignment.

06.02 Appointment. Appointment to a residency program requires that each resident develop and master competencies for each level of training expected of a beginning practitioner, as referenced below in the following 6 areas:

• 06.02.01 Patient Care. Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health;
• 06.02.02 Medical Knowledge. Medical knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences and the application of this knowledge to patient care;
• 06.02.03 Practice-Based Learning and Improvement. Practice-based learning and improvement that involves investigation and evaluation of a resident's own patient care, appraisal and assimilation of scientific evidence and improvements in patient care;
• 06.02.04 Interpersonal and Communication Skills. Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families and other health professionals;
• 06.02.05 Professionalism. Professionalism as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population; and
• 06.02.06 Systems-Based Practice. 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 value.

 

06.03 Scholarly Activities.

• 06.03.01 Scholarly Activities and Research. The responsibility for establishing and maintaining an environment of inquiry and scholarship rests with the faculty, and requires that an active research component be included within each program. The faculty and each resident must participate actively in scholarly activity. Scholarship is defined as any of the following:
  • A. The scholarship of discovery, as evidenced by peer-reviewed funding or publication of original research in peer-reviewed journals.
  • B. The scholarship of dissemination, as evidenced by review of articles or chapters in textbooks.
  • C. The scholarship of application, as evidenced by the publication or presentation at local, regional, or national professional and scientific society meetings, for example, case reports or clinical series.
  • D. Active participation of the teaching staff in clinical discussions, rounds, journal club, and research conferences in a manner that promotes a spirit of inquiry and scholarship; offering of guidance and technical support, e.g., research design, statistical analysis for each resident involved in research; and provision of support for resident participation, as appropriate, in scholarly activities.
• 06.03.02Resources for Scholarly Activities. Resources for scholarly activities for each resident, in conjunction with faculty, are available, e.g., laboratory space, equipment, computer services for data analysis, and statistical consultation services.

 

06.04 Resident Duty Hours and the Work Environment.

• 06.04.01 Professionalism, Personal Responsibility, and Patient Care. Programs and sponsoring institutions must educate residents concerning the professional responsibilities of physicians to appear for duty appropriately rested and fit to provide the services required by their patients. The program director and institution must ensure a culture of professionalism that supports patient safety and personal responsibility. All residents must demonstrate responsiveness to patient needs that supersedes self-interest.
• 06.04.02 Transition of Care. Programs must ensure that residents are competent in communicating with team members in the hand-over process.
• 06.04.03 Alertness Management. The programs must educate the residents to recognize signs of fatigue and sleep deprivation, and the residents must utilize alertness management and fatigue mitigation processes.
• 06.04.04 Supervision of Residents. Residents should inform patients of theirrespective roles in each patient’s care. Each resident must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence.
• 06.04.05 Clinical Responsibilities. The resident can only perform clinical responsibilities based on their PGY-level, patient safety, resident education, severity and complexity of patient illness/condition and available support services, as stipulated by the program.
• 06.04.06 Teamwork. Residents must care for patients in an environment that maximizes effective communication. This includes working as a member of effective inter-professional teams that are appropriate to the delivery of care in the specialty.
• 06.04.07 Duty Hours
  • A. Maximum Hours of Work per Week. 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.
  • B. Mandatory Time Free of Duty. 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.
  • C. Maximum Duty Period Length. Duty periods of PGY-1 residents must not exceed 16 hours in duration. Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
  • D. Minimum Time Off between Scheduled Duty Periods. PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods. Intermediate-level residents [as defined by the Review Committee] should have 10 hours free of duty, and must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty.
  • E. Maximum Frequency of In-House Night Float and In-House On-Call. Residents must not be scheduled for more than six consecutive nights of night float. PGY-2 residents and above must be scheduled for in-house call no more frequently than every-third-night (when averaged over a four-week period).
  • F. At-Home Call. Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly hour limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one-day-in-seven free of duty, when averaged over four weeks.

 

06.05 Moonlighting.

• 06.05.01 Moonlighting. Moonlighting is defined as participating in any medical activity beyond the scope of the residency program, including outside remunerative activity (External Moonlighting). TTUHSC does not provide professional liability insurance coverage for External Moonlighting. Because residency education is a full-time endeavor, each resident is discouraged, in general, from engaging in moonlighting. However, in the event any moonlighting does occur, it shall not interfere with the obligation and ability of the resident to fulfill the goals and objectives of the educational program and must be approved in writing in advance by the Program Director. This approval will become part of the resident's file. All moonlighting must be counted toward the 80-hour weekly limit on duty hours.
• 06.05.02 Internal Moonlighting. Internal moonlighting is defined as an activity within the scope of the TTUHSC residency program, affiliated hospital, and/or a non-hospital primary clinical site(s).
• 06.05.03 External Moonlighting. External moonlighting is defined as voluntary, compensated, medically related work performed outside the institution and/or scope of the resident program where the resident is in training
• 06.05.03 J-1 Visa and Moonlighting. Anyone holding a J-l Visa is prohibited by federal law from earning extra money or outside remuneration while in resident training, i.e., moonlighting. Therefore, any resident holding a J-1 Visa is prohibited from participating in any moonlighting activity, internal or external.
• 06.05.04 Moonlighting Not Required. No resident may be required to perform moonlighting or internal moonlighting.
• 06.05.05 PGY-1 Moonlighting. PGY-1 residents are not permitted to moonlight.
• 06.05.06 Oversight of Moonlighting by Program Director.
  • A. Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours and the working environment. These policies must be distributed to each resident and faculty.
  • B. Each Program Director shall monitor a resident's training and performance during any time s/he is moonlighting. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service.
  • C. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.

 

06.06 Conferences. Each resident is expected to attend house staff meetings and participate in required core curriculum activities

06.07 Elective Rotations.

• 06.07.01 Approval. Any proposal for a resident's elective rotation must first be approved by the Program Director, who shall then acknowledge his recommendation and supporting information by presenting the proposal in writing to the GME Committee for consideration and, if applicable, approval. If the Program Director cannot endorse the request at the departmental level, the Program Director should not advance the resident's request.
• 06.07.02 Bases for Elective Rotations. The written proposal must include goals and objectives, length of the elective rotation, qualifications of the preceptor and educational values of the elective rotation. The source of funding for the elective rotation, including salary for the period of such absence, shall be identified and determined by the program.

 

06.08 Evaluations.

• 06.08.01 Evaluation of Each Resident. The Program Director, in conjunction with members of the teaching staff, shall, at minimum, semi-annually evaluate each resident. The evaluation must be in writing and shall address the knowledge, skills, and professional progress of each resident. The evaluation should describe the strengths and weaknesses of the resident’s performance. Evaluations may be performed more often, if needed. In addition, the resident should be evaluated by the faculty during each rotation or similar educational assignment.
• 06.08.02 Plan for Improvement. Each resident shall be notified of any deficiencies, if applicable, at the earliest possible date. The Program Director shall prepare in writing a timely plan for improvement, which will be reviewed in person with the resident. Evaluation forms for each resident shall be maintained in the program file. Annual and final written evaluations are retained in the GME files.
• 06.08.03 Peer Review. The evaluation process and any action taken regarding a resident's status in the program including, but not limited to, probation, suspension and termination, is performed as medical peer review, as that term is defined under Texas law.
• 06.08.04 Final Evaluation. The Program Director must provide a final written evaluation for each resident who completes the program. The evaluation must include a review of the resident's performance during the final period of education and shall verify whether the resident has demonstrated sufficient competence to enter practice without supervision. The final evaluation must be part of the resident's permanent record maintained by the institution.
• 06.08.05 Evaluation of Faculty. Each resident shall participate at least annually in regular evaluation of teaching faculty.
• 06.08.06 Evaluation of the Residency Program. Each resident shall participate at least annually in regular evaluation of his/her residency program.

07.01 Unsatisfactory Progress. It is expected that any resident who qualifies for a training program is able to progress satisfactorily through the program. However, when performance and/or progress are unsatisfactory, actions of a disciplinary or adverse nature will be taken.

07.02 Disciplinary Action. Disciplinary action includes, but is not limited to, observation, probation and suspension with pay. When implementing disciplinary action against a resident, each Program Director shall complete a Disciplinary Action Form and, if applicable, a TMB Program Director's Report of Certain Types of Conduct. The Program Director shall forward the report(s) to the campus GME Office.

07.03 Adverse Action. Adverse action includes, but is not limited to, suspension without pay, a recommendation for non-renewal of the program agreement and dismissal. Before initiating adverse action, the Program Director shall first review the matter with the campus DIO and the Chair of the GMEC. After this review, the Program Director will implement adverse action against a resident, which will require that the Program Director complete (1) a Disciplinary Action Form and (2) a TMB Program Director's Report of Certain Types of Conduct. The Program Director shall forward both reports to the campus GME Office, as well as to the Chair of the GMEC (see Section 04,02.04 of this document for TMB reporting requirements).

07.04 Observation. Observation is defined as a disciplinary measure that is generally utilized prior to probation. It is the duty of the Program Director of each residency program to establish a mechanism for evaluating the performance of each resident including, but not limited to, written progress reports. In the event a resident's clinical or educational performance is found to be unsatisfactory, the Program Director shall meet with the resident at the earliest possible date, outline in writing the deficiencies, specify how they are to be corrected and indicate the period of time in which correction or improvement is to occur, and complete a Disciplinary Action Form for submission to the GME Office. If, after a specified amount of time, progress has not been demonstrated, the resident may be placed on probation. However, observation is not a prerequisite if probation or disciplinary measures are more appropriate. Observation may not be appealed and does not require reporting to TMB.

07.05 Probation. Where a resident's performance fails to meet the standards set by the department, the resident may be placed on probation by the Program Director. Probation occurs when a resident is notified that his/her progress, professional development or conduct is such that continuation in the program is at risk.

• 07.05.01 Notice. The Program Director shall notify the resident in writing regarding the probation, outline the reasons for the action, establish a time frame for the probation, provide a specific remedial plan with deadlines, and conduct a follow-up probation evaluation at the designated time, or sooner, if necessary. Notice of probation may be delivered to the resident by certified mail, Return Receipt Requested, at his/her last known address, or hand-delivered to the resident with written acknowledgement of delivery. In the event neither form of communication referenced above is successful, notice to the resident may be given via email attachment with read/receipt notation. Unless precluded by special circumstances from doing so, the Program Director must meet in person with the resident to discuss the probation.
• 07.05.02 Remediation. As a rule, 60 calendar days will be allowed for the resident to correct or remediate the identified deficiency or conduct. However, some probationary periods may be for a shorter period of time. If at the end of or during the probationary period the Program Director determines that the resident has not corrected or remediated the identified deficiency or conduct, the resident may be dismissed from the program. However, probation is not necessarily a prerequisite to dismissal if circumstances dictate otherwise. If at the end of or during the probationary period the Program Director elects to dismiss the resident, the dismissal procedures outlined in Section 07.07 shall be utilized.
• 07.05.03 Lifting of Probation. If the Program Director is satisfied that the resident has corrected or remediated the identified deficiency or conduct, along with any other deficiency that may have arisen during the probationary period, the resident will then be notified in writing that the probationary status has been lifted.
• 07.05.04 No Appeal of Probation. The decision to place a resident on probation may not be appealed.
• 07.05.05 Dismissal Following Appeal. If a resident is dismissed at the end of the probationary period, the dismissal may be appealed in accordance with the procedures outlined in Section 07.07 herein.
• 07.05.06 Reappointment Followed by Dismissal. If a resident is placed on probation or suspended after notice that a new Program Agreement has been/will be extended, but prior to beginning a new training year, the offer for re-appointment shall be automatically deemed abated until all requirements relating to probation are fully resolved. At the discretion of the Program Director, the program agreement/contract abated during the referenced probationary period may be declared null and void.
• 07.05.07 Reappointment During Period of Disciplinary Action. A resident may be placed on probation at any time without first having been placed on observation. At the discretion of the Program Director, the decision regarding whether or not to extend a new Program Agreement to a resident on probation or suspension may be deferred until the end of the probationary period
• 07.05.08 Report to TMB. Probation must be reported to TMB through a TMB Program Director's Report of Certain Types of Conduct form. In addition, probation should be reported on all credentialing documents requested on the resident.

 

07.06 Suspension.

• 07.06.01 Criteria for Suspension. The Program Director may suspend a resident with or without pay depending on the circumstances, which may include, but not be limited to, any situation where a serious charge is brought against the resident, or concern exists that the resident's performance of his/her duties is seriously compromised or may constitute a danger to patients, others or self.
• 07.06.02 Notice of Suspension. The resident will be notified of his/her suspension by certified mail, Return Receipt Requested, to his/her last known address, or hand-delivered with written acknowledgement of delivery. In the event neither form of communication referenced above is successful, notice to the resident may be given via email attachment with read/receipt notation.
• 07.06.03 Investigation. An investigation will be initiated within seven calendar days from the date of the suspension and shall be completed within 30 days. At the conclusion of the investigation, the Program Director shall confer with the resident as soon as practicable, but in no event later than 30 days from date of suspension, except as referenced hereinabove
• 07.06.04 Appeal of Suspension. The resident may not appeal suspension with pay. However, suspension without pay is subject to appeal.
• 07.06.05 Lifting of Suspension. Suspension will be lifted when the investigation is completed on or before the 30th day following imposition of suspension. Upon completion of the investigation and its findings, a determination will be made as to the proper course of action. Such action will be communicated in writing to the resident.
• 07.06.06 Report to TMB. Suspension must be reported to TMB through a TMB Program Director's Report of Certain Types of Conduct form.

 

07.07 Dismissal.

• 07.07.01 Authority. The authority to dismiss a resident resides solely with the Dean of the School of Medicine.
• 07.07.02 Criteria for Dismissal. The Program Director may recommend that a resident be dismissed for unsatisfactory performance, lack of professionalism or conduct during the term of his/her annual program agreement/contract. Examples include, but are not limited to, the following:
  • A. Performance that presents a serious compromise to acceptable standards of patient care or jeopardizes patient welfare.
  • B. Failure to progress satisfactorily in fund of knowledge, skill acquisition and/or professional development.
  • C. Unethical conduct.
  • D. Excessive tardiness and/or absenteeism.
  • E. Illegal conduct.
  • F. Unprofessional conduct.
• 07.07.03 Notice of Criteria for Dismissal. When recommending dismissal, the Program Director shall use the Disciplinary Action Form (DAF) and include any related documentation providing the basis for dismissal. The Program Director shall specify in writing the areas deemed unsatisfactory and state with specificity the reasons for the dismissal. A copy of the recommendation for dismissal must be provided to the resident made the subject of the action.
• 07.07.04 Appeal of Dismissal. Dismissal is subject to appeal, as it suggests poor performance, unprofessional conduct or malfeasance.
• 07.07.05 Appeal by Resident. Upon receipt of the written recommendation for dismissal and the Disciplinary Action Form, the resident may initiate an appeal by submitting to the Chair of the campus GMEC within five business days a written notice of appeal, outlining in detail his/her issues regarding the appeal and the remedy sought.
• 07.07.06 Timeliness of Appeal. In the event the resident elects not to appeal the decision, or the resident fails to appeal within the prescribed five business days, the resident will be deemed to have waived the right to appeal.
• 07.07.07 Report to TMB. Dismissal must be reported to TMB through a TMB Program Director's Report of Certain Types of Conduct form.

 

07.08 Job Abandonment

• 07.08.01 Definition. Job abandonment, defined as three consecutive days' unexcused absence from the program without notice to the Program Director, is tantamount to resignation. Any exception must first be approved by the Dean of School of Medicine.
• 07.08.02 Documentation. The Program Director shall use the Disciplinary Action Form (DAF) to report action taken and include information from the program for completing the DAF. The DAF and other documentation regarding such action shall be forwarded for signature to those individuals listed on the form, as well as to the Associate Dean for Graduate Medical Education and Resident Affairs on the Lubbock Campus.

08.01 Clinical Duties During Appeal. The resident shall have no clinical duties during the appeal process.

08.02 General Duties During Appeal. During the appeal process, the resident shall continue to perform duties as assigned by the Program Director, if benefits end.

08.03 Salary and Benefits During Appeal. The resident will receive salary and insurance benefits during the appeals process not to exceed 45 calendar days from the date of receipt of the request for appeal. If, for any reason during the appeal process, the resident is sick or takes any vacation days, which must be approved in advance, the maximum of 45 calendar days will not be increased. In the event the appeals process concludes prior to 45 days, and provided the Dean issues a dismissal, salary and benefits will end on the date of dismissal. If the appeals process continues beyond 45 days, as referenced hereinabove, salary and benefits will end on the 45th day.

08.04 COBRA Insurance. The resident shall contact the TTUHSC GME Office to arrange for continuation of health insurance under COBRA, if benefits end.

08.05 Appeal Procedure.

• 08.05.01 Hearing Subcommittee. Upon receipt of the resident's written notice of appeal, if applicable, the Chair of the Campus GMEC shall appoint an ad hoc Appeal Review Subcommittee (Subcommittee), which shall be charged with conducting a hearing to review the recommendation for dismissal (suspension without pay or non-reappointment) of the resident.
• 08.05.02 Composition of Subcommittee. The Subcommittee shall be comprised of three faculty members from the GMEC, a Chief Resident and a house staff officer. The chair of the campus GMEC shall appoint one of the faculty members as chair of the Subcommittee, who will serve as a non-voting member unless their vote is necessary to break a tie among the other members. Membership of the ad hoc Appeal Review Subcommittee shall exclude faculty and house staff from the department of the resident who filed the appeal. The Subcommittee shall set a date for the hearing and notify all parties concerned of any other procedural information that will be observed
• 08.05.03 Documentation for Appeal. At least 5 days prior to the hearing, the resident and the Program Director shall provide to each other and the Subcommittee all relevant documents that will be used in the appeal process to include, but not be limited to, the written request for appeal, all reports, evaluations and recommendations related to the action taken, and his/her file as maintained by the department and GME Office. The DIO may be utilized to disseminate the documents to the Subcommittee and Program Director. All documents submitted to the Subcommittee shall be deemed confidential and will be returned to the GME Office after making its recommendation to the GMEC.
• 08.05.04 Witnesses. At least 5 days prior to the hearing, the resident and Program Director shall provide to each other and the Subcommittee the names of witnesses, if any, that each will utilize at the hearing. The resident and Program Director shall each be responsible for arranging the participation of their respective witnesses for and during the hearing.
• 08.05.05 Legal Counsel. The resident shall have the right to appear in person before the Subcommittee and may be accompanied by legal counsel retained by the resident. If legal counsel is to accompany him/her, the resident shall notify the Subcommittee in writing at least 5 days in advance of the scheduled hearing, at which time the Chair of the Subcommittee shall immediately notify the Program Director and the Office of General Counsel (OGC). In the event the resident is to be accompanied by legal counsel, a representative from the OGC shall attend on behalf of the university. Legal counsel may serve only in an advisory capacity to the resident and TTUHSC and may not participate in the hearing.
• 08.05.06 Conduct of Hearing. At the beginning of the hearing, the Chair of the Subcommittee shall review with the participants the procedural rules that shall be observed.
• 08.05.07 Witness Available by Telephone. Only if a witness is not readily available to attend the hearing in person, the Subcommittee may consider allowing the witness to participate by telephone. If applicable, the resident and Program Director, respectively, shall notify the Subcommittee and each other at least 24 hours in advance of the hearing that a witness will not be available in person.
• 08.05.08 Audiotape of Hearing. The hearing will be audiotaped, and either of the parties may obtain a copy upon written request. No transcript will be provided.
• 08.05.09 Evidence. At the hearing, the resident shall present to the Subcommittee and the Program Director the basis of his appeal and may introduce evidence considered to be relevant and material to the case. However, all evidence offered must be reasonably related to the facts and statements concerning the reasons for dismissal and the resident's appeal. The resident bears the burden of establishing that the dismissal (suspension without pay or non-reappointment) is unjustified. The Subcommittee shall determine whether information provided at the hearing is relevant and material to the case and whether it is reasonably related to the matter of the dismissal.
• 08.05.10 Failure to Appear. Failure of the resident to appear at the hearing will result in automatic dismissal of the resident's request for consideration and any and all other rights of appeal.
• 08.05.11 Responsibilities of Subcommittee. Following each party's presentation of evidence, the hearing will conclude, and the Subcommittee will deliberate in closed session. The Subcommittee shall submit in writing a report and provide recommendations to the campus GMEC no later than seven calendar days from the conclusion of the hearing. The Subcommittee shall provide a copy of its findings and recommendations to the resident and Program Director at the same time it provides the findings and recommendations to the campus GMEC.
• 08.05.12 Procedural Due Process. If the resident believes procedural due process has not been followed up to and/or during the hearing, s/he may notify the Chair of the campus GMEC in writing within three calendar days after receipt of the Subcommittee's recommendations. It shall be the responsibility of the campus GMEC to determine whether the procedural due process claims of the resident, if applicable, materially affected the outcome of the decision. Only if the campus GMEC determines a procedural error materially affected the outcome of the case will a new Subcommittee be appointed to re-hear the resident's request for consideration of the dismissal. The campus GMEC must notify the chair of the Subcommittee, resident and Program Director in writing within 3 calendar days whether an alleged procedural error, if any, materially affected the outcome of the Subcommittee's findings and recommendations.
• 08.05.13 Responsibilities of Campus GMEC. Upon receipt of the findings of the ad hoc Subcommittee, or after time has expired to appeal dismissal, the campus GMEC shall review the findings and recommendations of the Subcommittee at a regular or called meeting that shall be held within 7 calendar days after receipt of the report from the Subcommittee. The campus GMEC will forward its report and recommendations to the Regional Dean.
• 08.05.14 Responsibilities of the Regional and Associate Deans. If applicable, the Regional Dean shall review the campus GMEC's report and recommendations and then forward his/her recommendations to the Associate Dean for Graduate Medical Education and Resident Affairs, who in turn, will forward his/her recommendations to the Dean of the School of Medicine.
• 08.05.15 Responsibilities of the Dean. The Dean of the School of Medicine shall then review the findings and recommendations and make a determination, which shall be communicated in writing to the resident, the Program Director, the Regional Dean, Chair of the GMEC and Chair of the ad hoc Appeal Review Subcommittee. Notice of the Dean's determination may be delivered to the resident by certified mail, Return Receipt Requested, at his/her last known address, or hand-delivered to the resident with written acknowledgement of delivery. In the event neither form of communication referenced above is successful, notice to the resident may be given via email attachment with read/receipt notation. The decision of the Dean shall be final.
• 08.05.16 Effect of Dean's Determination. A final determination by the Dean of the School of Medicine to dismiss the resident shall nullify or terminate any previous program agreement appointing the resident to a subsequent year of training.

 

08.06 General, Disciplinary and Adverse Actions.

• 08.06.01 Exhaustion of Remedies. Remedies and procedures contained herein, if applicable, must be exhausted in their entirety prior to the resident's resorting to any other forum.
• 08.06.02 Determination of Deadlines. Periods listed herein are guidelines and may be extended only by the Dean of the School of Medicine where justified. For the purpose of determining any deadline herein, the first business day following any event shall count as the first day.
• 08.06.03 Departure from Procedure. The Chair of the GMEC must approve any departures from these procedural guidelines, including established time frames, and only for justifiable reason.
• 08.06.04 Report of Final Adverse Action to Organizations. Except for those instances required by the Texas Medical Board for reporting adverse action, no specialty or sub-specialty certifying board or national, state, or local medical organization, exclusive of a licensing agency, shall be notified of a pending disciplinary action until a final determination has been made by the Dean of the School of Medicine.

09.01 Definition. A current resident is provided a process by which to resolve a complaint against another individual associated with his/her residency program. A complaint is a resident's formal expression of disagreement concerning issues related to the work environment or issues related to the program or faculty, e.g., hours, working conditions, performance evaluations, assignments or other matters involving management decisions concerning the resident. Complaints that are covered by an existing TTUHSC Operating Policy, including, but not limited to, sexual harassment, violence in the workplace and discrimination, shall be referred to the appropriate office for consideration. A resident's disagreement regarding an academic action such as the non-renewal of a program agreement/contract for continued training, or dismissal shall be addressed as provided in the House Staff Policies and Procedures hereinabove.

09.02 Disciplinary Actions Pending Complaint. The filing of a complaint shall not preclude TTUHSC from pursuing disciplinary actions or separation actions for reasons other than the resident's filing of a complaint.

09.03 Non-Adversarial. A complaint procedure shall be non-adversarial.

09.04 Complaint Resolution Procedure. In general, steps to resolve a complaint shall be oral/in-person initially, then in writing, if applicable. If not resolved at an early stage, the resident may ultimately meet with an ad hoc complaint committee, as provided hereinbelow:

• 09.04.01 Step One.
  • A. A resident must attempt to resolve the issue by first meeting with the individual(s) involved and discuss the specific incident or clearly defined matter within five calendar days of the incident's occurrence.
  • B. For complaints based on a continuing series of less clearly defined matters, the complaint must be communicated to the Program Director at this initial step no later than twenty 20 calendar days following the onset of the issue of complaint.
  • C. If the issue is not resolved at this initial step, the resident shall promptly attempt resolution by proceeding through the next step(s).
• 09.04.02 Step Two.
  • A. If the complaint is not against a faculty member, the resident should contact the Chief Resident. The resident will clearly present his/her concerns and suggestions for resolution to the Chief Resident. The Chief Resident shall make every effort to facilitate resolution of the issue, and shall inform the resident in writing of his/her response and reasons for that response within three calendar days. If resolution is not achieved with the assistance of the Chief Resident, the resident should meet with the Program Director to seek resolution. The Program Director shall make a determination within three calendar days and notify the resident in writing of the determination.
  • B. If the complaint is against a faculty member and resolution has not been achieved as a result of an initial meeting, the resident shall contact the Program Director. The resident will clearly present his/her concerns and suggestions for resolution of those concerns. The Program Director shall inform the resident in writing of his/her response and reasons for the response within three calendar days.
• 09.04.03 Step Three.
  • A. If resolution is not achieved as a result of the above, or the complaint involves the Program Director, the resident may then contact the department Chair regarding the complaint within 3 calendar days from the Program Director’s decision.
  • B. The resident will present a formal written complaint to the department Chair including a summary of specific events, describe prior attempts to resolve the complaint, and state the remedy sought. The formal complaint cannot be changed after submission without approval of all persons concerned. The department Chair will investigate the complaint, attempt to reconcile differences and propose a solution. The department Chair will provide a written statement of his/her recommendation to all parties within three business days from receipt of the complaint.
• 09.04.04 Step Four.
  • A. If the complaint is against the department Chair, or if resolution has not been achieved up to this point, the resident is to present the complaint in writing within three calendar days to the Chair of the campus GMEC including an explanation of all attempts to resolve the matter thus far, along with the resolution sought. The Chair of the campus GMEC shall designate an ad hoc Complaint Committee comprised of one member of the GMEC and one House Staff officer, who, with the Chair of the campus GMEC, shall informally review the complaint. The member of the campus GMEC and the House Staff Officer shall be members of a department different from the resident. The Chair of the campus GMEC shall provide in writing to the resident and the individual made the subject of the complaint a written determination addressing the resident's complaint within 3 calendar days. A copy of the written determination shall be forwarded to the department chair. The decision of the ad hoc Complaint Committee shall be final.

 

09.05 EthicsPoint. The EthicsPoint system is intended to offer an additional means of confidential reporting to TTU System students, staff, and faculty. However, we encourage residents to attempt the resolution of concerns through established channels outlined above. To utilize the EthicsPoint reporting system, go to www.ethicspoint.com and follow the instructions on the website.

10.01 Program Agreement. A program agreement shall not be for a period greater than 12 months. Acceptance into a Residency program does not constitute a multi-year agreement.

10.02 Program Agreement for Continued Training. The issuance of a program agreement for continued training, i.e., re-appointment, also referred to as a "new contract," is conditioned upon successful completion of the current training year.

10.03 Non-Renewal of Program Agreement.

• 10.03.01 Notice of Non-Renewal. If a resident is not to be issued a new program agreement for the following training year, s/he must receive written notice of non-renewal 4 months prior to the ending date of the current program agreement by (a) certified mail, Return Receipt Requested; (b) hand delivery with written acknowledgement of receipt/delivery from the Program Director or designee; or (c) if other attempts have failed as outlined herein, by email attachment, with read-receipt notation.
• 10.03.02 Appeal of Non-Renewal. In the event a resident elects to appeal his/her non-renewal, the appeals process for dismissal as outlined herein shall be utilized (see Section 07.07).
• 10.03.03 Effect of Leave of Absence on Program Agreement. If a leave of absence is requested or occurs during the interval after appointment to a new year of training, but before the new training year begins, any issuance of a program agreement/contract for continued training shall be deemed null and void. Any conditions or requirements relating to the leave of absence must be met prior to the resident's return to training, if applicable.
• 10.03.04 Effect of Probation/Suspension on Program Agreement. If a resident is placed on probation or is suspended, after issuance of a new program agreement/contract for continued training and prior to beginning a new year of training, at the Program Director’s discretion, the program agreement/contract may be deemed abated, or null and void, until such time that all circumstances and requirements relating to the probation or suspension are resolved.

 

10.04 Resignation.

• 10.04.01 Obligation to Notify TTUHSC. A resident who does not plan to continue in the succeeding year of his/her training program must notify the Program Director in writing at least 4 months prior to the ending date of the current program agreement.
• 10.04.02 Leave of Absence. As provided hereinabove, a leave of absence is defined as the interval when all accumulated vacation and/or sick leave time has been exhausted or when the resident voluntarily leaves a program. Extended leaves of absence, excluding pregnancy or FMLA leave, may require resignation of the resident and application for a new appointment to the residency program when, or if, the resident wishes to return to training (excluding pregnancy). Granting of the leave and issuance of a new program agreement/contract for continued training thereafter is at the discretion of the Program Director.

 

10.05 Changing Programs. When a resident in an existing TTUHSC residency program wishes to pursue the possibility of transferring to another TTUHSC residency, the following steps must be followed:

• 10.05.01 Responsibility of Resident. The resident must inform his/her current Program Director in writing that s/he desires to seek another residency position at the same institution.
• 10.05.02 Responsibility of Receiving Program. The receiving Program Director (of the residency to which a change is sought) shall inform the current Program Director in writing regarding possible recruitment of the resident.
• 10.05.03 Mutual Agreement of Program Directors. Both residency Program Directors must agree regarding the change.
• 10.05.04 Dispute Regarding Changing Programs. Any unresolved dispute regarding a resident's transfer to a new program shall be referred to the campus GMEC.
• 10.05.05 Verification of Resident's Training and Performance. If a TTUHSC resident transfers to another program outside TTUHSC, the current Program Director will, if requested by the receiving program, and with the written acknowledgment of the resident, provide the receiving Program Director written verification of the resident's previous educational experiences and a statement regarding the performance evaluation of the transferring resident.
• 10.05.06 J-1 Visa Holders. By federal statute, individuals on a J-l visa are permitted to change programs one time only.

11.01 House Staff Association. The House Staff Association provides a support system organized to promote professional and social relationships among residents. Information pertaining to the House Staff Association may be obtained through the campus GME Office.

11.02 Counseling Services. Confidential counseling services are provided by the institution and may vary from campus to campus. Information pertaining to available support and counseling services may be obtained from the campus GME Office. If applicable, the Program Director may issue a mandatory supervisory referral to counseling.

11.03 ID Badge. An ID badge is provided to each resident and must be worn at all times including, but not limited to, an affiliated hospital, clinic, any TTUHSC building. A lost or damaged ID badge should be reported immediately to the department residency program coordinator.

11.04 Parking. Parking for each resident is subject to the parking regulations of TTUHSC, as well as any affiliated hospital to which the resident is assigned. Parking and auto registration information may be obtained from each campus GME Office.

11.05 Lab Coats. Lab coats are provided by each respective department, or if applicable, the affiliated hospital. Information regarding laundry service is available within each department.

11.06 Meals. Meals provided to a resident vary from campus to campus. Information is available within each respective department.

11.07 On-Call Quarters. On-call quarters are provided at each affiliated hospital. Specific information is available within each respective department.

11.08 E-Mail address. A TTUHSC email address is provided for each resident. Each resident is required to check his/her email on a regular basis and shall be held accountable for information sent to the TTUHSC e-mail address. Use of a TTUHSC email account must comply with university policy regarding the use of computers.

11.09 Impairment of House Staff. As a physician, each TTUHSC resident is subject to the TTUHSC School of Medicine policies which address evaluation and treatment of an impaired physician including, but not limited to, intervention, drug testing, medical evaluation, treatment, rehabilitation, etc. (see Appendix A).

12.01 Completion Requirements. A post-graduate education program is not considered completed until the resident has satisfactorily fulfilled the total training time specified by program requirements. Failure to satisfactorily complete this requirement may jeopardize a resident's eligibility for Specialty Board Examination, the discretion and responsibility of which rest with the Program Director.

12.02 Certificate of Completion. Upon recommendation of the Program Director, a certificate of completion is awarded to a resident who satisfactorily completes the residency training requirements for board certification eligibility, and all exit protocols are appropriately completed.

12.03 Verification of Training. Letters verifying training are provided at the request of the resident who satisfactorily completes only a portion of training, but does not complete the training requirements for board eligibility. Advance written verification by the Department and written approval by the GME Office are required prior to issuance of a letter verifying training.

13.01 Notice Regarding Closure or Reduction of Program. In the event a Program Director determines the need exists to reduce the size of or close an ACGME-accredited program, the Program Director shall first confer with the Designated Institutional Officer (DIO), the Chair of the campus GMEC, Regional Dean, and the Dean, i.e., School of Medicine administration. After notice is given to the TTUHSC School of Medicine administration, the Program Director, in conjunction with representatives of the GME office, will notify each affected resident in writing at the earliest possible date.

13.02 Closure of the Sponsoring Institution. In the event the university, i.e., TTUHSC, or the School of Medicine, were to close, the Program Director, in conjunction with representatives of the GME office and TTUHSC School of Medicine administration, shall notify each resident in writing of the closure.

13.03 Effect of Closure or Reduction of Program. In the event of reduction or closure as outlined herein, TTUHSC will either allow a resident already in the program to complete his/her training, or assist the resident in obtaining a residency position in another ACGME-accredited program.

POLICY FOR EVALUATION AND TREATMENT OF IMPAIRED PHYSICIANS OR HOUSE STAFF

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I. PREAMBLE

Texas Tech University Health Sciences Center (TTUHSC) (also referred to as University) recognizes that its Physicians and House Staff, i.e., (interns, residents, fellows and physicians, (also referred to as Physician/s)) who are impaired are individuals in need of professional help. Additionally, the medical staff realizes that an impaired Physician can prevent the University from meeting its commitments to provide for high quality patient care in a safe environment. The University's employees and trainees at all campuses are expected to conduct their activities in this highly complex healthcare environment in full control of their manual dexterity and skills, mental faculties, and judgment.

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II. POLICY

TTUHSC regards the misuse or abuse of drugs or alcohol by a Physician as conduct subject to disciplinary action, which may include, but is not limited to, the immediate suspension of all or any portion of the clinical privileges granted to a member of the medical staff and eventual termination of employment. In addition to impairment as a result of substance or alcohol abuse or misuse, other neuropsychiatric and general medical illnesses may produce impairment covered under this policy. Actions taken under this policy shall be in accordance with policies established by the Texas Tech University System (TTUS) Board of Regents, or pursuant to the TTUHSC Operating Policies and Procedures (HSC OPs), the TTUHSC School of Medicine Professional Staff Bylaws (Bylaws), the TTUHSC SOM Faculty Handbook, and the TTUHSC School of Medicine House Staff Policies and Procedures, as well as state and federal laws to include the Texas Medical Practice Act, Chapter 151, Texas Occupations Code. Referral to an appropriate treatment program and follow-up in a supervised rehabilitation program are among the means by which Physicians may be assisted in returning to professional activities.

The Policy for Evaluation and Treatment of Impaired Physicians or House Staff (Policy) applies to all Physicians and House Staff who are employed, appointed, affiliated, or under contract with TTUHSC. Physicians and House Staff are subject to this Policy. If, or when, a reason exists to conclude that the individual is impaired or is exhibiting a behavior pattern suggestive of impairment, this Policy will be utilized to address this conclusion. The direct observation of chemical substance abuse or misuse, or observations of aberrations in job performance and/or behavior may be cause for this conclusion.

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III. DEFINITIONS

The following are definitions, explanations, qualifications, or stipulations regarding certain terms used in this policy:

• 1. Physician(s). Physician(s), as used throughout this policy, includes medical doctors, doctors of osteopathy, and doctors of dentistry who have completed training and are licensed to practice in the state of Texas. The term also includes practitioners providing healthcare services in correctional facilities on behalf of TTUHSC.
• 2. House Staff. House Staff, as used throughout this Policy, includes interns, residents, physicians and fellows, i.e., medical school graduates, who participate in a residency training or fellowship program at TTUHSC, which has been approved by the Accreditation Council for Graduate Medical Education (ACGME).
• 3. Alcohol abuse or misuse. (See chemical substance abuse/misuse below.)
• 4. Chemical substance abuse. Chemical substance abuse is the personal use of any chemical substance that is specifically prescribed by law or regulation pursuant to legal authority, (e.g., Schedule 1 drugs); the personal misuse of any legally controlled substance; or the personal misuse of any normally legal chemical substance, (e.g., alcohol) in a manner that produces the likelihood of the development of impairment.
• 5. Chemical substance misuse. Chemical substance misuse is the self-administration of any chemical substance for any reason other than its intended use.
• 6. Emergency. An emergency is one in which there may be an imminent or potential adverse effect on a TTUHSC patient, employee, student, or other person(s).
• 7. Impairment due to substance abuse or misuse. Impairment due to substance abuse or misuse refers to any condition, resulting from substance abuse that interferes with the individual's ability to function at work, or in fulfilling one's training or work responsibilities, as normally expected.
• 8. Impairment due to other neuropsychiatric illnesses or medical reasons. Impairment due to other neuropsychiatric illnesses or medical reasons refers to any other categories of impairment including, but not limited to, major debilitating illnesses, depression, dementia, or other psychopathology or disruptive behavior that may interfere with the individual's ability to function at work, or in fulfilling one's training or work responsibilities as normally expected.
• 9. Symptoms of impairment. Symptoms of impairment includes, but is not limited to, declining work performance as manifested by unavailability, missed appointments, lapses in judgment, incomplete medical records, poorly communicated nocturnal phone orders, mood swings, unexplained absences, embarrassing behavior, signs of intoxication or self-medication, and/or withdrawal from hospital or other professional activities. Personal problems and change in character or personality are further indicators of impairment.
• 10. TTUHSC Physician Health and Rehabilitation Committee. The TTUHSC Physician Health and Rehabilitation Committee (PHR Committee) is a medical peer review committee, as defined in the Texas Medical Practice Act, as may be amended, to assist Physicians with physical impairments, chemical or substance abuse problems, or mental and emotional difficulties that may affect clinical skill and/or judgment.
  • i. The PHR Committee shall be a standing subcommittee of the MPIP Policy Committee at each campus.
  • ii. The PHR Committee members shall be appointed by each Regional Policy Committee pursuant to the MPIP Bylaws, Article 3.
  • iii. Each campus PHR Committee shall consist of five (5) members, one of which shall be a psychiatrist or psychologist, and one of which shall be a House Staff member. The House Staff member shall be an officer, or elected by the House Staff Association. The PHR Committee shall exclude participation of the House Staff member in a faculty impairment situation.
  • iv. The term of each member on the PHR Committee shall be a minimum of three years, with the exception of the House Staff member, whose term shall be for one year. Original start-up appointments may be staggered for shorter periods of time. No member may serve more than three (3) consecutive three-year terms.
  • v. Each campus PHR Committee shall adopt bylaws consistent with other campuses to guide ensure the fulfillment of duties under this Policy.

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IV. REPORTING REQUIREMENTS

It is the responsibility of all TTUHSC employees, associates, or other affiliated persons to contemporaneously report observations of impairment to at least one of the following individuals:

• 1. Immediate supervisor of the Physician or House Staff,
• 2. Immediate supervisor of the work area where the Physician or House Staff provides health care services,
• 3. PHR Committee,
• 4. Associate Dean for Graduate Medical Education and Resident Affairs, or Regional Dean at Amarillo or Permian Basin,
• 5. Medical Director, Correctional Managed Health Care.

 

Reports of impairment shall be based on "reasonable suspicion," defined as a good faith belief, based on specific, contemporaneous, and articulable observations.

The Physician and/or House Staff are also encouraged to self-report and shall have an opportunity to voluntarily relinquish duties and privileges that cannot be performed safely and cooperate in the development of activity restrictions which may be imposed. This Policy does not preclude a Physician or House Staff from self-reporting to the Texas Medical Board (TMB) to obtain a protective Board order, or obtain support through the TTUHSC Employee Assistance Program (EAP) services.

Behaviors or actions, which are illegal or improper, shall also be referred for resolution under appropriate TTUHSC policies, including, but not limited to, the Sexual Harassment policy, Affirmative Action/Equal Employment Opportunity policy, or other applicable policies, laws or regulations.

When an employee's performance has deteriorated for other than identifiable, job- or training-related circumstances, a supervisor may implement the steps for supervisory referral to the TTUHSC Employee Assistance Program (https://www.ttuhsc.edu/centers-institutes/counseling/documents/Supervis…).

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V. DOCUMENTATION

Written documentation reporting impairment, or behavior suggestive of impairment, along with medical and psychiatric evaluation reports, and other correspondence pertaining to these events, and the treatment and rehabilitation of any Physician or House Staff, will be treated as confidential.

All such documentation shall be labeled "CONFIDENTIAL – PEER REVIEW."

Documentation is the responsibility, and is under the control, of the PHR Committee and shall be maintained in a secure location as the PHR Committee may designate.

The contents of the confidential file will be released by TTUHSC only upon written authorization of the affected Physician or House Staff, or as required by state and federal law.

Activity restrictions imposed as a result of actions under this Policy will be communicated to individuals or entities, including, but not limited to, residency Program Director, hospital quality assurance or similar committee, professional liability office, School of Medicine risk manager, and other supervisory personnel, ONLY on a need-to-know basis, commensurate with the level of risk. The overriding consideration will be the safety of patients, any other employees, or individuals at TTUHSC, as well as the affected Physician or House Staff.

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VI. AUTHORITY

TTUHSC's authority over Physicians who are employed, appointed, affiliated, or under contract with TTUHSC extends to termination of the relationship, as well as to the appointment and retention of faculty status and clinical privileges at TTUHSC.

TTUHSC's authority over House Staff extends to restricting residents' access to patients and, if necessary, dismissing residents from the training program, and reporting the individual to the Texas Medical Board for endangering the lives of patients and posing a continuing threat to the public welfare. Other action may include reporting the restriction and the reasons therefore, to the Graduate Medical Education (GME) office at each campus. The intern, resident, fellow or Physician may be prohibited from participating in any clinical activities at TTUHSC if found to be impaired and not yet subject to an official, ongoing monitored rehabilitation program.

The TMB is authorized under the laws of Texas to refuse to admit persons to examination, refuse to issue licenses or renew licenses to practice medicine to Physicians who are considered a continuing threat to the public welfare as a result of their impaired status or of the intemperate use of alcohol or drugs that could endanger the lives of patients. This also includes those who are unable to practice medicine with reasonable skill and safety because of illness, drunkenness, excessive use of drugs, narcotics, chemicals or impairment.

A person, healthcare entity, or medical peer review committee that, without malice, provides records, information, or assistance to a medical peer review committee or to the TMB regarding any physician who is a continuing threat to the public welfare is immune from any civil liability arising from such an act. (See the Texas Medical Practice Act, Chapter 151, Texas Occupations Code.)

Physicians or House Staff who assist in evaluation of an impaired Physician or House Staff under this policy will be considered agents of the PHR Committee, a medical peer review committee. If there is a conflict in obligation, the responsibility to the Institution takes precedence over the responsibility to the impaired employee.

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VII. RESPONSIBILITES AND ROLES

TTUHSC is responsible for the health and safety of its patients, employees or other persons. Through its administration, TTUHSC representatives must act upon personal observations or reports of symptoms of impairment regarding a Physician or House Staff that may endanger the life of a patient, or may increase the likelihood of immediate injury or damage to health or safety.

A. Associate Dean for Graduate Medical Education and Resident Affairs, Lubbock Regional Deans, Amarillo, Permian Basin

If a report of impairment is received by the Associate Dean for Graduate Medical Education and Resident Affairs or any Regional Deans, he/she may consult with the clinical department chair, and may refer the matter to the PHR Committee for consideration and, if applicable, resolution. Recommendations from the TTUHSC Credentials Committee and the department Chair or Regional Chair to which the affected Physician or House Staff reports may be considered in resolving an impairment situation.

If the affected Physician is a department Chair, the Associate Dean for Graduate Medical Education and Resident Affairs or Regional Dean shall identify a Physician within that department who shall act in place of the Chair for purposes of this Policy.

Actions MAY include, but are not limited to, the following:

• 1. Arrange for immediate medical leave for evaluation and treatment, if needed.
• 2. Immediately suspend all or any portion of clinical privileges or require an immediate withdrawal from any and all clinical duties. [NOTE: Actions that adversely affect clinical privileges for more than 30 days are reportable to state and national regulatory bodies.]
• 3. Immediately give written notice to the affected Physician or House Staff regarding the medical leave or suspension, if applicable, with confirmation by certified, return receipt requested. Hand delivery in person to the Physician or House Staff, with notation of delivery, may likewise constitute sufficient notice.
• 4. Immediately notify the Chair of the Credentials Committee.
• 5. Immediately notify the appropriate department Chair regarding the medical leave or suspension in order that patient care responsibilities may be reassigned for those patients whose treatment has been, or may be, interrupted by the action.
• 6. In the case of House Staff, notify the Graduate Medical Education office and Residency Director within two working days of action taken.
• 7. Report the Physician or House Staff member to the Texas Medical Board.
• 8. In all cases where notification or notice is required as stated above, the notice shall be in writing.

 

B. Chair, Regional Chair and/or Program Director

If a report of impairment is received by the Chair, Regional Chair, and/or Program Director, he/she may consult with the Associate Dean for Graduate Medical Education and Resident Affairs or the Regional Dean, and may refer the matter to the PHR Committee for consideration and, if applicable, resolution. Actions taken MAY include, but are not limited to, those listed above, as well as the following:

• 1. Verify the accuracy of the observations suggesting impairment.
• 2. Explain to the Physician or House Staff in question that these observations have been made.
• 3. Report to the Associate Dean for Graduate Medical Education and Resident Affairs or Regional Dean (or his/her designee) any Physician or House Staff conduct requiring that immediate action be taken to protect the life of a patient or to reduce the substantial likelihood of immediate injury or damage to the health or safety of any patient, employee, or other person in the hospital.
• 4. Take immediate steps to have the Physician or House Staff escorted directly to nearest Emergency Room (ER) to be seen for medical evaluation by the Medical Director or staff physician on duty, including a request for laboratory testing for the presence of illegal drugs or alcohol in body fluids.
• 5. Testing for drugs or alcohol is voluntary. In addition, a psychiatric evaluation by the staff psychiatrist may also be sought, particularly if there appears to be a need for immediate intervention or for the personal safety of the impaired individual. In such instances, an Emergency Detention or Order of Protective Custody may be considered. In the event that the ER staff physician or on-call staff psychiatrist is unavailable, the Associate Dean for Graduate Medical Education and Resident Affairs or Regional Dean, or his/her designee, will assign a physician to medically evaluate the fitness for duty of the reported Physician or House Staff.
• 6. The Physician or House Staff shall be advised that communications during the above evaluations may not be confidential and may be used to determine whether the Physician or House Staff has impairment to the extent that he/she cannot safely engage in providing health care.
• 7. Arrange for any Physician or House Staff deemed to be impaired by drugs or alcohol, or impairment for other reasons, to be evaluated by the Employee Assistance Program personnel through a mandatory supervisory referral and/or be escorted to a treatment facility or his/her residence. Input from the PHR Committee should be obtained if possible. If the Physician or House Staff refuses assistance, the TTU Police Department shall be contacted to prevent the individual in question from operating a motor vehicle while in an impaired condition.

 

C. Emergency Room - Medical Director

Upon the arrival of the Physician or House Staff at the ER, the Medical Director or the staff Physician on duty will perform a fitness-for-duty evaluation of the individual alleged to be impaired, and may also request the on-call staff psychiatrist to perform a psychiatric evaluation. The evaluations shall be accomplished within one hour of arrival, or as expeditiously as possible thereafter.

If the evaluation(s) indicates a neuropsychiatric impairment regarding the Physician or House Staff, the ER Medical Director or staff physician on duty shall inform the Associate Dean for Graduate Medical Education and Resident Affairs or Regional Dean, and the appropriate Chair or Regional Chair as expeditiously as possible.

In an emergency situation, the ER Medical Director, the PHR Committee, the department Chair or Regional Chair, in conjunction with the on-call staff psychiatrist, may temporarily remove the Physician or House Staff from work assignments, pending a medical evaluation and consultation with the Associate Dean for Graduate Medical Education and Resident Affairs or Regional Dean.

D. TTUHSC Physician Health and Rehabilitation Committee

Anyone who knows or has reason to believe that a Physician or House Staff is impaired may contact any member of the PHR Committee to refer the individual as outlined hereinabove, in lieu of an initial referral to the department Chair, Regional Chair, Regional Dean, or Associate Dean for Graduate Medical Education and Resident Affairs.

The PHR Committee will investigate all cases referred to it with the strictest confidentiality possible. If the PHR Committee determines that the conduct of the Physician or House Staff requires immediate action in order to protect the life of any patient or to reduce the substantial likelihood or immediate injury or damage to the health or safety of any patient, employee, or other individual, the PHR Committee may take any of the actions previously outlined in this Policy, with involvement of appropriate administrative authority as needed. If immediate action is deemed unnecessary, the PHR Committee may, with the approval of the department Chair, Regional Chair, Regional Dean, and/or Associate Dean for Graduate Medical Education and Resident Affairs, pursue intervention through the EAP's Supervisory Referral and/or the local Texas Medical Association (TMA) Committee for Physician Health and Rehabilitation.

E. Medical Director – Correctional Managed Health Care

Anyone who knows or has reason to believe that a Physician, or House Staff is impaired who is employed by, or is under contract with, TTUHSC to provide health care services at a correctional institution and/or is under the supervision of the TTUHSC Correctional Managed Health Care department, shall report the information to the Medical Director of Correctional Managed Health Care, or designee who shall be a medical doctor). The information may also be reported to the Associate Dean for Graduate Medical Education and Resident Affairs or Regional Deans, who shall refer the matter to the Medical Director of Correctional Managed Health Care.

The Medical Director-of Correctional Managed Health Care will investigate all cases referred with the strictest confidentiality possible. If the Medical Director-of Correctional Managed Health Care determines that conduct requires immediate action to protect the life of any patient or to reduce the substantial likelihood or immediate injury or damage to the health or safety of any patient, employee, or other individual, the Medical Director-of Correctional Managed Health Care may take any of the actions previously outlined in this policy with involvement of appropriate administrative authority as needed.

If evaluation in an ER is not available or feasible, the Medical Director of Correctional Managed Health Care may arrange for an evaluation at the most appropriate site according to his or her best judgment.

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VIII. TESTING GUIDELINES

Testing for drugs and alcohol

• Any Physician or House Staff being evaluated for a reported condition or impairment may be asked to undergo voluntary laboratory testing for the presence of illegal drugs or alcohol in body fluids or breath as a part of the medical evaluation for fitness for duty.
• If the Physician or House Staff refuses testing, this information will be communicated immediately to the Associate Dean for Graduate Medical Education and Resident Affairs, Regional Dean, or the Medical Director of Correctional Managed Health Care.

 

NOTICE: Although testing for alcohol or drugs is voluntary, refusal of recommended testing may result in prophylactic measures including, but not limited to, suspension from duties pending evaluation, and investigation of the conduct made the basis of the report regarding symptoms of impairment.

• To the extent feasible, laboratory tests shall be sent to a laboratory independent of TTUHSC and affiliated hospitals. A National Institute of Drug Abuse (NIDA) approved laboratory may be considered.
• A screening test positive for chemical substances will be confirmed by the best currently available laboratory techniques. If the accuracy of a positive confirmatory test is disputed by the individual, the confirmatory test on a different aliquot of the same sample will be repeated in a qualified laboratory, which may be chosen by the individual, with observation of proper chain of custody procedures. If the test result is not disputed, or if the additional confirmatory test is positive, the result will be taken as definitive evidence of chemical substance abuse in the case of illegal chemical substance. The entirety of the available evidence will be used to determine the presence or absence of chemical substance abuse if the substance involved is one for which a bona fide medical indication exists.
• The cost of chemical substance testing undertaken in the course of investigation for substance abuse and/or impairment will be borne by TTUHSC.
• The cost of chemical substance testing performed as part of a treatment program, including maintenance monitoring, will be considered to be part of the cost of the treatment program and will be the responsibility of the affected individual.

 

Testing for other than drugs or alcohol

• Any Physician or House Staff being evaluated for a reported condition of impairment other than from chemical or substance abuse may be asked to undergo physical or psychiatric evaluation as a part of the medical evaluation for fitness for duty.
• If the Physician or House Staff refuses testing, this information will be communicated immediately to the Associate Dean for Graduate Medical Education and Resident Affairs, Regional Deans, or the Medical Director of Correctional Managed Health Care.
• The testing required will be specifically tailored to each case, and the information sought will be specified.
• The cost of such testing undertaken in the course of investigation for other than substance or chemical abuse impairment will be borne by TTUHSC.
• The cost of future testing or treatment involved with the rehabilitation of an impaired physician will be borne by the affected individual.

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IX. RESOLUTION OF REPORTED IMPAIRMENT

A report of impairment shall be verified, investigated, and evaluated. Resolution may include a recommendation for any of the following:

• 1. Corrective action in accordance with Professional Staff Bylaws adopted at each campus,
• 2. Action under the TTUHSC House Staff Policies and Procedures
• 3. Plan for treatment issued by the PHR Committee for those impairments subject to rehabilitation.

 

If the PHR Committee recommends a Plan for treatment, each Plan:

• 1. Shall be prepared by the PHR Committee on a case-by-case basis. From the time of receipt of the initial report of impairment and as may be appropriate, input into the Plan may be sought from the Chair, Regional Chair, Program Director, Associate Dean for Graduate Medical Education and Resident Affairs, Lubbock, and Regional Deans, Amarillo and Permian Basin.
• 2. Shall be completed within 30 days of receipt of a recommendation.
• 3. Shall contain:
  • a. standards, work duty restrictions and/or reassignments,
  • b. supervision or any other requirements necessary to accomplish rehabilitation,
  • c. time deadlines for completion of the intervention steps and periodic reviews with Physician to assess progress,
  • d. on-going, random drug-testing and health evaluation as necessary,
  • e. other requirements for return to unrestricted practice, and
  • f. consequences if the Plan is not followed.
• 4. Physicians or House Staff shall provide written consent for the PHR Committee to contact any treating Physician while monitoring a Plan, including a personal physician.
• 5. Physicians or House Staff who self-report shall have input into the Plan. The PHR Committee may consider input from a Physician or House Staff who is the subject of a report of impairment.
• 6. The Physician or House Staff, along with his/her immediate supervisor, shall sign the Plan.

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X. FAILURE TO COOPERATE OR REPORT

Failure of a Physician or House Staff to cooperate with an investigation, or report for, or follow through with, specified rehabilitation steps shall be deemed lack of professionalism and misconduct under TTUHSC policies, and may result in disciplinary action independent of any results obtained from investigation under this Policy.