OSTEOPATHIC FAMILY PRACTICE

HOUSE STAFF MANUAL

COMMUNITY HEALTH CENTER OF BRANCH COUNTY

Training Year 2011 - 2012

TABLE OF CONTENTS Contents Page

Phone Listing - Deleted 1 Introduction 2 History 3 Oath of Hippocrates 3 Guidelines for House Staff 3 Osteopathic Musculoskeletal Examination 23 Requirements for Admission to the Educational Program 23 Family Practice Residency Program 24 Competency Assessment –Progressive By OGME Year 24 Universal Precautions 30 CDC Recommendations for Minimizing Risk to HIV/HBV 31

Service Protocols 31 Family Practice 31 Osteopathic Practice 33 Pediatrics 33 Internal Medicine 34 Emergency Medicine 35 Obstetrics 36 Surgery 38 Geriatrics 39 Behavioral Medicine 40 Community Medicine 41 Sports Medicine 41 Sports Medicine/Ambulatory Orthopedics (Hillsdale Community Health Center) 42 Radiology (Hillsdale Community Health Center) 45

Guidelines for Prescribing Controlled Medications 46 Forms Description Section 48 Patients Rights 49 Patients Safety 50 Abbreviation Do Not Use List 51 Fire Procedure 53 Annual Physician Education 54 Physician Role in a Disaster 54 Infection Control 55 Facility Security 55 Active Medical Staff - Deleted 56

Medical Education Department

1 INTRODUCTION

The Welcome to Community Health Center of Branch County, or CHC. This manual is a combined document for all house staff and is one of several documents that you may receive as a trainee at CHC. It is designed to outline specific duties and responsibilities you have as a trainee here. If you are an extern, you will also be responsible for the contents of the clerkship manual from your school.

If a resident, you will also receive the Hourly and Exempt Professional Employee Policies manual. That document will outline specific employee responsibilities. Your contract and any addendums should be considered part of your trainee manual. In addition, there are several AOA documents that should be included in your manual. These are updated and published yearly in the AOA Yearbook and Directory and include Protocol for Approval of Postdoctoral Training and Intern Training Program Policies and Procedures or Residency Training Requirements of the AOA. As the training program is affiliated with COGMET through Michigan State University, you will also receive additional information regarding your responsibilities to that organization. These should be added to your manual.

All house staff should use your manual as an instruction guide. As a professional, you represent the hospital, the AOA and yourself at the hospital and in the community. Take time to familiarize yourself with these guidelines. H. Lauren Vogel, D.O., the Director of Medical Education and Family Practice Program Director, is responsible for your training while associated with CHC. He should be consulted regarding any problems with your rotations and will be responsible for orientation and exit interviews.

Externs will be assigned to an individual service or to a specific physician or professional group. These physicians will be your immediate supervisors and may determine specific responsibilities for your rotation separate from the general requirements for students. They will direct your learning, give you specific assignments and critique your work. In addition, you may receive other assignments from the Director of Medical Education.

All house staff report directly to Dr. Vogel. He is responsible for your monthly assignments and will be responsible to direct your educational program. You will be assigned to a specific physician or professional group on a monthly basis. During your rotation, these physicians will be your immediate supervisors and will assign patients, reading assignments and other specific responsibilities for the rotation separate from the general requirements for interns.

Residents in Family Practice also report to Dr. Vogel. He is the Family Practice Program Director and Continuity Clinic Supervisor. Residents will set up their rotations with the direction and approval of the DME and the program director. While on a specific service, residents will report to an attending physician and will be responsible to that physician.

Throughout your clinical training here you should feel free to discuss any problems or concerns with any of your supervisors at any time. Whether an extern, intern or resident you should feel that you are an integral part of a team and should contribute as well as learn. Your feedback will be sought and will be used to formulate service and rotational objectives on an ongoing basis. The guidelines for trainees offer objectives and skills that should be obtained during your rotation on the specific service. They are separated by level of training. Externs should be exposed to all the objectives for the rotation but the depth of their ability to diagnose, manage and perform procedures would be expected to be less than those trainees with more experience. At the completion of the

2 resident’s training it is expected that he would be capable of meeting all the objectives for all the services represented within the core training program.

HISTORY

In 1991, CHC began an osteopathic training program with the desire to develop a primary care training program in a rural community. The hospital’s mission is to provide quality, excellence, caring and integrity in health care. The program was developed to provide a broad-based experience in primary care and to help in the recruitment of primary care providers to the rural area. The strength of the program here is the ability for trainees to receive excellent exposure to a wide variety of pathology and to have the opportunity to develop their skills in physical diagnosis and procedures with the supervision of physicians interested in their welfare. Much of the training will be received as one-on-one. All house staff, and those externs assigned to family practice, will attend a family practice clinic on an ongoing basis and will be assigned a battery of patients to follow for the duration of their training. In the family practice clinic, externs will be supervised by the resident staff.

The Oath of Hippocrates

I, (pronounce name), solemnly promise to God Almighty that according to my ability and judgment I will endeavor at all times to observe the stipulations of this oath which, through ageless tradition, has governed the conduct of my predecessors in the profession which I am about to enter.

Appreciating the benefits of the instruction accorded to me, I promise to esteem and revere the teachers who have trained me in the science and art of medicine, to share my good fortune with them and to relieve their necessities should want befall them. To all who are deserving, but to none who are unworthy, I will freely impart a knowledge of my science and art.

I will adhere to the doctrine and prescribe the treatment which my ability and judgment assure me are most beneficial for my patients. I will abstain from everything which may be harmful or dangerous to them. I will attempt no treatment which evidently requires training and skill superior to mine.

With purity of purpose and holiness of life, I will practice my profession. My every word and deed in the homes of my patients or in other places of treatment will be directed solely to the welfare of these patients. With the help of God’s grace they will find no occasion in my speech and actions to disrespect my profession. Whatever I see or hear as I practice my profession which should not be revealed, I will not divulge because such knowledge must remain secret. As long as I keep this promise, I hope to enjoy happiness in life, success in my profession, the respect of my fellow men. But may the reverse be my lot if I should willfully violate my solemn word now given before God.

GUIDELINES FOR HOUSE STAFF

Absence from the hospital

Any scheduled absence from the hospital must be excused by the attending physician and the DME. Forms for scheduled absences may be obtained in the office of the Director of Medical Education. These must be signed by the attending physician and DME before any absence is approved.

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Alcohol

Alcoholic beverages are forbidden in the hospital at all times.

Annual Logs and Training Reports

For residents, the AOA requires that you complete an annual report, a procedure log and that the residency director complete a narrative annual training report. Copies of these reports are to be submitted to the DME office within 2 weeks after the end of your current contract year. These are permanent records. Residents are required to complete a rotation summary for each rotation. This summary must include a log of all procedures performed, log of all procedures completed and a log of all reading assignments completed during the rotation. The resident must also include a narrative summary of the service to include the variety of patients seen, narrative of the working conditions and supervision and any other pertinent information. Forms are available to guide you in completing these requirements.

Externs are required to complete a log of activities in accordance with their individual college requirements.. In most cases, their college will provide the log or specify the correct format. They too must complete an evaluation of their service and will in turn receive an evaluation of their performance while on the rotation.

A thorough log is an asset. Forms are available in the DME office. Completed logs and evaluations should be turned into the DME office at the end of the rotation. They will be considered delinquent if they are not received by two weeks after the completion of the rotation. House staff with service evaluations or logs more than two months delinquent may be placed on administrative leave pending approval of all delinquent reports and logs. Originals should be turned into the medical education office. We will send copies to your college or the AOA as required.

AOA

All osteopathic trainees under contract as a house officer must remain a member of the AOA and ACOFP. Community Health Center will pay your AOA dues during your training program. Make sure that you bring any dues statements promptly to the DME office.

A-Team

The A-team is a response team for psychiatric emergencies. The psychiatric department offers an instructional course several times throughout the year. If you are interested, you may attend and become qualified to respond to calls for the A-team.

Attendance

Residents are required to attend the specific educational endeavors with specific priority. The SCS Educational Day must be attended by all Family Practice residents unless on an approved absence, sick or on vacation. The family practice clinic is the next highest priority and must be attended as scheduled. Case presentations, lectures and journal clubs will be scheduled around the clinics and should be attended unless excused by the DME. Trainees scrubbed in surgery or attending a delivery may be excused from a lecture or CPC as long as their total attendance for these programs is above

4 85%. Residents not attending 85% of scheduled SCS educational programs will not have completed the required educational component of their training program and will not receive a certificate of completion.

It is your responsibility to make sure that attendance sheets are completed for all educational programs and that the sheets are submitted to the DME office. You are expected to be on time for all didactic programs as a courtesy to your peers and the speaker. House staff attendance at staff meetings and family practice department meetings is required.

Call

A call schedule will be developed with the cooperation of the DME and your trainer. Generally, trainees will be assigned call on a regular basis depending upon interest, by service. Residents will be assigned call for their attending but not on a rotating basis. No trainee will be expected to take call more than three nights per week or more than two weekends per month. Trainees will not be allowed to be on service for longer than 16 hours without being away from their assigned responsibilities for 12 hours.

All patients admitted from the family practice ambulatory training site will be cared for by the resident staff under appropriate supervision. House staff will rotate call to accomplish this requirement. The resident is responsible to secure coverage if they trade within their call schedule.

Case Presentation

Case presentations are an integral part of any training program and are included in parts of the scheduled educational program for house staff. As a resident, you will be responsible for presenting a case presentation per schedule from the DME. You should select cases in medicine, surgery, obstetrics, pediatrics, family practice and to present these during a morning report. The format for the presentation should be a clinical case discussion similar to the CPC’s found in the New England Journal of Medicine. You may use journal articles or actual patient cases and the presentation should include a discussion of current diagnosis and treatment modalities.

A CPC is a multi-disciplinary discussion and is most often presented as tumor board. Your attendance is mandatory. When assigned to a clinical case conference you will be expected to present the clinical aspects of the case. You must also be prepared to discuss current therapy and differential diagnoses and must be knowledgeable regarding current journal articles regarding the diagnosis.

Charting

You will be responsible to complete a dictated history and physical on all assigned patients within 24 hours of assignment. You must also document your findings as a summary in the progress notes. Every patient encounter should be documented with an appropriate progress note. You are expected to complete a discharge or off service summary for every patient assigned at their completion of hospital stay or at the completion of your care. Your attending will review his specific requirements with you. Dating and timing of all chart entries is a requirement.

5 Clinic

The outpatient clinic is your main teaching resource. During orientation you will be introduced to the forms and procedures specific to the clinic. Each resident will be assigned storage and work space. We maintain a small, family practice specific library in the clinic. You are responsible to maintain it if you use it. Clinic assignments are made at the beginning of each training year. Your clinic responsibility takes precedence over all other activities.

Clinical Clerks

As a resident, periodically a clerk may be assigned to you. For the clinical clerk this is primarily a training and observation period. Clerks may not perform any procedure on a patient unless he is supervised directly by an attending physician that is approved to perform the procedure. Clinical clerks may write orders and progress notes and these must be countersigned by the supervising physician at the time they are written. Externs may not give verbal orders.

Communication

Making yourself understood is an art and lack of communication is a common problem. If you are not sure in your mind whether to notify someone of a problem usually means that you should. If you are not sure that your orders or comments were completely understood usually means that they weren’t.

Competency Assessment

The AOA and ACOFP require that residents complete a competency assessment by the end of their training program. Forms are available in the DME office. This information may be released to third parties requesting it unless you specify otherwise.

We currently assess all seven competencies for every resident. These are assessed at the completion of each rotation by their primary preceptor. We also assess clinic competency and review the service evaluations bi-annually. Finally, we complete the final competency evaluation at the completion of the family practice residency. Assessment is completed through service evaluations, bi-annual assessment and 360 reviews.

In all instances, there is interaction between the house staff and DME and program director with specific direction and recommendation for improvement when resident performance is below that expected for their level of training. We will use the AOA / ACOFP forms for documentation of competency (See Remediation).

At the discretion of the program director your residency program may be extended until you document competency in the seven domains. (See Remediation)

Clinical Knowledge

Resident understanding and application of clinical concepts are assessed by various means throughout the program. The clinic preceptors utilize observation and verbal testing as their primary methods of assessment. All family practice residents participate in the annual in-service examination. The clinic supervisor and the program director utilize the above and also conduct

6 monthly chart reviews to assess resident understanding and application of evidence-based medicine. Verbal assessment during continuity clinic hours is an important part of clinical assessment.

Osteopathic Philosophy and Management Skills

This is assessed mainly during clinic exposure. Preceptors actively utilize observation and verbal testing as their primary methods of assessment. All family practice residents participate in the annual in-service examination. The program director reviews in-patient charts to assure that osteopathic examination and diagnosis is included in all appropriate medical charts.

We have a monthly OPP lecture series that includes hands-on components for every session. The clinic supervisor and program director are responsible to assess and instruct house staff during these sessions. Resident participation is useful in assessing competency in this domain.

Professionalism

The clinical preceptors assess this modality via observation during clinic exposure. This modality is also assessed by the primary preceptor on each rotation. This evaluation is reviewed by the program director and the DME monthly. Demeanor, dress, interpersonal interaction and empathy are some of the components that we will assess as components of professionalism

Interpersonal and Communication Skills

Interaction among house staff, clinic physician and ancillary staff is assessed during clinic exposure. Assessment of verbal skills is completed by the clinic preceptors. Cultural and religious knowledge and resident awareness of disability issues is assessed on each rotation by the primary preceptor and in the clinic by the clinic preceptors. In addition, ancillary staff input is sought and reported through the monthly rural health clinic meetings.

Patient Care

Service rotation assessment completed by the rotation preceptor and reviewed by the program director and DME is conducted monthly. Direct observation is utilized during clinic assignment. Preventive service utilization is assessed by scheduled chart reviews. Chart review to assess resident assessment of activities of daily living, pain and social interaction is conducted monthly. Results are reported to the individual house staff and a summative review is presented at the monthly clinic meeting.

System Based Practice

Resident interaction with the health care systems is assessed by chart review and by the clinic preceptors during interaction with the house staff. Utilization of appropriate formularies, referral practices and utilization of services is assessed by the clinic medical director regularly and a report is presented during the monthly clinic meeting. Resident knowledge of the business of medicine and utilization of in-patient services is assessed during each rotation. These reviews are reviewed y the DME monthly.

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Procedural Skills

The ability of the resident to perform office-based procedures is assessed by direct observation by the clinic preceptors. Lectures relating to procedures include an interactive component and resident understanding and participation is assessed by the lecturer.

Summary

Wherever possible the competencies are assessed by in-service testing and by certification board examination. Direct observation is also utilized in all areas of competency assessment. Chart reviews are utilized to assess resident performance in those areas amendable to a chart review.

Computers

House staff has access to the library computer and FMC computers. Programs installed on this computer include word processing and Internet access. Other educational programs may be installed. These learning assisted programs enhance your education and you are encouraged to utilize them. Contact Dr. Vogel or the librarian for specific instructions on how to use these programs. As newer programs become available these will be added to the computer for your use. The student housing, hospital, and Family Medicine Clinic are wireless and the house staff can use PDA's or lap tops to access the Internet from these areas.

Residents also have their own computer in the Family Medicine Clinic. A security code is required and can be obtained from the librarian/Medical Education Coordinator. Be considerate of others and take care of this equipment.

Community Service

CHC is a contributor to community service. We have several functions that serve the community and promote the hospital. All house staff is welcome to participate. Interns and Residents should consider their participation as part of their competency requirements for professionalism.

At the completion of your residency training you must demonstrate a minimum of 50 hours or two weeks exposure to training in community medicine. Community based medical activities, attendance at area free clinics, participation in school health programs and work in occupational health care are examples of community medicine. Be sure to document your time on your service evaluations and on your annual report.

Confidentiality

Do not reveal the diagnosis or other pertinent information regarding a patient’s illness to him or his family without permission of your attending. Refer such questions to the attending. It is wise to appear cheerful, confident and sympathetic when you are in contact with the patient.

Dictation

As trainees you may be assigned H&P’s, discharge summaries, service notes and consultations. You may dictate these using the in-house dictation system. On each unit you will find an overview of the

8 dictation system. You should contact medical records if you have any difficulties with the dictating system. The format for your dictation may be specified by your attending. A suggested format for standard dictation can be utilized.

Discharge Summary

The resident assigned to the case is responsible for completing the discharge summary. Ideally this should be dictated on the day of discharge. The dictation should be in narrative form and should thoroughly list all pertinent diagnoses. An appropriate discharge summary must include the following components:

Date of admission and discharge Final primary diagnosis All Secondary diagnoses Complications, hospital engendered infections Surgeries and procedures performed History of chief complaint and reasons for admission (clinical) Narrative chronological summary of lab and x-ray findings Narrative chronological summary of hospital course and treatments Condition at discharge Disposition

Disaster Policy

All interns and residents will receive the CHC disaster policy manual during their orientation. A copy is also available online in our library and in the DME office. Externs should review the policy early during their rotation. Should you be notified of a pending disaster you should report to the DME office if it is open. If the DME office is closed, report to the emergency room. A phone tree that includes all interns and residents addresses and phone numbers is a requirement.

DME Call

Occasionally, the DME schedules a special meeting to discuss important topics. Attendance is mandatory. If you cannot make it, you must be excused by the DME.

Due Process

House officers training at CHC must hold a valid appointment from the board of trustees. Each appointment will be for a maximum of one year although it is anticipated that appointments will be renewed yearly for the duration of the training program. House officers are subject to the state and federal statues pertinent to licensing and practice in Michigan. House officers must comply with the ethical standards and by-laws of CHC. Violation of any of these will be construed as misconduct and shall subject the trainee to disciplinary action which may include dismissal from their training program. CHC Human Resources policy for employees shall be in effect for all misconduct issues.

9 Failure to meet established academic standards documents academic deficiency. A trainee may be placed on remediation for disciplinary problems, poor performance of normal duties and assignments or poor attendance at the discretion of the program director. Summary Suspension is the immediate removal from duties for cause when the best interest of the patient or the facility is jeopardized. The program director and the DME have the authority to summarily suspend a trainee.

For trainees assigned a summary suspension, the ability for remediation is usually not appropriate. Once removed from patient care for patient safety issues remediation or recommendations for termination are at the discretion of the FP program director. Consultation with the education committee is at the discretion of the program director. (See Remediation).

Remediation

Remediation is a process for trainees with academic deficiency or patient safety concerns that did not result in summary suspension. Placement of a resident into remediation and the duration of the remediation is at the discretion of the program director. Written documentation of the reasons for the assignment, goals and objective that must be achieved to resolve the remediation and follow up summary of the outcomes of the assignment shall be placed in the resident's file as a permanent document, discussed at the educational committee meeting and a copy shall be given to the resident.

Remediation will be resolved in one of several ways: The trainee will correct all the deficiencies as outlined in the remediation report and the remediation will be resolved allowing the resident to continue his assigned duties with all remediation time to be made up. The trainee will improve but not correct all deficiencies during the remediation period. Additional remediation time or dismissal from the program is then appropriate.

Educational and Travel Allowance

Residents receive a post-graduate allowance of $1500.00 per year. You may use these funds to purchase educational material such as books, journals, PDA's and computer software. You may also use this fund for reimbursement for travel expenses to educational seminars, clinics and other approved educational endeavors. Costs for tuition and room and board for educational seminars are reimbursable. As CHC is a tax-exempt hospital, you are not allowed to use post-graduate funds for purchase of non-medical equipment. Dr. Vogel can advise you regarding how you may use your allowance. See the CHC Travel Policy for additional information.

Employee Relations

In case of disagreement or differences of opinion with nurses, technicians or other hospital employees, do not attempt to engage in arguments with the individual involved. Bring your differences to the DME. Remember that you are a professional representative and that your interaction may be viewed by the public.

All house staff are responsible to review the hospital policy for sexual harassment yearly. Be aware of your attitude in relations with other employees. Certain language, jokes and mannerisms may be seen as inappropriate by others.

10 ERAS

All osteopathic applicants must participate with ERAS. We will accept applications through ERAS for all OGME-1 positions.

Ethics

Do not be critical in public of another doctor’s orders or his work. If you question a procedure, contact the attending physician or the DME. Do not be critical of nursing or other hospital personnel in front of patients or visitors. It’s unprofessional and many law suits originate from such instances. You could be involved.

Our patients come from many different ethnic backgrounds. Their culture may alter the way they communicate with physicians. They may not be comfortable with physician members of a different sex. You should ask the patient for more information if this appears to be a problem. You should always defer to their desire.

Evaluations

Your assessment of the program and your supervisor’s assessment of you are an important component of our educational program. Specific forms are kept in the DME office. You are responsible to complete an evaluation of your educational experience for every service. This is used to assure that educational goals are being met effectively. An evaluation of you by the attending will become a permanent part of your file. This assures successful completion of the rotation. Evaluations are to be completed within two weeks of the completion of the service.

A formal bi-annual review will be completed for each resident. This is a formative review of your participation in the seven domains of competency. Your final review will be summative and shall reflect your progression through the residency and an assessment of your clinical and procedural skills. This document may be shared with agencies requesting clinical information about your training.

Failure

Academic failure of a rotation is unexpected. As a professional, the trainee must assume responsibility for knowing the requirements for each service. The attending trainer is responsible to offer an honest critique of the trainee’s ability. In an instance where the trainee’s performance is substandard, the attending may recommend special assignments and/or extra time in training.

Failure on a rotation may occur for lack of attendance, lack of appropriate interest, inability to follow established policy or failure to complete assignments. The trainee may appeal any poor performance grade to the FP program director and DME. A resident evaluation is a consensus opinion and may be changed at the discretion of the program director. Following evaluation by the program director an evaluation may be changed or remediation instituted.

11 Female Patient Examination

Female patients should never be examined by a house officer without the presence of a nurse. Vaginal examinations on under-age females require the consent of the parent or guardian except in cases of rape, for birth control or for the diagnosis of sexually transmitted disease. In these instances, make sure that you document the reasons for the exam in the progress notes. In the event a patient refuses a vaginal examination document this in your progress note and notify the attending physician.

Finances

Do not discuss finances with patients. Refer all questions in such matters to the Business office.

Fire and Disaster

In the event of a fire, the hospital fire alarm will ring automatically and is also manually controlled. The switchboard must be notified by personnel in the area as to the location and extent of the fire. As a house officer, you will receive specific instruction in safety through Human Resources. This education will include fire safety, hazardous waste and infection control/blood borne pathogens which is mandatory on a yearly basis.

FMC2 Rotation

Residents may elect to take up to 6 weeks rotation in a clinic oriented rotation which serves to provide extra time for independent projects and community medicine. While on the FMC2 rotation residents must take all clinic call as scheduled. They are required to complete their scheduled clinic assignments and to attend all scheduled lectures and meetings. They will not be on a scheduled rotation except for their clinic responsibilities.

Health Care

If you incur any accident or injury while on duty at CHC you are required to contact employee health or the ER. A record must be made of the incident. Externs should have medical insurance through their college. You are encouraged to discuss any chronic health issues with Dr. Vogel.

History & Physical

You are required to complete an H&P on all assigned in-patients. An H&P is also a requirement for all new clinic patients assigned to you. In the hospital setting, the H&P must be complete and must include a breast exam, rectal and genital exam, osteopathic structural exam and diagnosis or a differential list. An omission of any component of the H&P, i.e., breast exam, requires an explanation. It is your responsibility to document that the patient realizes the importance of any component they refuse during your examination. Components of the exam deferred, because of medical condition, must be completed before discharge and documented in the progress notes.

Hours

Your primary responsibility is to the patients assigned to you. Traditionally, house staff works12

12 hour days. Your hours of duty are at the discretion of your trainer. You will have educational responsibilities at morning report beginning at 7:30 A.M. each working day. Whenever you are away from the hospital during your duty hours, it must be approved by the DME and your trainer in advance of any absence. It is your responsibility to make sure you have coverage for any house call.

Family practice rounds will be made at a time convenient for the attending. It is your responsibility to contact the attending to determine the time for daily rounds. Teaching rounds must be made with your attending on a daily basis.

Housekeeping

For trainees utilizing CHC housing, housekeeping will clean the student house once weekly. They will not disturb any personal property or change the bed linen. Housekeeping will deliver linens to the house. Housekeeping is not responsible for any trash disposal. They will clean and press your white coats. Make sure that you have identified them with your name in permanent ink. You may use your own linens and towels. If you want to use hospital linens and towels, you are responsible to drop them off at the laundry department.

Identification

All house staff will be issued an identification badge during their orientation. This should be worn (above the waist) whenever you are in the hospital or clinic and are attending patients. You may elect to wear your polo shirt with name inscribed in lieu of other identification.

Ink

Use only black ink in writing on a medical record. Other colors, including blue do not microfilm well. Nothing written on the medical record should be erased or obliterated. Place one line through your mistake and write error adjacent to it.

Insurance

All residents are covered with malpractice insurance through the hospital while on duty and on assigned hospital rotations. This coverage will extend to out-rotations if these are approved by the DME. Should you be named in a malpractice suit or should a patient suggest that you will be named it is your responsibility to notify the Director of Medical Education immediately. Externs will be covered through their college. It is the responsibility of the college to provide documentation of malpractice coverage for externs as part of their clerkship application process.

Specific coverage for medical insurance for the resident and his family is outlined in the employee packet. It is your responsibility to notify Human Resources of any coverage change, such as a new baby, that would alter the insurance coverage.

Intern

Traditionally, the first OGME-1 year is considered an internship. Although integrated within the 36- month family practice residency the OGME-1 and intern may be used interchangeably. Upon successful completion of the OGME-1 year the resident shall receive a letter of completion as required by the AOA.

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Journal Club

Journal Club is an excellent means of keeping abreast of current medical literature. As a family practice resident, you are expected to read several family practice journals on a monthly basis. In addition, you should be aware of and should try to read pertinent articles from journals of other specialties as they relate to family practice. All residents will be expected to attend journal club monthly. Residents will be assigned a journal article and will be expected to discuss the article at the journal club meeting. It will be all resident's responsibility to critique the journal in depth. DME office will assign journals for each resident. Additional articles may be included as appropriate. All externs are expected to attend journal club.

Kindness

Have sympathy and understanding for the patients. Most of our patients are not only sick but frightened and confused. They are not familiar with the hospital or with illness. A word of explanation, a kind and cheerful attitude will help you to establish a rapport with patients that will carry over into your private practice. This is an example of professionalism,

Library

The library is open from 7:30 A.M. till 4:00 P.M... Monday through Friday. House Staff will be provided with a key to the library. The library is to be kept locked during evening hours. Textbooks may be borrowed for two weeks. Journals may not be removed from the library (except for those assigned to journal club). You are responsible to sign out any material that you remove from the library.

Internet access is available through the library, and in the clinic. The library is a valued resource and should be treated as such. Self policing by all house staff will help prevent theft and damage. Please notify Medical Education if you see a specific problem.

Licensure

All house staff must have a valid Michigan medical license. Residents will have a restricted, education limited license issued by the state and good for the OGME-1 training year. Residents are encouraged to obtain a permanent unrestricted Michigan medical license. This is required if you plan to moonlight. An educational license can be extended yearly for the duration of your residency. Inability to obtain or maintain a valid license is grounds for dismissal from your program. A copy of your license must be kept in your file.

Mail

Any outgoing mail (excluding large packages) may be mailed through the medical education office. Externs may also have their mail forwarded to our office in care of:

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Medical Education Office Community Health Center of Branch County 274 E. Chicago St. Coldwater, MI 49036-2088

As you complete your training program, make sure that our office has a current address and phone number so any mail we receive can be forwarded to you.

Management

All of your work in the clinics and hospitals is under the supervision of an attending physician. Supervision may be “direct” meaning that the supervisor is physically present in the facility and is actively directing your actions. “Indirect” supervision means that the supervisor is aware of what you are doing and is available to directly supervise you as the need arises. It must be your responsibility to request direct supervision for any case where you don’t feel comfortable performing a procedure or if you have any question regarding what you are doing. Residents may be “checked- off” to perform a procedure with indirect supervision. Externs may perform any procedure assigned under direct supervision. Externs are not permitted to perform any procedure under indirect supervision.

While on a physician’s service remember that the patient has contracted with that physician and rightly expects that physician to be responsible for his care. Excepting an emergency, you should not “manage” a private patient’s care without the knowledge and approval of that patient’s private physician. In most cases, this implies that you discuss the case and your expectations with the attending on an ongoing basis.

You should check your assigned hospital patients daily and make daily progress notes which must be dated and timed. Never visit a patient without noting it on the patient’s chart. Telephone orders are discouraged, but when necessary, are permitted for residents. If phone orders are given they must be timed and signed within 24 hours.

Meals

Three meals a day are provided in the cafeteria. You must identify yourself by wearing your ID badge or monogrammed shirt to identify your employee status. Breakfast is served from 6:30 to 9:30 A.M.; Lunch is available from 11:00 till 1:00 P.M. Dinner is served from 5:00 till 6:30 P.M. You should identify yourself to the cafeteria cashier as an extern, intern or resident prior to them totaling your charges until you become familiar to them.

Medical Education

The medical education office is open from 7:30 till 4:00 P.M. on Monday through Friday. Our extension is 5462. Dr. Vogel may be reached at 5373 or by his cell phone 260-316-6222. Our telephone number is 800-860-3799 for out of area calls. The medical education coordinator is

15 available at 5462 to help you with any questions or problems. She can help you set up schedules and is a good resource person for questions about the hospital, community or our training program.

Dr. Vogel is available 24 hours daily through the office or by cell phone. You are encouraged to contact him with any questions about the training program. He should be consulted if any interpersonal problems arise. He will want to meet with you to provide orientation to the training program and will want to meet with you as you complete your training here.

Medical Records

You will be assigned a medical record number. You should identify yourself on all dictation by your medical record number. House staff must check with medical records on a weekly basis and make sure all your records are complete. Be sure to clarify any questions regarding the medical record with medical records personnel.

You will not receive credit for your rotation, internship or residency, and we will not send evaluations to your school or AOA until your medical records are completed. A check- out form is included in this manual for you to use. You may copy it as necessary (for additional extern rotations). You need to have the appropriate medical records personnel sign off your check out form during the last week of your rotation.

MOA

The Michigan Osteopathic Association offers free registration for osteopathic residents. They offer additional incentives, such as Epocrates software, for becoming a member. The organization sponsors educational programs, publishes a journal and is a benefit to the osteopathic profession in Michigan. Membership is encouraged. Applications will be available during orientation.

Moonlighting

OGME-1 house staff is not permitted to moonlight. Moonlighting is a privilege and may be permitted during your residency program with approval of the program director as long as it does not interfere with your responsibility to the hospital or your program. You will not be working under the hospital jurisdiction in this instance and must have a valid medical license and insurance. If the DME or program director feels that your moonlighting jeopardizes your training or responsibilities to the hospital it will be prohibited on a per case basis. Moonlighting when prohibited is grounds for dismissal from your residency program. All moonlighting hours must be reported on the resident log. These hours count toward the 80 hour maximum work week limit.

The following requirements must be followed if a resident plans to moonlight.

1. Moonlighting may only occur with specific approval by the DME and program director. 2. Residents cannot moonlight when on call and cannot moonlight during traditional resident work hours (7:00 A.M. through 6:00 P.M.). 3. For consideration of approval, the resident must submit an accurate time schedule listing the places, dates and times that he will moonlight. This form must be signed by the DME and will be kept in the resident's permanent file. 4. The hospital CEO reserves the right to prohibit moonlighting at any competing facilities

16 within our service area. Residents will be afforded a 30 day grace period to stop their moonlighting at a facility when deemed inappropriate by the hospital CEO. 5. When requested, the hospital will provide in writing written approval for specific locations that are appropriate for moonlighting.

Narrative log

An accurate log is important for you individually as a credentialing tool. It is important for the institution to document specific training requirements. The log will not be accepted if it is not complete. This includes a narrative statement of your experience on the service.

Identifying those physicians that provided education allows them to receive CME credit for their participation. Identifying where and when you participated in patient care allows CHC to bill Medicare for your training costs.

New guidelines require specific training in diagnostic imaging, geriatrics and sports medicine. These requirements are outlined in the resident manual. Rotations in these areas count as does individual participation in non clinic settings. Accuracy in reporting is important.

Orientation

All house staff is required to attend an orientation program at the beginning of their training program. For externs, this will consist of an interview with the DME or medical education coordinator, tour of the facility and introduction to their attending. Externs that have not had an OSHA program within the previous year will need to complete an orientation to universal precautions.

Residents will attend an orientation program at the beginning of their training program. Residents will also complete the employee orientation program and will be recertified in ACLS as appropriate.

Out Rotations

These must be approved by in writing by the DME. Forms are available through the DME office. A postgraduate fund to offset some of the costs of postgraduate training is available if requested and approved in advance of your rotation. Documentation of your exposure outside CHC is important. A letter from your preceptor outlining your progress and competence will be required and placed in your file.

During the residency program residents may be allowed to serve out of area rotations to benefit from educational endeavors not available in our service area. With DME approval, OGME-2 residents may take up to 1 month and OGME-3 residents may take up to 2 months training outside our service area. It is the resident's responsibility to obtain a letter outlining the service curriculum from the attending and a copy of his curriculum vitae. An attestation letter certifying compliance with all CMS regulations is required before the rotation can be approved.

17 Pagers

Externs assigned to pediatrics, obstetrics or general surgery will need to obtain a pager from the medical education office. All residents will be issued a pager. You are responsible for the pager and will be responsible to replace it if it is broken or lost. You are also responsible to return the pager to the medical education office as you complete your training here. It is also your responsibility to make sure you understand how the pager operates.

Pain Management

Every patient must be assessed and have regular reassessment for pain. The degree of pain a patient reports must be measured and documented in their medical record. The hospital will provide education and forms to report this. Any treatment of pain must be documented in the medical record. Chronic pain management requires a pain contract on file in the patients chart.

Paychecks

Residents are paid biweekly on Fridays. You may pick up your check in the DME office after 1 P.M. Direct electronic deposits may be arranged with Payroll.

Personal Conduct

Remember that you represent yourself, our profession, the hospital and the community and conduct yourself accordingly. While on duty, house staff and attending physicians should be addressed as “Doctor.” Other hospital staff should be addressed as “Mr.”, “Mrs.” or “Ms.” as appropriate. Be sure to thank those assisting you in front of the patients. This is not only common courtesy but is excellent public relations.

Procedures

All invasive procedures must be performed under direct supervision of an attending physician or other credentialed physician who is approved to perform the procedure he is supervising. A form to document your interaction with the procedure is available in the DME office. It is your responsibility to obtain written confirmation of supervision by an attending physician before you can be checked out on any procedure. The confirmation will be kept in your file. Specific guidelines have been developed and are updated periodically regarding how you may be checked-out for specific procedures. For non invasive ambulatory clinic procedures the clinic supervisor or program director will attest that the resident is capable of performing the procedure with indirect supervision. [See also Procedural training].

Portfolio

A portfolio will be maintained in the DME office for all trainees. A copy will be available at the completion of the training program. The portfolio will contain logs and evaluations, certifications (ALSO, PALS, ACLS, APLS), in-service board scores, competency assessment, licenses and other documents as required by the AOA or SCS.

18

WinScribe

The hospital maintains a phone system for dictation and for review of x-ray reports. You may access WinScribe via special phones or standard phone.

WinScribe Telephone Dictate Instruction

1. Call ext.5305 or (517) 279-5305 to access the system. 2. At the prompt; enter your 4-digit ID. 3. At the prompt; enter your security code. The DEFAULT is 0000, you must change to your own personal code of 2 to 5 digits (if a new user). 4. At prompt; enter the 2-digit work type. (See Work Type listing). 5. At prompt; enter the 6-digit Medical Record Number. 6. An intermittent blip will indicate the system is in PAUSE mode; press 4 to begin dictation. 7. Press 2 at any time to rewind. 8. During or at the end of rewind, press 1 to listen. 9. Press 9 to finish this job and dictate another 10.Press (*) for Review (Listen Access) and other options.

KEY PAD FUNCTIONS

1 = Play 2 = Rewind 222 = Go to Beginning of Job 3 = Fast Forward 333 = Go to End of Job 4 = Dictate 5 = Pause * = Cancel or Back to Menu 6 = Priority *4 = Review (Listen Access) 7 = Short Rewind/Play 8 = Settings 9 = End Job/Send for Typing 0 = End Job/Send for Typing

WORK TYPE LIST

00 = Letters 01 = Dietary Consult 10 = Stat Admission or Surgical H&P or Stat Report 11 = Admission H&P 22 = Respiratory Reports (EKG, EEG, Echo, Holter, Stress, PFT, Sleep Study) 33 = Consultation 40 = Labor and Delivery Note 44 = Operative Note 55 = Progress Note 66 = Clinical Resume/Discharge Summary 77 = Oncology/Hematology Notes 88 = ER Note

19 89 = Stat Admission or Transfer ER note 91 = Psych H&P/Initial Psych Evaluation/Assessment 95 = Psych Progress Note 96 = Psych Clinical Resume/Discharge Summary

WinScribe Report Review Instructions (Listen Access)

REPORT REVIEW (LISTEN ACCESS)

1. Call ext. 5305 or (517) 279-5305 to access the system. 2. At the prompt; enter your 4-digit ID. 3. At the prompt; enter your security code. The DEFAULT is 0000, you must change to your own personal code of 2 to 5 digits (if a new user). 4. Touch *4 to enter the Review Mode. 5. At the prompt, enter the 6-digit Medical Record Number.

An intermittent blip indicates the job has been found and is in pause mode. Press 1 to listen. ( A voice prompt will indicate if a match is not found and will prompt you for a different number. If there are multiple dictations under this medical record number, touch the (*) key to skip to the next job under this number, and then press 1 to listen.

Press 2 at any time while listening to Rewind. During or at the end of Rewind, press 1 to listen. Press 9 to end Review of reports under this Medical Record Number.

Enter another Medical Record Number for another job review or press *1 to dictate a new job. Hang up if finished.

So medical records can provide you with the most accurate transcription be sure to:

1. Use medical record numbers in your dictation and when accessing the WinScribe System. 2. Be sure you are in the dictate mode before beginning dictation (to avoid cutoffs). 3. Spell out anything unusual. 4. Give admits and discharge dates on Clinical Resumes/Discharge Summaries. 5. Tell us who you are dictation for. 6. We do out best to keep blanks to a minimum; however, should we have to leave one please fill it in and we will make the change. 7. Keep in mind that not only is your voice recorded, but also eating, drinking, talking, background noises, etc. 8. Please stop by or call with question/suggestions, extension 5350 (Transcription). 9. Please review you dictation before signing. We will be glad to make any changes!

CELL PHONE USE FOR DICTATION IS PROHIBITED, due to privacy concerns and quality of dictation.

Bi-annual Competency Review

All residents are required to complete the Service Exposure Requirements bi-annual review form.

20 This document outlines the program requirements for family medicine and will be utilized by the program director and DME to evaluate the program. It is not expected that all items listed in the form will be completed within any time frame. The form can also be utilized as an individual goal survey. The DME office will give each house officer a copy of the form to be completed throughout their training program. Accurate reporting is the goal. A copy of the form is included in this manual.

A competency based clinical summary will be completed yearly. Upon completion of the family practice residency, a global summary will be completed by the program director. These documents will remain a permanent part of your personal file. These reviews may be released to a credentialing organization only upon your request and approval.

Teaching Staff

Patients admitted to the hospital under the supervision of an attending physician are private patients. Trainees are allowed to interact with these patients only with the approval and supervision of the attending physician. If you are asked to see a private patient, you should be cognizant of the patient- physician relationship and discuss your recommendations with the attending before writing orders, except in an emergency situation.

Attending staff are encouraged to participate in the training program. This means that they will agree to allow trainee’s access to their patients and will offer supervision and constructive criticism as necessary. Acceptance onto the teaching staff is voluntary. To be a member of the teaching staff, the physician must be a member of the medical staff at CHC. They will be credentialed by MSUCOM.

Training Completion

Upon successful completion of your Intern and Residency training program a certificate will be issued to you. A checkout form must be completed and turned into the DME office. After the DME office has received this form your certificate and final check will be issued. For you to receive a certificate you must have completed all logs and annual reports, any scientific paper assignments and we must have documented appropriate compliance with all SCS guidelines.

Safety

All employees are required to complete an annual safety course as directed by Human Resources. This may consist of education given during staff meetings, Internet computer courses or other types of education. Safety education is mandatory and will be scheduled as necessary by the DME. HR is a resource and may be contacted at any time with any questions about your safety or patient safety issues.

Scientific Paper

Each resident must complete a research project or other scholarly activity. It is expected that this activity will be completed by the end of your OGME-2 year. A scientific poster representation of your project should be presented at a regional or national (STFM) convention for credit. In occasional instances, the program director may allow for the resident to submit a scientific or research paper suitable for publication.

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It is your responsibility to complete your project during your residency. A draft of your paper or poster should be submitted to your program director and the DME in time to have corrections made and a completed final paper presented before the completion of your training program. It is recommended that residents submit a rough draft of their paper to the DME and their program director within the first 16 months of their residency. You will not be considered to have finished your residency until an approved paper or poster has been approved by the program director.

Generally, OGME1 residents are not required to complete a scientific or research paper. Those interns interested in doing so are encouraged and should contact Dr. Vogel for direction. Grants and rewards may be available for formal presentations. A paper may be assigned to the any house staff for a specific reason and will become a part of the requirements for their training program.

Smoking

Employee and Visitors smoking is not allowed on the grounds. Patients are to be informed prior to admission, if possible that this in a non smoking facility and campus. Nicotine patches or gum may be offered to patients.

Time Off

To obtain time off you must: Complete a written request and return it to the DME office four weeks in advance of any planned out time; Arrange coverage for your house responsibilities or clinic assignments; you must complete the resident application for postgraduate training. When your request is approved, the DME will notify you in writing. Should you be away from your assigned rotation due to vacation or sickness in excess of 50 percent of the time (two weeks of a 4-week rotation) you will be required to repeat the rotation to receive credit. Please consider this requirement when you schedule your vacation.

The DME may limit approval of elective house staff absences for maintenance of coverage. Approval will be on a first come first served basis. The DME office will notify the clinics and medical staff secretary of the approved absence. It is the house officer's responsibility to cover any call assignments. Requests for time off shall not be considered if you have delinquent records or evaluations.

Unexcused Absence

Residents must attend all scheduled functions whenever possible. Staff and hospital committee meeting are required and missing one of these without an excuse will add one day to your training program at the discretion of the DME. Being absent without permission is grounds for disciplinary action.

Vacation

Vacation hours are front loaded at the beginning of each training year. You may carry over extra hours as necessary to assure coverage for vacations and educational endeavors. All time off must be approved in advance.

22 Work Hours

House staff cannot work longer than 16 hours continuously or more than 80 hours per week. Your rotation schedule is designed to assure that you remain in compliance with the work hours limits. Should you feel that your responsibilities violate this requirement you must discuss it with the DME. Any moonlighting time counts towards the 80-hour limit and must be reported on your monthly log at the completion of your current service.

Uniforms

Each resident will receive one lab coat and one monogrammed dress shirt for each day in the clinic (2 or 4) prior to the beginning of their residency program. As the lab coats wear out they will be replaced. You must turn in the old coat for the DME office to order a replacement. On surgical services, scrubs are necessary garments. Scrubs should be worn only when scrubbed in surgery or OB or in the ER. If scrubs are worn outside of the surgical area, a cover coat is necessary. It is not acceptable to appear in bloody, soiled or wrinkled clothing. Remember that you represent your profession and the hospital. Appropriate attire is mandatory whenever you are making rounds. Business Attire is the organization's accepted code of dress. Blue jeans and T-shirts are not considered appropriate attire anywhere in the hospital or the clinic.

Osteopathic Musculoskeletal Examination

AOA requirements dictate that a complete physical examination be completed on every patient admitted to the hospital. A complete physical includes an osteopathic examination. Minimum requirements for a structural assessment include examination in two or more positions, unless the patient’s condition precludes this. Examination should include inspection, palpation, segmental motion testing, and overall motion testing of the major areas of the spine and pelvis. Major findings in extremities should be included. There should be mention of AP spinal curves; notation of any lateral curves, gross changes of areas of tenderness, muscle tension or spasm, and limitation of motion. If the spine is not examined, this should be noted, and the reason why documented. When osteopathic abnormalities are documented an osteopathic diagnosis should be included in the patient's diagnosis list.

REQUIREMENTS FOR ADMISSION TO THE TRAINING PROGRAM

The training program at CHC is approved by the American Osteopathic Association and requires that all osteopathic trainees be members of the AOA for the duration of their training. In addition to a completed application, other specific requirements include:

1. Applicants for the osteopathic internship or residency must be graduates of a college of osteopathic medicine approved by the AOA.

2. Residents must be licensed to practice medicine by the state of Michigan. An educational license is required before beginning your training.

3. Applicants for the residency program must have passed all components of COMLEX-II. They must pass COMLEX-III before beginning their OGME-3 year.

23 4. Applicants for residency must provide a complete ERAS application.

After completion of the application, selection will be based upon the candidate’s academic ability, personality and interest and aptitude toward primary health care in the rural setting. No applicant will be denied on the basis of race, color, sex, religion, creed, national origin, age or handicap. The final selection of the applicant will be approved by the Board of Directors on the recommendation of the director of medical education.

FAMILY PRACTICE RESIDENCY PROGRAM

The family practice program is a structured curriculum of 36 months duration. Throughout the residency, residents are assigned to their continuity clinic for 2 full days per week. The program follows the AOA Basic Standards for Residency Training in Osteopathic Family Practice and Manipulative Treatment and all SCS (COGMET) guidelines. Although the program is a continuum, the rotational services are broken down by training year. During the residency program the resident will spend time on the following services:

Medicine and electives 32 weeks Obstetrics & gynecology 12 weeks Surgery and electives 20 weeks Family practice 16 weeks Emergency medicine 12 weeks Electives 44 weeks Pediatrics 16 weeks Away/Education time 12 weeks Geriatrics 4 weeks Sports medicine 2 weeks Community medicine 2 weeks Radiology 2 weeks

The didactic portion of the residency program is tiered. All residents are assigned a journal and present at journal club each month. Family practice core review is presented monthly. An ECG session is held monthly. Psychiatric and STARS lectures are held monthly. Additional lectures in surgery, obstetrics, ophthalmology, pediatrics and family practice complement the educational program. All residents attend the monthly full day SCS session in Lansing at MSUCOM.

All patients admitted from the family medicine clinic are followed by resident staff. Most patients are admitted to the family practice service. However, patients admitted to other specialty services remain the responsibility of the resident who may be supervised by other specialty physicians. Residents are responsible for the H&P, daily progress notes and the discharge summary. Residents are responsible for all procedures performed on their patients.

COMPETENCY ASSESSMENT - PROGRESSIVE BY OGME YEAR

The purpose of this document is to establish specific learning objectives for the seven competencies to assist in evaluation of resident progression throughout their training program. This document will provide specific milestones for residents to achieve for each training year. Achievement of specific milestones shall serve as criteria supporting advancement of the resident into the next training year and shall document the degree of competency at the completion of their training program.

The objectives listed are expected to be progressive so that achievement of a competency at one training level allows for continued development of that competency during the subsequent training year. Upon entry into the residency program, most residents are at the learning level. They advance to the competency level and finally to mastery of the competency at an individual pace. Not all residents will obtain mastery by the end of their residency program.

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However, residents not deemed competent may be required to spend additional time beyond the 36 months of formal residency time to achieve a level of competency that assures patient safety. Trainers may use this information to assess resident participation and residents may use this document as a guide for individual improvement.

Core Competency - Osteopathic Philosophy and Manipulative Medicine

Required Elements: Residents must understand and integrate osteopathic concepts and OMT in the care of their patients. Residents must be able to document the need for and response to osteopathic care.

OGME-1

1. Be able to complete an osteopathic screening exam on the adult patient 2. Be able to complete an osteopathic screening exam on the pediatric patient 3. Be able to identify the regional components of T-A-R-T 4. Be able to discuss osteopathic principles and philosophy in the care of ambulatory patients. 5. Be able to discuss the contraindications for osteopathic treatment for selected patients 6. Be able to appropriately document osteopathic findings and response to treatment in the medical record

OGME-2

1. Document utilization of osteopathic diagnosis in the care of patients integrating osteopathic diagnosis with medical and surgical diagnoses 2. Be able to utilize different techniques for specific disease processes 3. Increase OMT utilization from the OGME-1 year 4. Be able to access OMT information on the computer

OGME-3

1. Develop expertise with more advanced techniques 2. Include osteopathic diagnosis and treatment in formal presentations 3. Teach OMT techniques to peers and medical students 4. Actively utilize osteopathic principles and practice in patient care in both ambulatory and hospitalized patients 5. Utilize osteopathic diagnoses as a component of the patient's problem list during office visits 6. Be able to critically review medical information related to osteopathic care

Core Competency - Medical Knowledge

Required elements: Residents must demonstrate both the understanding and utilization of clinical and behavioral medicine in patient care. Residents must demonstrate knowledge and application of evidenced based medicine.

25 OGME-1

1. Be able to describe the components of evidence based medicine 2. Be able to utilize medical texts and journals to obtain pertinent medical information to assist in patient care 3. Be able to identify the primary medical issue and develop a treatment strategy specific for the patient's chief complaint 4. Be able to utilize electronic teaching tools for patient information 5. Be able to describe poly-pharmacy and know how to screen for adverse drug interactions 6. Attend scheduled educational programs 7. Be able to integrate Internet search information into clinical practice 8. Demonstrate the ability to use independent study to enhance medical knowledge 9. Understands the basic interpretation of lab and x-rays test results

OGME-2

1. Apply evidence based medicine in clinical practice 2. Be able to construct a differential list for patient complaints and formulate an appropriate diagnostic plan for complex patient conditions 3. Be able to use constructive criticism to improve medical knowledge 4. Be able to utilize electronic teaching tools at the point of care for treatment options 5. Demonstrate utilization of drug interaction programs at the point of care 6. Successfully pass COMLEX III 7. Actively participate in educational programs 8. Be able to develop an appropriate treatment plan for the majority of assigned patients with limited physician input 9. Be able to integrate components of the H&P to develop a comprehensive diagnostic and treatment plan for the patient 10. Be able to incorporate preventive care into the clinic office visit

OGME-3

1. Include EBM in individual lecture programs and journal presentations 2. Be able to integrate Internet search information into clinical practice at the point of care 3. Demonstrate ability to develop a comprehensive treatment plan for complex patient cases with minimal physician input 5. Be able to define current gaps in knowledge and develop a learning plan to fill these gaps 6. Demonstrate leadership qualities in educational programs 7. Demonstrates ability to develop in-depth differential diagnoses lists for complex patients

Core Competency - Patient Care Required elements: Residents must be able to gather accurate and essential information from numerous sources and use this information to formulate and apply an appropriate treatment plan to maximize patient care. Residents must be able to provide compassionate health services that include health maintenance, preventive care, behavioral and psychiatric service and osteopathic care consistent with best current medical practice.

26 OGME-1

1. Demonstrate respect and compassion and empathy 2. Be able to identify religious and cultural diversity within the continuity clinic practice 3. Be able to complete a complete H&P that includes osteopathic assessment and diagnosis 4. Be able to describe clinic specific policies defined for patient care 5. Be able to identify abnormal lab and x-ray findings and formulate an effective method for patient education and understanding 6. Be able to identify the components of health maintenance for appropriate aged patients 7. Be able to define appropriate techniques for patient procedures 8. Be able to define the importance of time management in patient care

OGME-2

1. Be able to integrate the components of lab, x-rays findings and consultation reports to define a differential list with minimal direction 2. Be able to assess the components of health maintenance with minimal direction 3. Be able to identify the need for and perform ambulatory procedures with minimal direction 4. Be able to utilize patient education as a component of each office visit with minimal direction 5. Be able to utilize time management skills in patient care during each clinic session 6. Be able to define risk management and demonstrate specific risk management techniques in patient care 7. Be able to identify specific patient needs and modify treatment plans to encompass specific patient needs

OGME-3 1. Be able to integrate information and formulate a treatment plan for ambulatory and hospitalized patients without direction 2. Be able to demonstrate technical proficiency for office based procedures without supervision 3. Be able to integrate patient education into each office visit 4. Demonstrate increased proficiency in time management in patient care 5. Demonstrate proficiency in effective risk and cost management for the patent, clinic and hospital

Core Competency - Interpersonal and Communication Skills

Required elements: Residents must demonstrate effective doctor-patient relationships. They must exhibit effective listening, written and oral communication skills.

OGME-1

1. Provide thorough, succinct and pertinent verbal presentations that reflect understanding of the patient's condition and support for the treatment plan 2. Demonstrate utilization of constructive criticism from members of the nursing and ancillary staff 3. Be able to discuss patient diagnosis and care with the family in terms that is understandable and appropriate 4. Be able to complete a surgical consent and time out forms for clinic procedures 5. Be able to discuss advanced directives with patients

27 6. Demonstrate proficiency with completion of discharge summaries for hospitalized patients 7. Develop a clinical research question to serve as the basis for a resident research project 8. Completes charts and service evaluations in a timely fashion

OGME-2

1. Demonstrate proficiency with written office notes using approved abbreviations only 2. Communicate effectively with consulting physicians 3. Communicate care plans with the nursing staff 4. Participate in end of life discussions with family members with minimal preceptor input 5. Refine and develop the research project

OGME-3

1. Provide family counseling with minimal preceptor input 3. Complete and present the finished research project 4. Assist in student education 5. maintains legible, succinct and relevant clinical notes

Core Competency – Professionalism Required elements: Residents must demonstrate compassion and respect for patients and families while demonstrating awareness and attention to issues of culture, religion, age, gender, orientation and disabilities.

OGME-1 / OGME-2 / OGME-3

1. Demonstration appropriate treatment for all patients without regard to societal issues 2. Demonstrate respect for nursing and ancillary staff 3. Demonstrate advocacy for patient needs within the healthcare system 4. Demonstrate knowledge of and adherence to HIPPA policies 5. Demonstrate honesty and integrity in all aspects of professional life 6. Demonstrate commitment to self directed learning, self-evaluation and self-improvement 7. Comply with CHC and ACOFP policies and regulations 8. Complete all administrative assignments in a professional fashion

Core Competency - Practice Based Learning and Improvement

Required elements: Residents must be able to perform self-evaluation to investigate and evaluate their own patient care practice, must appraise and assimilate scientific evidence and must continually strive to improve their individual patient care. Residents must develop an understanding of research methods, medical informatics and the application of technology in their daily patient care.

OGME-1

1. Demonstrate ability to utilize senior residents as a resource 2. Be able to identify rotation specific learning goals

28 3. Be able to formulate clinically relevant questions relating to the evaluation and treatment of assigned patients 4. Participate in quality improvement in the ambulatory clinic 5. Present journal club assignments and demonstrate ability to prioritize content 6. Be able to demonstrate awareness of E/M coding requirements 7. Demonstrate use of the common databases for medical literature and common Internet search engines 8. Demonstrate ability to extract and apply evidence from scientific studies for patient care

OGME-2

1. Actively participate in medical student education and assist as a resource for junior residents 2. Seek feedback from attendings and demonstrate utilization of this feedback for self- improvement 3. Be able to delineate long term goals for future practice 4. Develop expertise in journal presentations 5. Demonstrate awareness of junior resident and student needs 6. Demonstrate awareness of AOA CAP project goals and HEDIS standards 7. Utilizes evidence based medicine principles in patient care

OGME-3

1. Demonstrate ability to direct junior resident and medical student education 2. Demonstrate knowledge of quality improvement indicators and use of HEDIS standards and hospital wide improvement initiatives to improve patient care

Core Competency - System Based Practice

Required elements: Residents must demonstrate awareness of national and local health care delivery systems and how these impact on local health care. Residents must be able to work within existing health care systems to optimize patient care.

OGME-1

1. Be able to identify the health care systems participating in patient care at the continuity clinic 2. Be able to demonstrate awareness of referral requirements specific to individual health care plans 3. Be able to identify specific formularies for the major health care systems 4. Demonstrate awareness of EBM guidelines 5. Demonstrate awareness of utilization review and peer review processes 6. Be able to define and utilize cost management in patient care

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OGME-2

1. Demonstrate utilization of plan formularies in patient care medical decisions 2. Demonstrate utilization of EBM guidelines in patient care with minimal physician supervision 3. Demonstrate awareness of discharge planning 4. Demonstrate effective use of utilization standards in patient care

OGME-3

1. Demonstrate utilization of EBM guidelines in patient care without preceptor input 2. Direct patient discharge care needs and actively participate in discharge planning without preceptor input 3. Actively participate in utilization review for assigned patients in the hospital setting

UNIVERSAL PRECAUTIONS

The best way to reduce the potential for infection is to follow universal precautions. Health care workers must assume that every patient is infectious and should take adequate precautions to protect themselves from exposure to all body fluids. They must use care in handling contaminated material and sharps, and be knowledgeable regarding their responsibilities and rights in keeping their work place safe. The following standards are summaries of Universal Precautions Recommendations.

1. Hands should be washed before and after every patient contact. If hands are contaminated with body fluids, they should be washed immediately. Alcohol washes should be used before & after each patient contact. 2. Gloves should be worn whenever there is a possibility of contact with any body fluid. 3. Masks must be worn whenever there is risk for splatter or splashing of body fluids. 4. Gowns should be worn if soiling of exposed skin or clothing is likely. 5. During resuscitation, pocket masks or mechanical ventilation devices should be used. 6. Spills of blood containing fluids must be cleaned up using a dilute solution of bleach (one teaspoon in one ounce of water). 7. Health care workers with open lesions or cuts or active dermatitis should not participate in direct patient care. 8. Used needles are considered contaminated. They should not be recapped, clipped or bent. Immediately after use they should be discarded in puncture resistant, appropriately marked containers. 9. All reusable equipment is to be disinfected. All equipment that is contaminated with blood or mucus is to be disinfected by soaking in commercially available disinfectant that has been prepared in accordance with company recommendations. Equipment that touches intact skin is to be washed in disinfectant soap followed by alcohol. 10. Body fluids to which universal precautions apply: blood, serum, semen, vaginal secretions, all cavity fluids, amniotic fluid, wound exudates. 11. Other body fluids: sweat, tears, sputum, saliva, nasal secretions, feces, urine, vomitus, breast milk should be considered infective for HBV/HIV when blood is present.

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CDC RECOMMENDATIONS FOR MINIMIZING RISK FOR HIV/HBV:

1. All health care workers should adhere to the universal precautions. 2. Health Care Workers (HCW’s) with exudative lesions should not handle equipment or have direct patient care. 3. HCW’s should comply with current guidelines for disinfection and sterilization of reusable equipment. 4. HCW’s that are HIV/HBV infective pose no risk provided they perform no exposure prone procedures, follow universal precautions, and follow recommendations for disinfection and sterilization. 5. HCW’s that perform exposure prone procedures should know their HIV/HBV status. 6. Infected HCW’s should inform their prospective patients of their seropositive status before undertaking exposure-prone invasive procedures. 7. Mandatory testing for HIV/HBsAg/HBeAg is not recommended. 8. Education, training and appropriate confidentiality safeguards are the best means to insure HCW compliance with recommended prevention procedures.

SERVICE PROTOCOLS

This section will outline the service requirements for each of the clinical services. These are identified as educational objectives, concepts (goals), and skills by level of experience (category). Generally, all trainees should be exposed to all of the educational objectives for the specific service and should have the opportunity to participate in most of the skills outlined. Residents will be expected to be comfortable with all objectives, concepts and skills by the completion of their training program.

Your assigned attending may add additional requirements for the service. During your first day of service your attending will review the goals and objectives for the service with you. You will have the opportunity to discuss any of your personal goals for your rotation. There is no generic or specific requirement for patient loads. Generally, you will be responsible to an individual attending, and will be responsible for all of his patients. On some services, i.e., the emergency room, you will be assigned to the department. On busy services, you may be assigned a specific group of patients.

Educational objectives common to all services include the development of expertise in problem- oriented diagnosis, effective time management, development of physical diagnosis skills specific to the particular area of specialty, and expertise in good record keeping.

Family Practice

With the exception of clinical clerks which may be assigned to only specialty services, the primary emphasis of the training program at CHC is family practice and ambulatory medicine. The primary care training sites shall be the central focus of the intern and resident’s continuity care experience. Teaching within the department will be focused on those illnesses one would expect to find in the primary care setting. Residents will spend a minimum of two full days in their ambulatory setting each week. When the trainee is not in the ambulatory training site, (s)he is responsible to his assigned service.

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In-patient family practice is an integral part of total medical care. Although the majority of family care is delivered in the ambulatory setting, the resident must develop experience in recognizing those patients needing in-patient care and should be able to manage patients from their ambulatory training site whenever they are admitted. OGME-1 trainees need a broader experience in the hospital care of patients and their responsibilities and assignments will be structured to provide this.

All patients admitted from the ambulatory training site are to be managed by their assigned trainee. Trainees are expected to interact with the emergency room staff whenever their assigned patients are being evaluated there.

Educational Objectives

1. Learn the skills and art of delivering ambulatory and in-patient care to the majority of the patients under appropriate supervision. 2. Learn to recognize those patients needing more intensive therapy and to recognize the early and subtle signs of medical complications for those diseases one would be expected to recognize and treat in the ambulatory setting. 3. Learn time management to effectively handle a normal case load during a scheduled day. OGME1 residents should be able to effectively handle 4 patients per hour by the end of their training year. By the end of the resident’s training program he should be competent to manage 6 patients per hour on the average. 4. Develop medical practice management skills to include patient referral, counseling, patient education, industrial injury and reporting of communicable diseases. 5. Develop expertise in family oriented problem lists, effective charting and medical records. 6. Develop expertise with medical and surgical procedures that one would complete as a family practitioner.

Procedural

1. Throughout the training program the trainee is responsible for the care of his patient panel. On specialty services, patients will be assigned by the attending. 2. The trainee will manage the care of all assigned patients in the ambulatory and in-patient setting with supervision of the attending. 3. Trainees will be responsible for the history and physical including structural assessment, progress notes, referrals and medical orders for all assigned patients. For hospital patients, daily rounds will be made and daily discussion with the attending is expected. 4. The trainee will keep the attending physician apprised of the patient’s status and lab and x- ray findings and will consult with the attending as appropriate regarding the care of the patient. 5. Trainees will be responsible to perform procedures on assigned patients with the approval and supervision of the attending. 6. The trainee is responsible to complete all reading assignments. 7. A complete log of all patient contact, reading assignments, lectures attended and procedures performed will be submitted to the DME office on a monthly basis. 8. Residents will be assigned call for their patient panel on an ongoing basis so that continuity of care is maintained.

32 Osteopathic Manipulative Medicine

Osteopathic practice and principles play an integral part of medical care. The application of these principles must be taught in a longitudinal fashion throughout the training program. Exposure must include didactic methods as well as clinical application. There will be in-house instruction at CHC but the main didactic component will be obtained through SCS. Documentation of osteopathic care in the ambulatory and in-patient setting is important. The resident must develop an individual philosophy for osteopathic care.

Educational Objectives

1. Develop expertise in evaluating patients using osteopathic principles and be able to identify the role of the musculoskeletal system in disease. 2. Develop expertise in developing a treatment plan for patients with disease of other systems. 3. Learn to recognize the contraindications for OMT. 4. Learn the proper ICDM coding for OMT

Procedural

1. Incorporate osteopathic findings into your differential diagnosis. 2. Perform osteopathic examination and treatment using a variety of methods in the ambulatory and in-patient setting. 3. Document osteopathic diagnosis and treatment in the progress note.

Pediatrics

Pediatrics is a critical component of family practice. OGME-1 residents will rotate through the pediatrics department for rotations of one to two months. Residents will spend two months during their second year (OGME-2) and one month during their third year in pediatrics. Ambulatory pediatrics will be emphasized although the trainee is expected to manage in-patients and newborns as assigned under the supervision of an attending pediatrician.

Educational Objectives

1. Recognize common pediatrics problems that will be encountered in the ambulatory setting. 2. Be familiar with the management of pediatric emergencies, immunization schedules and specialty referral. 3. Develop expertise in the interview of infants, children and adolescents. 4. Broaden your expertise in pediatric physical diagnosis. 5. Recognize developmental milestones and abnormalities of growth and development in infants, children and adolescents. 6. Develop expertise in those procedures appropriate for a family physician. 7. Recognize psychosocial issues in families and children.

Procedural

1. Trainees will be assigned patients from the practice office. Patients may also be assigned from the emergency room, delivery room and nursery. 2. Ambulatory patients will be evaluated by the trainee who will complete the appropriate

33 history and physical, develop a differential diagnosis list, formulate an evaluation plan and treatment and present the case to the attending.

3. Assigned in-patients will be managed by the trainee. The H&P, daily progress notes, discharge planning and summary will be the trainee’s responsibility. 4. Trainees are expected to complete reading assignments on all topics assigned. They are to research diseases for all cases seen. 5. Residents will be expected to take call on an ongoing basis throughout their rotation. Assignments will be made by the trainer and will not include more than three days per week or consecutive weekends.

It is the trainee's responsibility to contact the pediatrics office in advance of the rotation to determine time to be with the pediatrician and where to start the rotation. The intern / resident will take call with the pediatrician of their choice during the rotation.

Internal Medicine

The internal medicine experience provides the trainee with the opportunity to expand his knowledge of adult, non-surgical disease under the guidance of an internist. OGME-1 residents will spend 16 weeks on the internal medicine service. ICU exposure is integrated throughout the experience. During the subsequent two years the resident will serve 8 weeks yearly in medical selectives. Residents may focus on sub-specialties such as cardiology, infectious disease, oncology, dermatology and others as are appropriate for family practice.

Educational Objectives

1. Learn to recognize those medical patients who should be managed in a hospital setting and to manage those patients with appropriate supervision. 2. Learn when to seek specialist consultation. 3. Develop expertise in evaluating patients with medical conditions using osteopathic principles; Develop expertise in developing a treatment plan for patients with medical disease. 4. Develop general knowledge and appropriate medical procedural skills in medical sub- specialty areas.

Procedural

1. Trainees on the medical service have a primary responsibility to the ambulatory patient panel. When not in their assigned clinics, the trainee assigned to the medical service will be responsible to their assigned trainer. 2. All patients admitted to the trainer are the responsibility of the trainee. Patients may be assigned from the emergency room, nursing home or by the attending specifically. 3. Trainees are responsible to complete the H&P, daily progress notes, and discharge summary on all assigned patients. 4. Daily rounds are to be made with the attending and the trainee is responsible to be knowledgeable regarding the status and results of any ordered tests or procedures.

34 5. Trainees are to read about the diseases they are managing and should be able to present appropriate differential diagnoses and treatment protocols for their patients. 6. Trainees are to perform appropriate procedures under the approval and supervision of the attending physician. 7. Trainees are to take call on their assigned services. Their assignments will be made by the attending but will not exceed three days per week or consecutive weekends. 8. Trainees are to complete all reading assignments and the necessary logs. 9. On the specialty services, i.e., cardiology, dermatology, oncology and infectious disease, the trainee will attend all assigned patients in the ambulatory and in-patient setting. The trainee is required to attend all scheduled clinics and will be under the direction of the attending trainer for the month. 10. Reading assignments given by the attending constitute a required component for successful completion of the rotation. 11. During the cardiology rotation the trainee should become familiar with interpretation of the ECG, preoperative evaluation of the cardiac patient, cardiac arrhythmia and cardiac manifestations of systemic disease. Trainees should participate in cardiac procedures appropriate for an ambulatory specialist. 12. While on oncology, the trainee should become familiar with the clinical presentation of malignant and benign neoplasm’s, psychosocial impact of cancer on the patient and his family and should perform and interpret screening procedures for cancer detection. 13. During the dermatology rotation, the trainee should become familiar with the common skin disorders of children and adults, out-patient dermatology procedures such as biopsy, culture, cautery and excision of skin lesions. 14. The trainee on the infectious disease service should become familiar with the presentation, diagnosis and management of bacterial sepsis, urinary tract infections, sexually transmitted disease, pulmonary infection, parasitic infection, AIDS, intrauterine infection, and those procedures appropriate for the ambulatory specialist.

Prior to beginning the rotation the trainee must contact his assigned internist for introduction and information regarding where to meet on the first day of the service. IM call will be with your attending on his schedule or as he directs.

Emergency Medicine

Residents will receive one month exposure to emergency medicine during each training year. Emphasis should be placed on those procedures and experiences that would most likely present in the ambulatory setting. During the training program, trainees should remain ACLS providers. The ER rotation for interns is combined with radiology and pathology exposure.

Educational Objectives

1. Trainees should understand the basis principles of emergency assessment, triage and life support. 2. Obtain exposure to procedures that would be incorporated into a primary care practice. 3. Develop expertise in evaluating emergency patients using osteopathic principles and be able to identify the role of the musculoskeletal system in acute and traumatic disease. 4. Trainees should gain knowledge through exposure to x-rays and x-ray procedures appropriate for an ambulatory specialist with the supervision of the attending radiologist. 5. Trainees should gain knowledge of laboratory medicine including hematology and

35 histopathology appropriate for an ambulatory specialist with the supervision of the attending pathologist.

Procedural

1. Attendance in the emergency ward under the direction of the ER attending is expected during scheduled hours except for clinic attendance. Hours will be determined by the ER staff and will be consistent with the AOA requirements. Shifts may be assigned if more than one student is assigned to the ER service. 2. During slack hours in the emergency room the resident is expected to obtain instruction in radiology and pathology under the direction and supervision of the appropriate trainers. 3. In radiology, the intern trainee is to spend time viewing films with the radiologist. He is also responsible to evaluate all x-rays obtained on his assigned patients. Specific assignments may be given by the radiologist and these constitute requirements for successful completion of the rotation. 4. While in pathology, the resident is expected to work with the pathologist. This will include viewing slides, attending autopsies and spending time in the various departments under the direction of the lab personnel to become familiar with laboratory procedures appropriate for the ambulatory setting. 5. Trainees are to evaluate all assigned patients, completing the H&P and ER notes as appropriate. They are to formulate a differential diagnosis list and treatment protocol and to present the patient to the ER attending. 6. Trainees are to read about the diseases and procedures seen and should be able to carry on an appropriate clinical discussion about them at the appropriate level for their training. 7. Residents are to become certified (recertified) in ACLS during their training program. 8. Trainees are to participate in all procedures on assigned patients in the emergency room under the supervision of the ER attending. 9. Trainees should develop a working knowledge of laboratory medicine and should know the normal values of all lab tests they will perform in the ambulatory setting. 10. Trainees should gain experience in the interpretation of x-rays obtained on the emergency room patient. This would include interpretation of the chest x-ray, abdominal surveys and long bone studies. 11. Trainees will learn the DRG criteria for hospital admissions for all patients attended that require admission. Trainees should also know the relative costs for all medications and procedures that are prescribed.

The trainee must contact the ER department, Marion Labadie, R.N. and / or the ER medical staff for additional instruction.

Obstetrics/Gynecology

OGME-1 residents will receive 4 weeks exposure to obstetrics and gynecology. More senior residents will be assigned for two months during their second year (OME-2) and one month during their senior year. Pre and postnatal care shall be emphasized during this rotation. All trainees will attend the OB out-patient clinic under the direction of the attending obstetrician. Exposure to sexually transmitted disease will be obtained through attendance at the area county STD clinics during the PGY-1 rotation. OGME-1 trainees will participate in the management of the patient in labor under the supervision of the attending. The curriculum will be adapted to the final practice

36 goals of the resident on an individual basis. All residents are expected to complete ALSO training through SCS.

Educational Objectives

1. The trainee should become comfortable and able to demonstrate skills in the handling of low- risk obstetrical cases in the out-patient and in-patient areas. 2. Recognize the early signs and symptoms of the abnormal pregnancy. 3. Become familiar with vaginal cytology appropriate for the ambulatory setting. 4. Become familiar with contraception methods and comfortable with patient education and counseling in this area. 5. Become familiar with the evaluation, diagnosis and management of patients with abnormal uterine bleeding, benign and malignant neoplasms of the reproductive system, menstrual and sexual dysfunction and infertility. 6. Obtain instruction and experience in the pediatric and adult vaginal exam. 7. Become familiar with the recognition, diagnosis and treatment of sexually transmitted disease.

Procedural

1. Trainees assigned to the obstetrical service will be under the direction of the obstetrician on call for the day. 2. Trainees will make daily rounds on all assigned patients and write an appropriate progress note. Trainees are to complete the history and physical, delivery note and discharge summary on all assigned patients. 3. During the rotation, trainees will attend the patient in labor and will participate in the delivery of the infant under the direction of the attending obstetrician. 4. The trainee will evaluate the infant and complete the newborn assessment on all patients attended. 5. The trainee will attend all gynecologic surgeries after having evaluated the patient presurgically. The trainee will be responsible for the history and physical, daily progress notes and discharge summary on all patients assigned. 6. The trainee will perform or assist in all procedures while on the obstetrics service. 7. Attendance at the obstetrics clinic is part of the required rotation. An appropriate log must be kept of all procedures completed.

8. The resident assigned to the obstetrical service will be expected to be on call Monday through Friday in the evenings. The attending obstetrician may use his discretion in assigning patients during the evening hours. 9. Residents assigned to the obstetrics service will meet with the obstetrics attendings to individualize their rotations in accordance with their individual goals prior to beginning the rotation.

Contact Dr. Lake for more specific information at least two weeks before the beginning of the rotation.

37 Surgery

The surgical component of the curriculum shall provide the trainee with a broad spectrum of experiences in the diagnosis and management of surgical patients. OGME-1 residents will be assigned to the general surgical service for one month and on the sub-specialty surgical services for an additional month. Residents will be assigned to the sub-specialty surgical services for two months during their advanced training years. Trainees may request a rotation with a specific physician and will then be responsible to that specific surgeon. Residents will receive exposure to orthopedics, urology, ENT and ophthalmology appropriate for the ambulatory specialist. Pre and postoperative management and differential diagnosis will be emphasized during these rotations. Exposure to anesthesiology is an OGME-1 requirement and the resident on the surgical service will be expected to work with the anesthesiologist to become familiar with anesthesia techniques, medications and patient assessment.

Educational Objectives

1. Be able to evaluate the patient with an acute and chronic condition relative to surgical need and to assess surgical risk factors. 2. Become proficient with the preoperative evaluation and postoperative management of the surgical patient. 3. Facilitate understanding of the surgical approach to clinical problem solving. 4. Obtain exposure and experience in basic surgical procedures. 5. For residents, obtain exposure and experience in the sub-specialty areas of surgery appropriate for ambulatory medicine. 6. For OGME1 residents and assigned externs, obtain exposure and experience in anesthesia focusing on the evaluation of the patient and anesthesia medications and techniques.

Procedural

1. Trainees will be assigned to the surgical service under the direction of an individual surgeon. 2. Trainees will be responsible to the attending and will be assigned call within the limitations specified by the AOA by his attending. An individual call schedule will be determined by the attending and DME office. 3. Trainees will be responsible to evaluate all assigned patients preoperatively; they will complete the history and physical and write an appropriate initial progress note. 4. Trainees will attend the patient during surgery and will follow the patient post surgically. Daily progress notes and the discharge summary are the responsibility of the trainee. 5. During the general surgical service, trainees will obtain exposure and experience in anesthesia under the direction of an anesthesiologist. Exposure will be focused on assessment of anesthesia risk, patient education and counseling for anesthesia and the use of the various anesthesia agents. A log and service evaluation for this exposure is required. 6. Trainees should participate in the surgical management of all patients and should focus on those procedures appropriate for the ambulatory setting such as repair of lacerations, sigmoidoscopy and proctoscopy, incision and drainage and aspiration. 7. On the sub-specialty services, the trainee is responsible to the attending. While focusing on the out-patient management of surgical disease the trainee should gain exposure to the diseases and procedures appropriate for the ambulatory setting. 8. On ophthalmology, the trainee will participate in the evaluation of the ambulatory patient in the attendings office.

38 9. While on otorhinolaryngology the trainee will participate in the management of all assigned patients. He will participate in those procedures such as foreign body removal, hearing testing, cerumen removal and nasal packing as are appropriate for the ambulatory setting. 10. On urology, the trainee will focus on the medical evaluation and management of common urological conditions. He will also follow all assigned in-patients gaining exposure and experience in urologic procedures. 11. On orthopedics, the trainee will be assigned to the individual attending and will be responsible for all assigned patients. The focus will be directed toward the medical recognition and management of common orthopedic problems such as foot disorders, sprains, dislocations and simple fractures.

Report to Kathy Meccia, R.N. prior to beginning the rotation for specific information regarding the surgical suite. Contact your assigned surgeon before beginning your rotation to find out more specific requirements for the rotation. Orientation and training in sterile technique is required before beginning your surgical rotation.

Geriatrics

Geriatrics at CHC is a sub-specialty of family practice. All residents are required to complete a minimum of 100 hours of exposure to geriatric care separate from their continuity experience. During your FMC rotations, residents will spend one day per week with Dr. Davis in the nursing home. Monthly didactic lectures are also provided and shall count toward the 100 hour requirement. Time spent with Dr. Stewart in hospice care should be entered in the resident log. Time on service rotations with geriatrics care or education should be documented on the rotation log.

Geriatrics is part of the continuum of patient care but is different in approach, pathophysiology and participation. Patients admitted to extended care facilities and nursing homes have different needs and different rules for care. All house staff should consider a separate geriatrics rotation. This experience requires a log / narrative summary, service and trainee evaluations.

Educational Objectives

1. Be able to complete an H&P on the elderly patient. 2. Distinguish normal from pathologic aging with respect to cognitive functioning, personality and illness. 3. Be able to identify special needs of the elderly patient. 4. Be familiar with HCFA requirements specific to the geriatric extended care admission. 5. Be familiar with the Beer Table.

Procedural

1. Each trainee will have a block assignment for the Family Medicine Clinic. The Fridays of this rotation will be spent with the geriatric specialist (Dr. Davis). 2. During the first session the trainee will receive an orientation to geriatrics and will learn where and when to meet with the supervisor. 3. Trainees will see all assigned patients individually and on teaching rounds with the supervisor. Trainees will write the appropriate service note on all patients assigned. 4. Reading assignments may be given by the supervisor. These become a required component

39 for completion of the rotation. 5. A patient log or narrative summary and evaluations will be submitted to the DME office to receive credit for the experience.

The resident is responsible to contact Dr. Davis before the rotation begins to determine when and where to meet for the geriatrics exposure. A separate service evaluation is required.

Behavioral Medicine

Exposure to behavioral science is an important component of residency training. The program will present 10 hours of didactic training in adolescent behavioral issues. STARS presents 12 hours of didactics yearly in substance abuse treatment. SCS provides behavioral lectures in their 36-month curriculum. Attendance at these sessions is mandatory. A specific log is not required.

Practice Management

During the residency program 20 hours of exposure to practice management is required. Resident exposure to practice finances will be obtained during the monthly rural health clinic meetings. Didactic sessions on E/M coding and billing practices, risk management, Care plan specifics are presented in a structured yearly program. No separate log is required.

Diagnostic Imaging

A structured program for resident training in diagnostic imaging is provided. During your medicine service and while on the ER service training in interpreting x-rays is completed. This exposure must be included in your narrative log. Didactic sessions on ACR appropriateness for radiology procedures are presented yearly. Your attendance log will document your participation in this endeavor.

Procedural Training

At the completion of your residency program you must have received training in accessing the need for procedures and experience in performing the required procedures. This documentation should be present in your monthly narrative log. Current policy requires that your preceptor sign the procedure log at the time the procedure is completed under his supervision. The resident must be aware on the specific procedures needed. Competency is determined by the program director and shall be assessed during the bi-annual reviews. Didactic sessions at CHC and at SCS are part of the overall resident experience. Exposure to the required procedure may be obtained on many of the service rotations. It is the resident's responsibility to document completion of the procedure and to get the procedure form completed.

Residents are expected to document competency in the following procedures. It may be necessary to extend training beyond the 36 months of formal residency to complete competency training in all of the required procedures.

Joint injections Biopsy of skin lesions Excision of SQ lesions I&D of abscess Cryosurgery Curettage of skin lesions Laceration repair Endometrial biopsy Office microscopy

40 Splinting ECG interpretation Office spirometry Toenail removal Defibrillation (ACLS) Removal of cerumen Endotracheal intubation PAP / Breast exam Male genital exam

Specific forms have been developed to assess competency in the required procedures. It is the resident's responsibility to get the form completed at the point of care. An attending supervising the procedure, the clinic supervisor and the program director may sign the procedural forms. Forms should be turned in to the medical education office to be entered into the resident portfolio.

Community Medicine

Exposure of 50 hours or two weeks of documented training in community medicine is required by the completion of your residency program. Exposure to occupational health, community based screening programs (Headstart, prostate and breast screening), participation in the local free clinics or at the local schools are parts of this experience. It is the resident's responsibility to document compliance with this requirement in their narrative log. Assessment during the bi-annual review will be completed. Completion of the residency may be extended to complete this requirement.

Electives / Selectives

By definition an elective is a freely chosen rotation while a selective is focused in a specific area or specialty. In our program description each resident is presented with 40 weeks of selectives in the areas of medicine or surgery and 48 weeks of electives. Assignment is on a first-come-first-served basis. It is important for you to determine any areas of special interest or educational need and make selections for your electives and selectives.

Sports Medicine – (Community Health Center of Branch County)

Exposure to sports medicine is a program requirement. Training in assessment of the athlete, management of sports injuries, injury prevention and training and rehabilitation of athletic training injuries are parts of this rotation the resident must document 50 hours of exposure during their program.

Procedural

1. Residents may set up rotations though our physical therapy department spending time with therapists dealing with sports injuries 2. Rotations on the ambulatory orthopedics service can be utilized to increase exposure to sports injuries. 3. SCS didactic training can be used for sports medicine education. Casting clinics are examples. 4. Participation in community sports activities as a team consultant is an important consideration

The resident is responsible to document participation in the sports medicine requirement through completion of appropriate logs of activities.

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Sports Medicine / Ambulatory Orthopedics (Hillsdale Community Health Center)

General Description: The sports medicine rotation is a two week block, usually during the PGY 2 year. The resident spends time with the sports medicine attending physician in his outpatient office, the emergency room and the operating room. There may also be sports medicine clinics during the rotation.

Supervision and Evaluation: The resident will be supervised on a daily basis by the attending physician on duty at Hillsdale Community Health Center. The resident’s evaluation will be completed by the attending with which the resident spends the greatest amount of time. The evaluation can be preformed by the collaboration of several attending physicians. Successful completion of the Family Practice program requirements for sports medicine will require the resident to fulfill the listed objectives, skills and procedures on a longitudinal basis prior to graduation.

Goals: 1. The resident will understand the anatomy and physiology the musculoskeletal system relevant to the practice of orthopedic and sports medicine. 2. The resident will learn the physiology of exercise and the adaptation of the body to exercise in men, women, and children. 3. The resident will understand the role of nutrition and supplements in sports and their role in enhancing performance. 4. The resident will understand the function of pre-participation exam and learn to appropriately screen individuals prior to exercise. 5. The resident will recognize the common sport injuries seen in athletes and the appropriate treatments. 6. The resident will recognize the common medical problems seen in athletes and understand the appropriate evaluation and treatment. 7. The resident will understand the use of laboratory and x-ray in the evaluation of sports medicine problems. 8. The resident will understand the role of physical therapy in sports injury rehabilitation. 9. The resident will understand the function of the sideline physician at team sports events.

Competencies: Residents will be expected to demonstrate proficiency in the six competencies of Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism and Systems-Based Practice.

I. Patient Care 1. By the end of the PGY-2 year, the resident will demonstrate competency as assessed by one of the family medicine faculty or orthopedist in the following: a. Proper exam of the knee and shoulder on a simulated patient b. Participation in athletic pre-participation physicals.

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2. By the end of the PGY-3 year, the resident will demonstrate competency as assessed by one of the family medicine faculty or orthopedist in the following: a. Application of a short leg walking cast and a short arm cast. b. Joint injections of both the should and knee. c. Interpretation of an X-ray of a major join of a patient. d. Coverage of a least 1 sporting event with a sports medicine physician.

3. The resident on the PGY-2 year will present three cases involving a patient with the following: a. Acute musculoskeletal injury. b. Chronic musculoskeletal injury. c. Medical problem related to athletics.

II. Medical Knowledge 1. The resident will list the common symptoms, physical findings, diagnostic methods, and management of the following acute injuries: a. Rotation cuff tear. b. Glenohumeral dislocation c. Acromioclavicular separation d. Clavicle fracture e. Navicular fracture f. Ankle sprain g. ACL tear h. MCL sprain i. Meniscal tear j. 5th metatarsal fracture

2. The resident will list the common symptoms, physical findings, diagnostic methods, and management (including physical therapy) of the following chronic conditions: a. Dequervain’s tenosynovitis b. Rotator cuff tendinitis c. Lateral epicondylitis d. Carpal tunnel syndrome e. Biceps tendinitis f. Iliotibial band syndrome g. Patellofemoral stress syndrome (PFSS) h. Patella tendinitis i. Plantar fascitis j. Achilles tendinitis

3. The resident will list the most common abnormalities discovered during the pre-participation physical of a high school athlete.

4. The resident will recite a classification of concussion injuries and discuss the proper return to play after a concussion.

5. The resident will define the role of carbohydrates, fats, and protein and energy sources for exercising persons.

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6. The resident will discuss exercise and its relation with the following medical problems / conditions: a. Hypertension b. Cardiac arrhythmias c. Exercise-induced asthma d. Diabetes mellitus e. The female athlete triad f. Pregnancy g. Infectious disease h. Heat illness / stroke

III. Practice-Based Learning and Improvement 1. The resident will demonstrate an appreciation of the benefits of exercise on the following cardiovascular risk factors: a. Obesity b. Hypertension c. Hyperlipidema d. Smoking e. Diabetes mellitus, Type 1 and Type 2.

IV. Interpersonal and Communication Skills 1. The resident will counsel a patient who has suffered a musculoskeletal injury in the following areas: a. Physical management of the injury (non-surgical vs. surgical, rehab). b. Psychological effects of the injury.

2. The resident will teach a home physical therapy program to at least one patient with a musculoskeletal injury. 3. The resident will coordinate care for a patient between their role as a primary care physician and an orthopedic or sports medicine specialist.

V. Professionalism The resident will be consistent and punctual in attendance on the rotation. While on this rotation, the resident will carry out all professional responsibilities as assigned, will adhere to ethical principles and will be sensitive to patients and patient’s families, especially diverse ethnic and or cultural backgrounds.

VI. System-Based Practice 1. The resident will demonstrate an awareness of the surgical vs. non-surgical approaches to musculoskeletal injuries. 2. The resident will demonstrate competency on knowing when to refer a musculoskeletal injury to a specialist.

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Radiology Rotation (Hillsdale Community Health Center)

General Description: The radiology rotation is a two week block, usually during the PGY2 year. The resident spends time in the radiology reading room with the attending radiologist reading films at Hillsdale Community Health Center. The resident will also accompany the radiologist to evaluate the patient and observe all invasive radiological procedures.

Supervision and Evaluation: The resident will be supervised on a daily basis by the attending radiologist on duty at Hillsdale Community Health Center. The resident’s evaluation will be completed by the attending with which the resident spends the greatest amount of time. The evaluation can be preformed by the collaboration of several attending physicians.

Institutional Policies, Rules and Regulation: The resident will abide by all applicable rules and regulation of Hillsdale Community Health Center as well as the institution that acts as their base Hospital.

Duties: 1. The resident is expected to present to the radiology reading room by 8:30 a.m. on the days they are not attending their clinic. 2. The resident is expected to share their schedule and proposed clinic days with the radiology attending so they can anticipate when a resident will be present. 3. The resident is expected to read assigned reading from the text. 4. The resident is expected to view at least one imaging or invasive procedures in each of the following areas: a. Special procedures b. CT c. MRI d. Ultrasound e. Nuclear Imaging

5. The resident should seek opportunities to view other radiologic procedures as they are available.

COMPETENCIES Residents will be expected to demonstrate proficiency in the six competencies of Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism and Systems-Based as outlined below.

I. Patient Care The resident will competently read chest x-rays and plain abdominal films at the conclusion of the rotation. The resident will be able to select appropriate radiological test for patients with primary care complaints. Particular distinction is made with respect to appropriate selection of CT versus MRI, and contrast versus non-contract procedures.

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II. Medical Knowledge The resident should be able to describe normal chest anatomy as seen on plain chest films. The resident will describe findings that help distinguish benign versus malignant chess masses. The resident will describe appropriate evaluation of such lesions based on location and size. The resident will describe expected normal finding on plain abdominal films.

III. Practice-Based Learning and Improvement The resident will daily review the medical literature related to at least one patient seen during that day. The resident will learn what measurable quality indicators apply to radiological services.

IV. Interpersonal and Communication Skills The resident will learn the skill of asking appropriate clinical questions of a radiologist.

V. Professionalism The resident will be consistent and punctual in attendance on the rotation. While on this rotation, the resident will carry out all professional responsibilities as assigned, will adhere to ethical principles, and will be sensitive to patients and patient’s families, especially diverse ethic and/or cultural backgrounds.

VI. Systems-Based Practice The resident will gain an understanding of the capabilities and limitation of the radiological services available at Hillsdale Community Health Center.

GUIDELINES FOR OUTPATIENT PRESCRIPTION OF CONTROLLED SUBSTANCES - SCHEDULES II-IV (non malignant pain control)

Purpose of Guidelines

Repeated, long term use of prescription controlled substances for non-malignant pain is a factor in the development of long-term disability and dependence on controller medication. This condition is preventable if at-risk patients and practices are pro-actively identified and managed appropriately.

Application of Guidelines

These guidelines are intended for use in the management of chronic nonmalignant pain. They are intended for outpatient prescriptions for non-parenteral controlled substances. Guidelines cannot be applied uniformly to every patient and guidelines cannot replace thorough assessment of the patient. Guidelines do not supersede detailed prescribing information from pharmaceutical references. Guidelines are intended for use by physicians who begin treatment of patients within 6 months of an injury.

46 General Information

Physicians can be held accountable if their prescribing patterns fall outside established guidelines. Patients presenting with acute pain are exempt from these guidelines. For patient with pain lasting longer than 6 weeks without antecedent injury are considered to have chronic pain. The primary focus in management of patients with chronic pain is to restore functional activity. Complete suppression of all pain may not be possible.

When treating chronic pain a thorough assessment including history and complete physical assessment is required. A pain plan is required. Documentation of recommendations must be outlined in the chart and understood by the patient. Schedule II drugs should not be prescribed longer than 2 weeks without physical and x-ray conformation of pathology. Schedule III and IV drugs should not be prescribed longer than 6 weeks without confirmation. Most controller medications depress respiration and this must be considered when prescribing these medications.

Extreme caution should be used in prescribing controlled substances in patients with relative contraindications for their use. Referral to a chronic pain specialist and/or psychiatrist may be considered for conditions lasting beyond 6 months.

Consider habituation or addiction when:

1. Underlying tissue pathology is minimal or absent and correlation between current clinical findings and severity of impairment is not clear 2. Suffering and pain behaviors are present and patients requests medication 3. Standard treatment measures have not been successful 4. Relative contraindications for prescription for controlled substances exists and medication is prescribed

Relative Contraindications for Use of Controlled Substances

1. History of alcohol or other substance abuse 2. Active alcohol or other substance abuse 3. Borderline personality disorders 4. Mood disorders, depression or psychotic disorders 5. Off work longer than 6 months 6. Inability to wean patient from chronic medication

Documentation Recommendations When Controlled Substances are Prescribed:

1. Thorough current H&P documented in the chart 2. A pain treatment plan is documented in the chart and documentation that the plan is understood by the patient. Specific goals and objectives should be clearly defined. 3. Treatment program is consistent with current practice guidelines 4. There are clearly stated, measurable objectives 5. A current accurate listing of all current medications (from all sources) 6. Random drug testing is completed at least bi-annually

47 7. A MAPS is updated at least bi-annually 8. Description of response to current therapy (each medication) 9. Documentation of attempts to wean and why they failed

FORMS

A multitude of forms have been developed to help document, monitor or assess resident performance and service throughout the residency program. These forms may be updated periodically. All forms are available in the medical education office. Some forms are colored to help identify their use. These should not be copied. All other non colored forms may be copied at your convenience. Some forms are specific to the continuity clinic.

Educational forms that are utilized include:

Narrative log Time out request Moonlighting request Service evaluation Final check out Resident evaluation Procedure documentation Bi-annual assessment Expense report

Clinic forms include:

Diabetes RX FAX form Procedure forms COPD / Asthma ECG interpretation Coumadin therapy Colposcopy ABI study Time out / Consent Mobility assessment Referral Drug screening Apnealink / Sleep study

PHYSICIAN RISK MANAGEMENT/PI/SAFETY ORIENTATION/EDUCATION

ADVANCE DIRECTIVES: There are certain requirements that we as a health-care organization must provide to all adult inpatients relative to their right to make their own health care decisions including the right to accept or refuse treatment. The organization must ensure that there is written documentation of the patients= life sustaining treatment. IT=S THE LAW...:As a result of OBRA 1990 (omnibus Reconciliation Act) we are required to ascertain from all adult (age 18years and over) inpatient and observation patients their advance directives status, location of the directive if they have one, and their desire for further knowledge regarding advance directive, Not only do we need to inquire about the advance directive, we need to document the substance of the advance directives on the CODE STATUS FORM. It is important to document the substance of the advance directive since the form itself may not be available. The wishes of a patient who does not have an advance directive should be documented in the record by the healthcare professional.

48 PATIENT RIGHTS: MEDICAL RECORD  A patient has a right to view their medical record.  Patients have a right to make an amendment to their medical record by making a request to create a written statement concerning their care that will be added to the medical record. The Risk Manager and the Director of Medical Records will aid in the request.  The process involves filling out a form that will be supplied the Director of Medical Records. This form must be notarized and the amendment prepared by the patient, legal guardian, and/or attorney. Once completed, the statement and accompanying documents will be made a permanent part of the medical record  Only authorized staff directly involved in the treatment of the patient, acquisition of payment of services rendered or other organizational operation are allowed access to the patient=s medical record or the information contained in the record

CUSTOMER RELATIONS PROGRAM: Patient concerns are investigated and resolved as soon as possible. Concerns are forwarded to the Quality Services Representative, Director of Quality Services or the appropriate administrator. Patients may notify Medicare, Michigan Department of Health &Human Services directly, and or JCAHO regarding their care.  Toll Free Medicare Information Line - Medicare beneficiaries and their representatives may call this line for questions/concerns related quality of care at the facility. 1-800-365-5899, Monday - Friday 9am - 5pm.  Toll Free Michigan Department of Health & Human Service (Department of Consumer & Industry) Hot Line for Care Concerns - 1-800-882-6006.  JCAHO - 630-792-5855.

CONFIDENTIALITY: Strict confidentiality is a basic value accepted by staff and a protected right of the patient that is adhered to by all employee, contracted workers, volunteers, agents and credentialed staff of CHC.

PRESERVATION OF EVIDENCE: In the event of a device malfunction that results in the death, serious illness, or injury of a patient, any equipment shall be removed from the patient care setting and be sent to the Material Management Department. Notify Risk Management and the Department Director, or Administration of the incident immediately.  MATERIAL MANAGEMENT DIRECTOR OR THE KEY CONTACT PER SHALL SECURE THE EQUIPMENT INVOLVED IN THE INVESTIGATION OF THE INCIDENT UNTIL THE INVESTIGATION IS COMPLETED.

SENTINEL EVENT: A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk there of. Serious injury specifically includes loss of limb or function. The phrase Aor risk there of@ includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. These events signal the need for immediate investigation. ROOT CAUSE ANALYSIS: A Root Cause Analysis (RCA) is a process for identifying the basic or causal factor that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event. The root cause analysis:  Focuses primarily on systems and processes, not individual performance.

49  Progresses from special causes in clinical processes to common causes in organizational processes  Identifies potential improvements in processes or systems that would tend to decrease the likelihood of such events from happening in the future or determines that no such improvement opportunity exists.

ACTION PLAN: An action plan is the product of the root cause analysis. It identifies the strategies that the organization intends to implement to reduce the risk of similar events occurring in the future. The action plan addresses responsibility for implementation, oversight, pilot testing, time lines and measuring the effectiveness of the actions. SENTINEL ALERTS: There are 37 Sentinel Alerts put out by JCAHO that discuss known serious incidents and events. The publications provide recommendations or solutions to prevent such incidents. The recommendations must be incorporated by the facility if at all possible. The most often reported Sentinel Event as of December 31,2006 is Wrong-site Surgery (532) followed by Suicide. (522). These alerts can be read on the JCAHO website; http://www.jacho.org/jaucohome/jaycohomepage.asp or you can obtain a copy from you department director.

Patient Safety The community Health Center of Branch County has an active Patient Safety Program which consists of policies, protocols and actions recommended by members of the CART team, the Safety Committee and CQC Committee which provide oversight for the program. National Quality measures for improvement of patient care are incorporated into the Patient Safety Program at CHC as well. National Patient Safety Goals: The Joint Commission on Accreditation of Healthcare Organizations has approved National Patient Safety Goals for 2007. The 2007 goals include previous goals with two additional goals:

Goal 1: Improve the Accuracy of patient identification.  Requirement 1A: Use at least two patient identifiers (neither to be the patients= room number) whenever administering medications or blood products: taking blood samples and other specimens for clinical testing or providing any other treatment or procedures.

Goal 2: Improve the communication among care giver.  Requirement 2A: For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result Aread-back@ the complete order or test result.  if a physician is present the order should be written by the physician. When verbal orders are used, they must be authenticated within 48 hours per CMS Conditions of participation.  Requirement 2B: Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.

Abbreviations that are not to be used at the Community Health Center Include:

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DO NOT USE USE INSTEAD

u - (unit) IU (international unit write Aunit@ qd (daily) write Ainternational unit@ QOD (every other day ) write Adaily@ Trailing zero (X.0mg) write Aevery other day@ Lack of leading zero (,X mg4 write AXmg@ MS, MSO write A 0.xmg @ 4 write A morphine sulfate@ write A magnesium sulfate@ MgSO Physician Legibility and ability to read signatures may result in a Requirement for Improvement from the Joint Commission if illegible order/signatures are found. For the safety of our patients and to comply with the joint Commission National Safety Goal number 2B, CHC is closely monitoring compliance with this standard.  Requirement 2C: Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed care giver of critical test results and values.  Requirement 2E: Implement a standardized approach to Ahand off@ communications, including an opportunity to ask and respond to questions.

Goal 3: Improve the safety of using medications.  Requirement 3B: Standardize and limit the number of drug concentration available in the organization.  Requirement 3C: Identify and at a minimum, annually review a list of look-alike/sound alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.  Requirement 3D: Label all medications, medication containers (for example syringes, medicine cups, basins) or other solutions on and off the sterile field.  Requirement 3E: Reduce the risk of patient harm from anti-coagulation therapy.

Goal 7: Reduce the risk of Health Care-associated Infections.  Requirement 7A: Comply with current Center for Disease Control and Prevention (CDC) hand hygiene guidelines.  Requirement 7B: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare - associated infection.

Goal 8: Accurately and completely reconcile medication across the continuum of care.

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 Requirement 8A: Implement a process for obtaining and documenting a complete list of the patient=s current medications upon the patient=s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.  Requirement 8B: A complete list of the patient=s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.

Goal 9: Reduce the risk of patient harm resulting from falls.  Requirement 9A: Implement a fall reduction program and evaluate the effectiveness of the program.

Goal 13: Encourage patients= active involvement in their own care as a patient safety strategy.  Requirement 13A: Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

Goal 15: The organization identifies safety risks inherent in the patient population.  Requirement 15A: The organization identifies patients at risk for suicide. Implementation expectations for Requirement 15A: 1. The risk assessment includes identification of specific factors and features that may increase or decrease risk for suicide. 2. The patient=s immediate safety needs and most appropriate setting for treatment are address. 3. The organization provides information such as a crisis hotline to individuals and their family members for crisis.

Universal Protocol to prevent wrong site, wrong procedure, wrong person surgery 1A- Conduct a preoperative verification process including verification of the correct person, procedure and site. 1B- Mark the operative site as describe in the Universal Protocol Policy.

1C- Conduct a ATime Out@ immediately before starting the procedure as described in the universal protocol policy. Follow procedure for non OR settings including bedside procedures.  Site marking must be done before any procedure that involves laterality (right or left side) multiple structures or levels.  Verification, site marking and ATime out@ procedures should be followed as described in the Universal Protocol policy.  Exception: Cases in which the individual doing the procedure is in continuous attendance with the patient from the time of decision to do the procedure and consent from the patient through to the conduct of the procedure may be exempted fro the site marking requirement. The requirement for a Atime out@ final verification still applies.

Excerpted from the Comprehensive Accreditation Manual for Hospitals: the Official Handbook 2008

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HEALTH  Recognize signs of stress in Peers  Safe Workplace  Signs of Impairment  Frequent late arrivals  Personal hygiene or dress deteriorates  Frequent absences  Behavior toward staff or patients becomes unpredictable  Irritability and or use of abusive language  Performance issues, i.e., quality of documentation deteriorate increased patient or staff complaints about a provider.  Unexpected blow ups.  Mannerisms threatening or disruptive  Unavailable or behavior inappropriate when on call  Know How to refer. Yourself or Peers.  EAP  Organization for Impaired Professionals, RN=s, M.D.=s  Health Professional Recovery Program: 800-453-3784.  www.hprp.org

FIRE PROCEDURE In the event of a fire, Physician in the facility are expected to:  Activate RACE if first on the scene.

R - Rescue the patient (or any person in the immediate area). A - Alarm (pull the alarm) C - Confine the fire (close all doors). E - Extinguish the fire, if small.  Do not use the elevators  Eliminate use of the phone  Assist staff in evacuating patients if necessary.

Fire Alarm Pull Stations are located near every exit. Know where 02 shut off valve is located.

ANNUAL PHYSICIAN SAFETY EDUCATION CONDITION CODE/SIGNAL PHONE NUMBER Fire or Drill 56 and Signal 56 all Clear 4500

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Cardiac Arrest Code Team - Room 4300 Number/Area Disaster or Drill Announced as in Plan

Abdication Nursery Abduction (NA) 4300 Pediatric Abduction (PA) Bomb Threat Announced as directed 911 DO NOT HANG UP PHONE DO NOT USE CELL PHONE

Tornado Watch/Warning Announced as in Plan

A Team Assistance response for 4300 / 0 Management of unruly/violent Patient. Announcement Assistance Needed or A Team Floor, Room number.

PHYSICIAN ROLE IN DISASTER The physician role in the disaster plan is to report to the Command Center, Conference Room 3. Let them know that you are in the Hospital and then take on your assigned role from the Physician in charge, or your specialty area.  Bioterroism: The facility is preparing for unsuspected attacks from may sources. We have a team who has been attending meeting of the 5th District Medical Response Coalition in Michigan to prepare for disaster or emergency response from any cause including infections disease.

HAZARDOUS MATERIAL/COMMUNICATION 1. Hazardous materials found in the facility include: Infectious agents and medical gases Radiation and ethylene oxide  Hazardous Chemicals and Chemotherapy drugs, Hazardous Spills:  Chemotherapy Spills: Kits provided will be used by staff trained in their use.  Large hazardous spill: Contact fire department at 911.  Contained hazardous spills: Notify the spill response team. Dial 0  Infections Waste: Put in red biohazard bag. Only use for infectious waste.

2. Material Safety Data Sheets (MSDS) provide detailed information on a specific chemical product including ingredients, potential hazards and safety precautions. ALL MSDS SHEETS CAN BE ACCESSED ON THE INTERNET by going to www.safetylogicmsds.com log in ID is chcmsds password msds123. MSDS sheet for new chemicals used in the department are sent to departments for posting a staff education.

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INFECTION CONTROL Physicians are to follow facility approved infection control policies (see infection control manual on the Intranet) The CDC Hand Hygiene Guidelines must be followed for all patients care including sanitizing hands before and after patient contact. Isolation protocols must be followed when indicated, including gloves, mask, and gown. In addition to standard/universal precautions, CHC uses CONTACT PRECAUTIONS, DROPLET PRECAUTIONS, and AIRBORNE PRECAUTIONS when indicated. Patients= who are infected with or colonized with drug resistant organisms are placed in contact precautions. Supplies that are available on all patient units that serve as protective measures against blood and body fluid are: gowns, masks, face shields, head and shoe covers, and gloves. Post an exposure packet to blood and body fluids: Red packets are available on all units. This packet should be used when an exposure occurs. It contains information on reporting and information on prophylactic medication and time frames. Report to the Occupational Health office during business hours and to the ER after business hours.

Protocols have been developed for prevention of infection in vulnerable patients such as:  Vent Bundles in ICU.  Protocol for insertion of central lines using chlorhexadine for skin antisepsis and full barrier precaution for insertion  Standardized orders for influenza and pneumococcal vaccination for patients when indicated and no contraindication.  Appropriate antibiotic prophylaxis for selected surgical patients. (See SCIP project).

CHC has an active employee influenza immunization program. All employees are expected to receive the seasonal influenza vaccination. Employees who do not wish to receive the immunization are required to sign a declination statement. Physicians are included in the influenza immunization plan and are provided the flu shot at no cost.

FACILITY SECURITY 1. Building is locked after 8pm. Only one door is open for use. Obstetrics is locked down and visitors must use the security system for entrance. Instructions are located at the elevator to call the OB unit for access. Wear ID Badge when coming in the facility; not all personnel may know who you are. Be watchful of unidentified persons in the facility. Question reason for being here, contact Facility Operations, or Security for concerns. Bill Earl is the Safety Officer for CHC (extension 5492). Report any unusual happenings or persons to security/Facility Operations Department. Handling an angry visitor/family/or patient:  Do not get blocked if at all possible in the. Keep the door between you and the person.  Defuse the situation if possible; if unable tell the person you will speak with them at a different time.  Call 911 if you consider you or anyone else in danger

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Active Medical Teaching Staff

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