University of Utah Hospitals and Clinics

UNIVERSITY OF UTAH HOSPITALS AND CLINICS

GRADUATE MEDICAL EDUCATION

2015-2020 PROGRAM LETTER OF AGREEMENT (Supplement to Master Agreement dated July 1, 2014 – June 30, 2019 filed in GME office) ______

Insert current date Insert name and address of affiliated hospital:

Re: Resident Training Program Letter of Agreement between Insert Name of Program at the University of Utah School of Medicine and Insert Name of Hospital. (For University: University of Utah Hospitals and Clinics)

Dear Insert Name of Affiliated Hospital Administrator or Executive Director:

This Resident Training Program Letter of Agreement (the “Letter of Agreement”) is entered into between the University of Utah, on behalf of its School of Medicine (the “School of Medicine”) and Insert Name of Hospital (“Hospital”). (For University: University of Utah Hospitals and Clinics)

I. PURPOSE

The purpose of this Letter of Agreement is to document the specifics of the Insert Name of Program residency training program (the “Program”) at the Hospital, in compliance with the Institutional and Common Program Requirements of the Accreditation Council for Graduate Medical Education and the special requirements of the Residency Review Committees. This Letter of Agreement is also intended to supplement the Master Affiliation Agreement between School of Medicine and Hospital, dated July 1, 2014 (the “Affiliation Agreement”), which is incorporated herein by this reference, as required by Section 2 of the Affiliation Agreement.

II. PROGRAM DIRECTOR AND CHIEF OF TEACHING SERVICE

The Program Director for the Program, as designated by the School of Medicine Graduate Medical Education Committee, is Insert Name of Program Director. The Chief of the Program Teaching Service at the Hospital is Insert Name of Program Director or Chief at Affiliated Hospital (may be same person if agreement is with University of Utah Hospitals and Clinics).

Dr. Insert Last Name of Affiliated Hospital Program Director recognizes responsibility to the program for all joint education and/or research. Dr. Insert Same Name as above has a full-time faculty appointment as Insert Faculty Rank in the School of Medicine. These appointments are made in accordance with the Affiliation Agreement.

III. TRAINING PROGRAM TEACHING STAFF (ACGME Requirement I.B.1.a)

Names and faculty ranks (if applicable) of all teaching staff for the Program at the Hospital (the “Hospital Program Faculty”) will be provided by the program on an annual basis and attached to this agreement. Unless otherwise approved by the School of Medicine, all Hospital Program Faculty must have current board certification or be board-eligible in the specialty that they are supervising. They must also possess current medical licensure and appropriate medical staff appointment at the training location. Hospital Program Faculty must have liability coverage in the amount of $1 million per occurrence and $3 million aggregate to include continued (tail) coverage for at least two years. Attach a list of names and faculty ranks of all faculty who will be supervising residents at this training site during the current year. Provide a new list yearly if there are any changes to Hospital Program Faculty.

All faculty responsibilities and appointments shall be consistent with the Affiliation Agreement. Hospital faculty assumes administrative, educational, and supervisory responsibility for the residents while training at the Hospital.

IV. EDUCATIONAL CONTRIBUTION (ACGME Requirement I.B.1.c)

The following are expected contributions to the educational goals and objectives of this program as provided by the Hospital:

Insert here a description of special expertise, unique patient population, etc. Use your program Standards of Performance or Goals and Objectives for the rotations at this hospital to specify what the residents will learn while they are on these rotations. Be specific, the ACGME requires the training agreement to describe in detail the content of the educational experience.

All patients admitted to the Program teaching service will be available for participation in the teaching program. Insert here a description of restrictions if all patients not available.

V. ASSIGNMENT OF RESIDENTS AND FINANCIAL COMMITMENT TO THE PROGRAM (ACGME Requirement I.B.1.c)

The number of residents assigned to the Program on a rotating basis shall be: Insert here # per month, months per year, or hours per week, whatever is appropriate

The period of assignment will be specified in the Resident Rotation Schedule for the applicable year.

INSERT THIS PARAGRAPH FOR AFFILIATED HOSPITALS OUTSIDE THE UNIVERSITY HOSPITAL SYSTEM:

The Hospital agrees to pay for a total of Insert # here FTE's each year for the above residents for 2015- 2020 house staff academic years according to reimbursement standards as determined by the Graduate Medical Education Committee and may report the total number of FTE’s rotating at the Hospital on Hospital’s CMS cost report. Any changes to funding will be provided on an annual basis by an addendum attached to this agreement and signed by all parties. Residents who are funded by the Utah Medical Education Council will not be billed to IHCHS Hospital, however may be claimed on the CMS cost report when rotating at the Hospital.

INSERT THIS PARAGRAPH FOR UNIVERSITY HOSPITAL OR ITS SITES: ARUP, HCI, HCH, ORTHOPAEDIC CENTER, OR ANY OF THE UNIVERSITY-OWNED COMMUNITY CLINICS.

University Hospital agrees to pay for a total of Insert here the TOTAL # residents to be paid by University Hospital FTE's, which total number includes the number of residents assigned to any of the University-owned sites (A.R.U.P., The Orthopaedic Center, Huntsman Cancer Institute, Huntsman Cancer Hospital, John Moran Eye Center, and any of the University-owned community clinics), for 2015- 2020 house staff academic years according to reimbursement standards as determined by the Graduate Medical Education Committee and may report the total number of FTE’s rotating at University Hospital or University Hospital-owned sites on University Hospital’s CMS cost report. Any changes to funding will be provided on an annual basis by an addendum attached to this Letter of Agreement and signed by all parties. Residents who are funded by the School of Medicine UMEC and whose funding has already paid by Hospital to School of Medicine, will not be billed to Hospital by the School of Medicine a second time; however, they may be claimed on the CMS cost report when rotating at the Hospital. It is assumed that one FTE will provide the following kind of coverage:

Insert here a description of coverage. (Note this clause is not about on call coverage, the intent is to describe the residency coverage of the actual sites where the residents rotate) Example, 1 FTE shall be assigned to the following clinics; orthopedics, specialty and consults, and 3 FTE’s shall be assigned to the inpatient teams.

Residents will be expected to take call every Insert here frequency of call, i.e. third, fourth day. Backup call for Residents will be provided by Insert here a description, i.e. hospital faculty in house, or faculty at home, or faculty at UUMC.

The following minimum support services will be available to residents and faculty participating in the Program:

Insert here a list of support services. Examples: A regularly scheduled series of clinical grand grounds; conference room and office space for teaching conferences and study; faculty and house staff will have the facilities of the Spencer S. Eccles Health Sciences Library in the Health Sciences Center available, in addition to the [Name of Library] in the [Name of Hospital].

(ACGME Requirement I.B.1.b) Hospital Program Faculty will have responsibility for teaching, supervision, and formal evaluation of the residents’ performance in accordance with the program Standards of Performance.

It is understood that all residents participating in the Program will be responsible for the timely completion of medical records, and that the Program Director will be responsible to ensure that residents complete patient charts in a timely manner.

VI. MEETINGS

Regular meetings of the Program Director, Chief of Teaching Service, and faculty will be held to ensure mutual goals and objectives of the program are being achieved. The frequency of such meetings may vary depending on the size of the program, number of faculty, etc.

VII. PERIODIC REVIEW OF PROGRAM (ACGME Requirement V.C.2)

The Hospital Program Faculty will participate in the resident internal review process of the School of Medicine as determined by the Graduate Medical Education Committee. The Hospital Program Faculty will also evaluate the Program annually in combination with the faculty at other training sites and a representative from the residency program and the program will implement improvements to the Program based on these recommendations. The following is the Program’s process of program evaluation:

Insert here a description of the evaluation process which includes faculty at all sites in evaluating the program annually. Note this clause is not about resident evaluation; the purpose is to describe how the program is evaluated as per ACGME requirement.

VIII. RESIDENTS (ACGME Requirement I.B.1.d)

Policies and procedures which govern resident education while rotating to the Program can be found in the University of Utah and Master Hospitals House staff Policy Manual, located at http://www.med.utah.edu/SOM/education/GME.

IX. RENEWAL Hospital and School of Medicine must renew this Letter of Agreement every five years, which renewal will be appended to the Affiliation Agreement. This program renewal will be complete by June 15 for the following 5-year period.

X. ANTICIPATED CHANGES

The parties acknowledge the possibility that Hospital may fund fewer or more positions than specified above, and that School of Medicine may deliver fewer or more residents than the number specified above. Prior to December 15 of the year prior to the commencement of the Program, the parties will meet by phone or in person to discuss and agree upon any such changes in funding or resident numbers, and the financial obligations and FTE’s reported on the CMS cost report, as described at Article V above, will be adjusted accordingly.

XI. INSURANCE/INDEMNIFICATION

The parties acknowledge that all insurance and indemnification questions pertaining to this Letter of Agreement are governed by the Master Affiliation Agreement between School of Medicine and Hospital.

XII. GRIEVANCE PROCEDURES AND DUE PROCESS

The University of Utah, the University of Utah Hospital, and the University of Utah Hospital House staff have adopted policies and procedures governing house staff grievances and due process. This Letter of Agreement incorporates within it applicable University of Utah and University of Utah Hospital Policies and Procedures (available on the Internet at http://www.regulations.utah.edu/humanResources/ and University Hospital House staff Policies and Procedures (available on the Internet at http://medicine.utah.edu/gme/ ), including the House staff Counseling Programs policy (which programs include counseling, employee assistance for house officers and family members, and substance abuse treatment assistance and/or diversion). House staff policies are also available through the Graduate Medical Education Office and at house staff orientation. Any changes, updates, or additions, and all other policies and procedures of the University of Utah, University of Utah Hospital, and University Hospital House staff will be posted to the electronic manual websites referenced, respectively, above, and any changes or updates will be incorporated and effective as of the date of the change or update.

This Program Letter of Agreement is effective for 2015-2020 house staff years beginning July 1, 2015, and ending June 30, 2020.

______Insert here Program Director Name Alan J. Smith, PhD, MEd Program Director, Insert Name of Program Assistant Dean and Director, Graduate Medical Ed. University of Utah, School of Medicine ACGME Designated Institutional Official University of Utah School of Medicine

Please indicate Hospital’s acceptance of the terms of this Letter of Agreement by signing below and returning a fully executed original to the School of Medicine at the address above.

______Insert here Affil. Hosp Administrator Name Insert here Affil. Hosp. Program Director Name Chief Executive Officer or Chief of Teaching Service Insert here Hospital Name Insert here Hospital Name

Revised 1/15 ACGME PLA Requirements

The PLA should:

I.B.1.a) identify the faculty who will assume both educational and supervisory responsibilities for residents;

I.B.1.b) specify their responsibilities for teaching, supervision, and formal evaluation of residents, as specified later in this document;

I.B.1.c) specify the duration and content of the education experience; and,

I.B.1.d) state the policies and procedures that will govern resident education during the assignment.

CURRENT AFFILIATION AGREEMENTS

INSTI INSTITUTION DATE OF AGREEMENT Salt Lake Regional Medical Center July 1, 2014-June 30, 2019 IMC & LDS Hospital (IHC) July 1, 2014-June 30, 2019 Primary Children’s Medical Center (IHC) July 1, 2014-June 30, 2019 Shriner’s Hospital July 1, 2014-June 30, 2019 University of Utah Hospitals and Clinics July 1, 2014-June 30, 2019 A.R.U.P The Orthopaedic Center Huntsman Cancer Institute Huntsman Cancer Hospital University of Utah Clinics (community based) University of Utah Neuropsychiatric Institute (UUNI) July 1, 2014-June 30, 2019 Veteran’s Affairs Medical Center-Salt Lake City July 1, 2014-June 30, 2019

CURRENT HOSPITAL ADMINISTRATORS

INSTITUTION ADMINISTRATOR

Salt Lake Regional Medical Center Dale Johns, CEO LDS Hospital & IMC (IHC) Larry Hancock, VP Primary Children’s Medical Center (IHC) Katy Welkie, VP, CEO Shriner’s Hospital (use Shriner’s Template) Ralph W. Semb, President University of Utah Medical Center David Entwistle, CEO University of Utah Neuropsychiatric Institute Ross VanVranken, Executive Director Veteran’s Affairs Medical Center-Salt Lake City Steven W. Young, FACHE, Director

Amended 7/14