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Department of Anesthesiology

Resident Manual

TABLE OF CONTENTS
Preface
Graduate Medical Education Mission
Residency Program Information
General Description
Lectures and Conferences
Faculty Advisor Program
Meetings with the Program Director
Anesthesiology Faculty Members
Evaluation of Faculty by Residents
Periodic Reporting Obligations of Residents
Evaluation of Residents by Faculty and Others
Criteria for Advancement in Training Level
ACGME General Competencies
Facilities
Libraries
Lockers
Mail and Postings
Employee Health Service
Logistics
Parking
Identification Badges
White Coats
Pagers and the Paging System
Hospital and Laboratory Information Systems
On-Call Duties at Hahnemann University Hospital
Duty Hours and Call Requirements
Resident Call Structure at HUH
General O.R. call
Obstetric Anesthesia call
Late call
Faculty Call Structure
Employment Information
Policies

Last Revised, November, 2009

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PREFACE
This manual contains an introduction for new resident and fellow trainees to the
Department of Anesthesiology at Drexel University College of Medicine, including
several important policies and procedures. Because the Department is dynamic,
information contained in printed versions of this manual becomes outdated quickly. If
you are reading a printed copy of this manual, kindly check the on-line version at the
Departmental website, using the Administrative Resources tab.

Your years of training will go by quickly. You need to acquire a large amount of clinical
expertise and theoretical knowledge in that time. The faculty of the Department will guide
you in obtaining both, and in the proper balance; however, only by taking an active role
in your education, will you succeed in learning both basic and advanced anesthesia
knowledge and skills, and develop the competencies for life-long learning so essential to
your career.

You must set aside adequate time for study from the beginning of your training. Guard it
jealously; use it effectively. Make daily reading a habit as routine as brushing your teeth;
if you read only 1 page every day, you would cover more than 1100 pages by the end of
3 years of training. Now imagine how much you will learn by reading for 2 hours every
day, unless on call. This is the amount you need to cover for success. Start today! Your
faculty advisor can help you devise a reading plan for your 3 years. You cannot fail if you
follow it. Also, utilize resources on the web, particularly the Drexel University Library
website. Review material periodically; repetition enhances memory.

GRADUATE MEDICAL EDUCATION MISSION
Residency education in the Department of Anesthesiology will result in physicians who
are competent consultants in anesthesiology, able to complete the certification process
of the American Board of Anesthesiology (ABA) successfully. This education will meet
the standards of the Accreditation Council for Graduate Medical Education (ACGME)
and specifically address the Anesthesiology Residency Review Committee’s (RRC)
requirements for Residency Education in Anesthesiology published by the ACGME in
the Graduate Medical Education Directory. The Department of Anesthesiology produces
anesthesiologists who are:

1) safe, independent anesthesia providers
2) flexible, effective team members
3) viewed as consultants by their physician peers
4) experienced in the variety of practice settings for consultant anesthesiologists
5) effective communicators
6) versed in economic and ethical issues relevant to anesthesiology
7) life long learners
8) consultants that understand the application of research methods to clinical practice.

Members of the Departmental Clinical Competency Committee
Michael Green, DO Assistant Professor and Chair of the Clinical Competency
Committee
Mian Ahmad, MD Assistant Professor and interim Chair
Jay Horrow, MD, MS Professor, Program Director

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Michelle Murtha, MGA Academic Coordinator, non-voting member
Melissa Brodsky, MD Assistant Professor
Susan Kaplan, MD Associate Clinical Professor
Marcus Zebrower, MD Associate Professor

Members of the Departmental Education Committee
Mian Ahmad, MD Assistant Professor and Chair of the Education Committee
Gary Okum, MD Associate Professor, Clinical Pathway Director for Medical
Students
Joseph Berger, CRNA Student Nurse Anesthetist Education Coordinator
Navneet Grewal, MD Instructor
Michael Green, DO Assistant Professor, Associate Program Director
Jay Horrow, MD, MS Professor, Program Director

The residency program in Anesthesiology at Drexel University College of Medicine is
accredited by the Council on Graduate Medical Education of the American Medical
Association. Residents are supervised by faculty at a maximum ratio of 1:2.

RESIDENCY PROGRAM INFORMATION
GENERAL DESCRIPTION

Preliminary Year
The Department of Anesthesiology in collaboration with Drexel University College of
Medicine’s Departments of Medicine and Surgery offers a preliminary (PGY1) education
in surgery. Preliminary education in Internal Medicine is offered in collaboration with
Mercy Fitzgerald Hospital in Darby, PA. This enables qualified applicants to obtain
medical training in preparation for the three-year educational experience in
anesthesiology.

Clinical Base Year
In the future the Department will offer a Clinical Base Year that forms a 4-year
continuum with the years of Clinical Anesthesia training. More information on the
structure of this continuum will appear here as it becomes available.

Clinical Anesthesia Years 1-3
Following a preliminary or clinical base year or its equivalent, anesthesiology residents
complete three years of clinical anesthesia curriculum as outlined by the American
Board of Anesthesiology (applicants are encouraged to obtain the American Board of
Anesthesiology Booklet of Information, American Board of Anesthesiology, 4101 Lake
Boone Trail, Suite 510, Raleigh, NC 27607-7506).

In the first Clinical Anesthesia Year (CA-1) an initial orientation under the supervision of
faculty members will be followed by a board based introduction to anesthesia patient
care of increasing complexity. The CA-2 year furthers that progression of resident
knowledge and skill with increasing more complex cases and specialty experiences in
critical care, pain management, and in cardiothoracic, neurosurgical, obstetric, and
pediatric anesthesia.

The CA-3 year allows residents to select advanced training experiences, which focus on

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one of two areas. Residents in the Advanced Clinical Track complete a minimum of
six months of advanced anesthesia training. They may spend the remaining six months
in advanced anesthesia training or in one to three selected subspecialty rotations.
Residents may train in one anesthesia subspecialty for at most six months during the
CA-1 through CA-3 years. While all specialty areas are available for CA-3
concentration, particular strengths of the Drexel University College of Medicine
Residency Program currently include cardiothoracic, obstetric, and pediatric anesthesia.
The Clinical Scientist Track consists of clinical training in combination with research
experience. (All residents participate in clinical research beginning in the CA-1 year as
part of clinical research teams formed mid-way through that year and continuing to the
end of the CA-3 year.) Residents interested in pursuing the Clinical Scientist Track must
be enrolled in an ACGME-accredited anesthesiology program and remain active in the
educational component of the program while pursuing research. There are two options
for fulfilling the requirements of this track. Please see your ABA Booklet for more
details.

LECTURES AND CONFERENCES

Residents enjoy a rich and diverse out-of-the-O.R. teaching schedule. Attendance at
teaching functions is mandatory for all residents present at work on a given day. The
teaching curriculum features an integrated structure, so that all teaching components
follow a monthly theme. See the departmental website for a full appreciation of the
Integrated Curriculum.

In the Fall, Winter, and Spring (45 weeks) the program provides 4 hours of conferences
each week: morning Grand Rounds (1 hour), morning text review (1 hour), morning key
word review (½ hour), and a 1.5 hour afternoon conference with weekly rotating themes.

Grand Rounds and afternoon conference continue through the summer. An additional 20
morning conferences, 45-minutes each, over the 1st 6 weeks of training provide basic
information to new residents. Although the 6-week summer orientation lecture series
targets CA-1 residents, all residents are invited and encouraged to attend.

GRAND ROUNDS. Grand Rounds topics cover not only the ABA Content Outline over
the course of 3 years, but also include presentations by Visiting Professors
(approximately 5 per year) on topics relevant to anesthesiology and critical care. The
Department faculty prepare and present the vast majority of these lectures. Arrangement
of topics into monthly themes yields a concentrated effort on specific topics, with
repetition using multiple teaching modalities to suit a variety of learning styles.

KEY WORDS. Morning Key Word Review utilizes a list of phrases supplied by the In-
Training Examination Council. Each phrase corresponds to a question answered
incorrectly by a sizeable number of trainees. Phrases are organized as much as possible
according to monthly topic, and assigned in rotating fashion to residents. At each
session, two or three residents so assigned present briefly (<10 minutes) on the subject.
An assigned faculty moderator assures appropriate coverage of the material.

MORNING FULL-DEPARTMENTAL CONFERENCE. Material varies from week to
week. Each conference occurs once a month.
• Morbidity & Mortality Conference. In classic style, we review cases referred
from both within the department and outside the department for discussion of

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improved practice and best practices. Residents benefit from discussions by all
faculty, CRNAs, residents, and students.
• Case Conference. Another weekly session each month uses a case-based
approach, presented by a resident and discussed by all department personnel. A
case description and relevant reading is distributed well in advance, to facilitate
discussion. Cases typically follow the current topic covered by the Integrated
Curriculum.
• Journal Club. Odd-numbered months use an important evidence-based
medicine article, with a list of question to guide the discussion. All departmental
personnel participate, with emphasis on the elements of evidence-based medicine,
good clinical trial design, and statistical analysis. Everyone receives the article for
discussion at least one week in advance, along with the study sheet containing
questions to guide the discussion. In even-numbered months, two residents each
present the interesting articles appearing in a recent issue of an anesthesia journal
(assigned in advance). All departmental personnel participate in the discussions.

ADDITIONAL MONTHLY CONFERENCES (weekly in mid-afternoon – residents are
relieved from clinical work to attend)
• Text Review. The text review conference series uses one selected text in
anesthesiology as the basis for bi-weekly readings relevant to the monthly teaching
topic. The department Education Committee determines when to supplement
readings in the selected text with additional materials; they select and incorporate
them into the weekly assignments. At each text review conference, a faculty member
leads the residents in a discussion of the reading. Residents MUST come to the
conference having read the assignment and prepared for discussion.
• Q&A. Every month contains one weekly session reviewing multiple choice
questions similar to those that appear on the In-training /Written ABA Examination.
• Simulation Sessions. About six sessions per year focusing on different
aspects of Anesthesiology from very basic in the summer to more advanced latter in
the year. Multi-disciplinary sessions are also incorporated.
• Oral Board Review Sessions. Structured to follow the ABA format for oral
board examination. Done on a monthly basis. Eight residents are examined per
session in two different locations done by a number of rotating faculty. Residents are
given immediate feedback for improvement on presentation skills and medical
knowledge.
• Chair’s Rounds. The Chair chooses the format and content of this session.
Previous sessions have included didactic presentations, Socratic discussions,
review of multiple choice questions, and workshops.

FACULTY ADVISOR PROGRAM

New residents are assigned a faculty advisor for the first six months of training, after
which they may select a new faculty advisor. All residents have an opportunity to select
a different advisor every July. The program provides faculty-resident interaction outside
the classroom and the operating room, in support of training activities, professional
growth, and personal development. It strives to develop an atmosphere of trust and
confidentiality between residents and faculty. The program also provides informal
feedback (see below regarding formal feedback) to faculty on residents’ perceptions of
the training program to help make curriculum and educational activities more effective.

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MEETINGS WITH THE PROGRAM DIRECTOR

Each resident meets with the Program Director every 3 months, at which time the
following are reviewed and discussed:
• Case log
• Evaluations
• Test scores
• Plans for scholarly activity
• Interactions with faculty advisor
• Suggestions for program improvement
For each topic, the discussion focuses on past and current performance and plans for
continuing improvement. The meeting includes time to discuss any additional topics or
areas of concern of the trainee. A written summary of the meeting is agreed and signed
by both the Program Director and the trainee, with copies to the resident’s training folder
and to the resident.

ANESTHESIOLOGY FACULTY SPECIALTY INFORMATION
Our faculty possess a wide range of expertise. Below is a list of faculty members
categorized by areas of specialization. Please use these individuals as resources in
their specific areas.

Airway Management
Mian Ahmad, MD
Alex Zonshayn, MD

Ambulatory Anesthesia
Melissa Brodsky, MD
Bryan Chambers, MD
Jack Shutack, DO

Cardiothoracic Anesthesia
Jack Cohen, MD
Jay Horrow, MD, MS
Nagaraj Lingaraju, MD
Vance Nielsen, MD
Gary Okum, MD
Alex Zonshayn, MD
Michael Green, DO

Critical Care
Navneet Grewal, MD

Neuro Anesthesia
Jerry Levitt, MD

OB Anesthesia

Susan Kaplan, MD
Marcus Zebrower, MD
Parmis Green, DO

Orthopedic Anesthesia

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Mian Ahmad, MD

Melissa Brodsky, MD
Vincent Odenigbo, MD

Pain Management
Jerry Levitt, MD
Dan Nasr, MD
Wes Prokop, MD
Alex Zonshayn, MD

Pediatric Anesthesia
Faculty at St Christopher’s Hospital for Children

Regional Anesthesia
Maria Muñoz-Allen, MD
Jack Cohen, MD

EVALUATION OF FACULTY BY RESIDENTS

At least once a year, residents evaluate the faculty in written, anonymous fashion. The
evaluation includes quantitative scores on a variety of desired faculty behaviors and
qualities; an overall score; and provision of unstructured comments. All faculty see
summary statistics (i.e., de-identified) of the scores for individual questions; each faculty
member sees their personal results. The Program Director or Chariman meets with each
faculty member to discuss their results and suggest improvements where appropriate.
The most recent survey employed a web-based instrument. In addition, residents rate
faculty encountered on each rotation as a part of their evaluation of their monthly
rotations (see evaluation forms).

PERIODIC REPORTING OBLIGATIONS OF RESIDENTS

ACGME WEBSITE. Residents regularly track their clinical cases using a website
specifically designed by the ACGME. These case logs provide details on the total
number of cases performed by anatomic region, by technique, by patient age, and with
additional details for certain subspecialty areas such as ambulatory anesthesia and pain
management. The Program Director expects residents to update their electronic case
logs on the ACGME website monthly or more frequently, and reviews them individually
with each resident at quarterly meetings.

AMERICAN BOARD OF ANESTHESIOLOGY. The ABA requires minimum numbers of
various types of cases (e.g., traumas, intracranial, epidurals) for acceptance into the
examination system of the Board. Most of the needed information derives from the
information entered into the ACGME website. However, residents should keep personal
logs of all cases in order to assure that they can assure adherence with all ABA
requirements by the end of their training.

EVALUATION OF RESIDENTS BY FACULTY

The faculty complete evaluations of each resident’s performance at the end of each
training period, based on the goals and objectives for their level of training, in the
framework of the 6 ACGME competencies. The Program Director reviews these

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evaluations whenever completed, and provides immediate intervention when
appropriate. The Program Director reviews all evaluations for each resident, newly
completed in a 3-month period, at the resident’s quarterly meeting (see below). Should
a resident’s performance not meet predetermined expectations, the Program Director
and faculty advisor devise and implement a remediation plan to build and/or enhance the
needed skills. Residents may not participate in elective or specialty rotations at other
institutions without the necessary cognitive, clinical, and technical skills. Click here to
view evaluation forms for all rotations.

The department implements the Anesthesia Knowledge Test (AKT) during day one of
training of the CA-1 year. Residents take the AKT again upon completion of the first 30
days, 6 months, and 18 months of training. All residents are required to take these
examinations. Test results may initiate mandatory remedial measures for areas of
weakness.

The department also requires residents to take the Anesthesia In-Service Training Exam
every March. Residents who have completed their CA-1 year by June of the same year
must achieve at least a 25-percentile score for the American Medical School Graduates
at their respective level of training (CA-1, CA-2, or CA-3). Failure to achieve this level of
competence may result in denial of 6-month competency by the Departmental Clinical
Competency Committee.

ABA policy requires that the Department certify every six months the level of clinical
competence of each resident. The Department Clinical Competency Committee meets
every 6 months for this purpose. It considers all information regarding a resident in
confirming or denying competence. The committee members have discussed and
agreed that clinical competence depends upon a minimum level of knowledge, as
demonstrated by standardized tests.

EVALUATION OF RESIDENTS BY OTHERS
In selected, appropriate rotations, nursing personnel and/or patients (or their guardians)
also evaluate residents. Click here to view evaluations forms.

CRITERIA FOR ADVANCEMENT IN TRAINING LEVEL
Please also see the Policy section regarding Departmental process. The knowledge,
skills, and performance criteria noted below may or may not appear in the goals and
objectives sections of individual rotations or on the periodic evaluation forms of residents
by faculty. Because they represent important milestones in development as a competent
anesthesiologist, the department expects residents to achieve these milestones or
undergo remediation procedures that may involve prolongation of the training period.
Objectives for 6-month and yearly milestones are keyed to evaluation forms for the
Hahnemann University Hospital General O.R. rotations for those time periods.

End of Second Month

Knowledge:
• Complete assigned readings in Clinical Anesthesiology (Morgan, ed.)
• Score at least 25th percentile on one month Anesthesia Knowledge Test

Skills:
• Maintain an airway in an anesthetized patient with no anatomical airway problems

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• Perform laryngoscopy and oral tracheal intubation in most anesthetized patients
• Perform spinal anesthesia for uncomplicated surgical procedure in healthy patients
• Obtain intravenous access on the majority of patients without assistance

Performance:
• Present ASA Physical Status I or II patients to an attending anesthesiologist in a
concise manner including all important anesthetic factors and problems
• Formulate and present an anesthetic plan for PS I or II patient for routine surgery
• Set up anesthesia machine with full safety check and equipment
• Set up anesthesia monitors
• Anesthetize a PS I or II patient for uncomplicated surgical procedure with close
supervision, but without assistance; includes induction, maintenance, emergence
and transfer to PACU
• Communicate patient status effectively to nursing and surgical personnel
• Pass ACLS

Objectives: End of Six Months

Medical Knowledge:
1. Complete assigned readings in Clinical Anesthesiology (Morgan, ed.)
2. Score at least 25th percentile on 6-month Anesthesia Knowledge Test
3. Apply fundamentals of anesthesia induction agents and volatile anesthetics to patient
care
4. Apply basics of neuromuscular blocking drugs and reversal agents
5. Apply pharmacology of vasoactive drugs
6. Apply scientific basis of monitoring and anesthetic equipment
7. Cite scientific evidence for the value of a pre-operative evaluation

Practice-based Learning:
8. Use occasional quizzes to identify areas for targeted reading
9. Contribute at least one case report to Case conference or Morbidity & Mortality
conference

Patient Care:
10. Perform airway maintenance and intubation without assistance most of the time
11. Place intravenous catheters with minimal assistance
12. Place arterial and central venous catheters with assistance
13. Provide regional anesthesia with supervision, and without assistance

Interpersonal and Communication Skills:
14. Communicate effectively with patients, nurses, surgeons, and support staff
15. Present in a concise, organized fashion at conference
16. Keep legible and accurate pre-, intra- and post-operative notes

Systems based practice:
17. Utilize hospital information systems to acquire patient information
18. Utilize the departmental website for orientation to clinical services, rotation and
residency objectives, and review of didactic material.

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Professionalism:
19. Punctual attendance at departmental conferences.
20. Well-groomed appearance and appropriate dress when interacting with patients,
colleagues, and other health care professionals.
21. Demonstrate respect for patients, families, peers, other health care professionals,
and other hospital workers.

Objectives: End of First Year

Medical Knowledge:
1. Comprehensive understanding of hypnotics, volatile anesthetics, opioids, and
neuromuscular blocking agents
2. Demonstrate advance preparation for all conferences by informed participation
3. Score at least 25th percentile for American Medical Graduates finishing CA-1 year in
the In-Training examination

Practice-Based Learning:
4. Use the internet to obtain additional information on complex medical and/or
anesthetic issues
5. Participate in and demonstrate understanding of departmental process-improvement
initiatives
6. Participate in departmental research team activities

Patient Care:
7. Plan and perform general anesthesia techniques without assistance, with supervision
8. Perform all basic monitoring techniques, including arterial and central venous
pressure monitoring, without assistance
9. Perform spinal and epidural anesthesia in most patients without assistance
10. Perform two other regional anesthetic blocks with supervision

Interpersonal and Communication Skills:
11. Communicate effectively risks and benefits of various anesthetic techniques to a
receptive patient
12. Present a complicated patient in a concise, organized fashion
13. Discuss with other medical professionals additional pre-operative preparation
needed for a patient

Systems based practice:
14. Demonstrate cost consciousness in selection of anesthetic plan
15. Utilize consultation appropriately to optimize patient care

Professionalism
16. Provide high quality care to all patients regardless of their ethnicity, status, gender,
disability, or demeanor
17. Act as a role model to medical students interested in pursuing a career in
anesthesiology

End of Two Years

Medical Knowledge:
1. Demonstrate advance preparation for all conferences by informed participation

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2. Complete assigned readings in sub-specialty texts
3. Demonstrate familiarity with content of major anesthesiology journals, i.e.,
Anesthesiology and Anesthesia and Analgesia
4. Score at least 25th percentile on the AKT-18 and also for American Medical
Graduates finishing CA-2 year in the In-Training examination
5. Explain physiology and anesthesia issues relevant to subspecialty areas of OB,
Neuroanesthesia, Pediatric anesthesia, Cardiothoracic, Pain Management, and
Critical Care

Practice-Based Learning:
6. Participate in research team activities
7. Use a case-based paradigm to guide readings in sub-specialty texts

Patient Care:
8. Perform all general anesthesia and monitoring techniques without assistance
9. Perform spinal, epidural and major nerve blocks with success most of the time
10. Perform technical procedures in pediatrics (i.e. IV insertion, caudal, regional blocks)
11. Manage ICU patients with attending assistance
12. Demonstrate ability to function appropriately in emergent situations

Interpersonal / Communication Skills:
13. Actively teach medical students in the operating room and Maternal Care Unit
14. Present effectively at resident and subspecialty conferences

Systems Based Practice:
15. Use experience in critical care to modify intra-operative anesthetic choices for
optimal patient care
16. Partner with consultants to avoid inappropriate medical tests in critical care and pre-
operative preparation

Professionalism:
17. Hone bedside manner to decrease peri-operative anxiety of patients and families
18. Treat colleagues and helpers with respect

End of Three Years

Medical Knowledge:
1. Demonstrate comprehensive knowledge of anesthesiology via Socratic dialog and at
Mock Oral examinations
2. Explain selection of basic statistical tests for different types of data
3. Provide rationale for selection of any given anesthetic drug or technique

Practice-Based Learning:
4. Critically analyze studies in the anesthesia literature using evidence-based medicine
techniques
5. Complete a team-based anesthesia research project.

Patient Care:
6. Successfully supervise the anesthesia care team for most patients / procedures
7. Provide anesthesia care in emergency cases with poise and confidence

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Systems-Based Practice
8. Participate in and explain the rationale, methods, results, and positive impact of a
departmental process improvement initiative
9. Compare any two anesthetic plans on a cost-effective basis

Interpersonal and Communication Skills:
10. Effectively teach medical students fundamentals of anesthesia
11. Explain and defend publicly the methodology and results of a completed anesthesia
research project

Professionalism:
12. Master the ABA qualities and attributes of a consultant in anesthesia
13. Be viewed as a respected anesthesiology consultant by physicians in other
departments

ACGME GENERAL COMPETENCIES

The residency program must require that its residents obtain competence in the six
areas listed below to the level expected of a new practitioner. Programs must define the
specific knowledge, skills, behaviors, and attitudes required and provide educational
experiences as needed in order for their residents to demonstrate the following:
1. Patient care that is compassionate, appropriate, and effective for the treatment of
health problems and the promotion of health.
2. Medical knowledge about established and evolving biomedical, clinical, and
cognate (eg, epidemiological and social-behavioral) sciences and the application
of this knowledge to patient care.
3. Practice-based learning and improvement that involves investigation and
evaluation of their own patient care, appraisal and assimilation of scientific
evidence, and improvements in patient care.
4. Interpersonal and communication skills that result in effective information
exchange and collaboration with patients, their families, and other health
professionals.
5. Professionalism, as manifested through a commitment to carrying out
professional responsibilities, adherence to ethical principles, and sensitivity to a
diverse patient population.
6. Systems-based practice, as manifested by actions that demonstrate an
awareness of and responsiveness to the larger context and system of health care
and the ability to effectively call on system resources to provide care that is of
optimal value.

General Competencies
At its February 1999 meeting, the ACGME endorsed general competencies for
residents in the areas of:

patient care,
medical knowledge,

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practice-based learning and improvement, and
interpersonal and communication skills,
professionalism,
systems-based practice.

Identification of general competencies is the first step in a long-term effort designed to
emphasize educational outcome assessment in residency programs and in the
accreditation process. During the next several years, the ACGME’s Residency Review
and Institutional Review Committees will incorporate the general competencies into
their Requirements. The following statements will be used as a basis for future
Requirements language. If you have any questions, comments and other requests for
assistance, please address them to outcomes@acgme.org.

ACGME GENERAL COMPETENCIES Vers. 1.3
(9.28.99)

The residency program must require its residents to develop the competencies in the 6
areas below to the level expected of a new practitioner. Toward this end, programs
must define the specific knowledge, skills, and attitudes required and provide
educational experiences as needed in order for their residents to demonstrate the
competencies.

PATIENT CARE

Residents must be able to provide patient care that is compassionate, appropriate, and
effective for the treatment of health problems and the promotion of health. Residents
are expected to:

• communicate effectively and demonstrate caring and respectful behaviors when
interacting with patients and their families
• gather essential and accurate information about their patients
• make informed decisions about diagnostic and therapeutic interventions based
on patient information and preferences, up-to-date scientific evidence, and
clinical judgment
• develop and carry out patient management plans
• counsel and educate patients and their families
• use information technology to support patient care decisions and patient
education
• perform competently all medical and invasive procedures considered essential
for the area of practice
• provide health care services aimed at preventing health problems or maintaining
health
• work with health care professionals, including those from other disciplines, to
provide patient-focused care

MEDICAL KNOWLEDGE

Residents must demonstrate knowledge about established and evolving biomedical,

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clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the
application of this knowledge to patient care. Residents are expected to:

• demonstrate an investigatory and analytic thinking approach to clinical
situations
• know and apply the basic and clinically supportive sciences which are
appropriate to their discipline

PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents must be able to investigate and evaluate their patient care practices,
appraise and assimilate scientific evidence, and improve their patient care practices.
Residents are expected to:

• analyze practice experience and perform practice-based improvement activities
using a systematic methodology
• locate, appraise, and assimilate evidence from scientific studies related to their
patients’ health problems
• obtain and use information about their own population of patients and the larger
population from which their patients are drawn
• apply knowledge of study designs and statistical methods to the appraisal of
clinical studies and other information on diagnostic and therapeutic
effectiveness
• use information technology to manage information, access on-line medical
information; and support their own education
• facilitate the learning of students and other health care professionals

INTERPERSONAL AND COMMUNICATION SKILLS

Residents must be able to demonstrate interpersonal and communication skills that
result in effective information exchange and teaming with patients, their patients
families, and professional associates. Residents are expected to:

• create and sustain a therapeutic and ethically sound relationship with patients
• use effective listening skills and elicit and provide information using effective
nonverbal, explanatory, questioning, and writing skills
• work effectively with others as a member or leader of a health care team or
other professional group

PROFESSIONALISM

Residents must demonstrate a commitment to carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to a diverse patient population.
Residents are expected to:

• demonstrate respect, compassion, and integrity; a responsiveness to the needs
of patients and society that supercedes self-interest; accountability to patients,
society, and the profession; and a commitment to excellence and on-going

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professional development
• demonstrate a commitment to ethical principles pertaining to provision or
withholding of clinical care, confidentiality of patient information, informed
consent, and business practices
• demonstrate sensitivity and responsiveness to patients’ culture, age, gender,
and disabilities

SYSTEMS-BASED PRACTICE

Residents must demonstrate an awareness of and responsiveness to the larger context
and system of health care and the ability to effectively call on system resources to
provide care that is of optimal value. Residents are expected to:

• understand how their patient care and other professional practices affect other
health care professionals, the health care organization, and the larger society
and how these elements of the system affect their own practice
• know how types of medical practice and delivery systems differ from one
another, including methods of controlling health care costs and allocating
resources
• practice cost-effective health care and resource allocation that does not
compromise quality of care
• advocate for quality patient care and assist patients in dealing with system
complexities

• know how to partner with health care managers and health care providers to
assess, coordinate, and improve health care and know how these activities can
affect system performance

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FACILITIES
LIBRARIES
Each training site features a library containing anesthesiology texts relevant to the
training needs of residents at that site. Trainees have access to those texts at all times
during their duty hours. Each site also provides trainee access to electronic resources,
including texts, journals, and literature searches.

The dedicated Anesthesiology Classroom at Hahnemann University Hospital (7322 New
College Building) contains relevant, comprehensive texts and journal issues in
anesthesiology and closely related fields, several computers with broadband internet
access and printers, and classroom materials. All trainees have access to the facility at
any time. Journals published since 1995 are specifically NOT kept because they are
available on-line. Anyone removing material from the room must so inform the
department academic coordinator, so that it may be tracked and returned. Copying
equipment, available at all times to all trainees, resides in the departmental offices in the
adjacent corridor.

The Obstetric anesthesia workroom, located in the Maternal Health Unit of Hahnemann
University Hospital, contains the latest print edition of a reference obstetric anesthesia
text, and broadband web access via a dedicated computer.

Each trainee, via their Drexel University identification number, may access the
DrexelMed Library resources from any web-access portal, world-wide. Resources
include electronic texts for all major medical disciplines and access to most medical
journals. Examples of information available in this fashion include the latest editions of:
• Miller’s Anesthesia text
• Clinical Anesthesiology (Morgan, Mikhail, Murray, eds.)
• Goodman & Gilman’s The Pharmacological Basis of Therapeutics
as well as dozens of journals in anesthesiology, and hundreds beyond it.

A full-resource medical library on site at Drexel University College of Medicine (2 nd Floor,
New College Building) provides full reference materials, an extensive book and journal
collection, copying and scanning facilities, study and conference rooms, a computer
training room, and organized instruction in electronic literature searches.

LOCKERS
Each of the department’s residents and fellows receives a locker at the base facility in
Hahnemann University Hospital, and secure gender-appropriate changing facilities,
when needed, at other sites.

MAIL AND POSTINGS
Every trainee receives an electronic mail (e-mail) account on the drexelmed website,
accessed via the URL https://webmail.drexelmed.edu. Most communications occur
electronically. Residents should check their departmental e-mail account at least once
each day during the workweek and at least once each weekend.

In addition, each resident or fellow receives surface mail and miscellaneous
communications via an individual mailbox in the department offices, at 7502 New
College Building. Trainees should check the mailbox daily when on site, weekly when on

16
nearby rotations, and empty it completely every month or more frequently.

A board immediately outside the Anesthesia Classroom/Library (7322 NCB) posts
important departmental teaching schedules and visual summaries of recent
departmental research efforts. Another board outside the departmental offices contains
additional schedules and information of interest to all department members, viz., faculty,
CRNAs, trainees, and support staff. A third board near the mailboxes contains
communication and other information. The alert trainee will scan these boards daily
when on site, to keep informed of valuable opportunities.

EMPLOYEE HEALTH SERVICE
Health Care services are available through the Hospital’s ER care, which is located on
the first floor of the North Tower Building. Follow-up care, counseling for needle-stick
incidents, and immunizations are handled by Student Employee Health Services (ext.
7820).

LOGISTICS
PARKING
Free parking is a privilege. The GME office provides free parking for those residents and
fellows who provide evidence of a valid driver’s license and automobile registration.
Current regulations require parking at or above level 7 of the Wood Street Garage;
random verification identifies violators. Frequent violators lose parking privileges.

I.D. BADGES
Identification badges prepared by the Security Department must be worn at all times
while in the hospital. Restricted access to select patient care areas, including the
Maternal Care Unit and Intensive Care Units, requires swiping this badge. Please attach
the Hospital’s mission statement to your ID badge.

WHITE COATS
The GME office provides three white coats to each new resident and 1 coat per year
after that if needed. Each trainee is responsible for laundering their white coats and for
wearing a clean coat. Trainees may not wear green scrub suits outside the surgical or
obstetric care areas without covering them with a white coat. TRAINEES MAY NOT
ENTER OR LEAVE THE HOSPITAL WEARING A SCRUB SUIT. Removal of scrub suits
from the hospital constitutes theft.

PAGERS AND THE PAGING SYSTEM AT HAHNEMANN UNIVERSITY HOSPITAL
• Each resident receives a personal pager for use throughout the training period.
(In addition, residents may carry fixed-ID pagers when on duty, and for responding to
trauma events or pain therapy issues.)
• Residents are expected to be available by pager from 6:00 AM until 7:00 PM, or
until dismissed, if dismissal is after 7PM.
• If a pager is broken or left at home, the attending running the schedule, the
Departmental receptionist, and the Academic Coordinator must be informed at the
start of the day.
• Trainees may exchange a depleted battery for a new one in the 8th floor
workroom.
• Any member of the department who misplaces or loses his/her pager must

17
reimburse the department for its replacement.

To Page from inside HUH / DUCOM:
1. Dial 53 and follow the verbal directions, which are:
2. Enter the 5-digit ID # of the person you want to page, followed by the # sign
3. Enter your call back extension followed by the pound (#) sign
4. Hang up your telephone

To Page from outside the hospital, dial 215-762-PAGE (7243) and follow the verbal
directions (same as above). You may also access the page operator directly at 215-762-
7000.

HOSPITAL INFORMATION AND LABORATORY INFORMATION SYSTEMS
Computer systems are available for accessing up-to-the-minute patient location and
laboratory results. All medication and other patient orders are written through the
computer system. You will receive instruction on the use of these systems.

ON CALL DUTIES AT HAHNEMANN UNIVERSITY HOSPITAL
DUTY HOURS/CALL REQUIREMENTS
Each resident typically begins the day at 6:30 AM by setting up the assigned operating
room. Anesthesiology residents take both overnight and “late” calls in rotation, with the
number of calls varying somewhat from month to month. Trainees on call in-house for 24
hours receive the next 24 hours free of obligations.

The program adheres strictly to all ACGME regulations regarding:
• Hours on duty per week (<80, when averaged over a 4-week period)
• Days per week assigned overnight call (no more than 2.5 per week, averaged
over 4 weeks)
• Maximum number of continuous hours worked (no more than 30 hours)
• 24-hour periods completely free from all educational and clinical responsibilities
(at least 4 over a 4 week period; exclusive of reading at home)
• Time off between duty shifts (at least 10 hours)
• If released from work between 8:30 – 10:30 pm report time for the following
morning is at 8:30 am to ensure at least 10 hours off.
• If released from work after 10:30 pm then the resident is excused from clinical
duty the following day.

Residents must report to the Program Director any instance or request that does not
conform to ACGME specifications.

RESIDENT CALL STRUCTURE AT HAHNEMANN UNIVERSITY HOSPITAL
The attending faculty anesthesiologist in house (1st call) holds complete privilege and
responsibility for managing the call team. This person may assign, re-assign, or
otherwise distribute clinical responsibilities and assignments to residents, CRNAs, and
faculty serving other call duties (2nd call, 3rd call, etc.).

It is best to follow the 1st call faculty directives at all times; discussion regarding
controversial decisions may follow at a later time with the departmental leadership.

18
Engage the Clinical Service Chief immediately, however, should a serious ethical
question arise regarding loss of life, limb, or sight.

Sleeping rooms are located on the 10th & 12th floors of the South Tower at HU. Please
keep them clean and in good condition.

The Chief Residents create and manage the on-call schedule. Changing the on-call
assignments after the schedule is published requires notification of multiple offices within
the department and the hospital. For this reason, the department utilizes a clear, written
record of call changes. Click here for the form (.pdf version).

GENERAL OR CALL (HUH pager 42141)
1. Emergency surgical cases and “STAT” pages.
2. Carries the code pager and may carry the trauma pager.
3. Completes late cases and emergencies; helps in OB as needed.
4. Coordinates changes in anesthesia orders dictated by changes in the OR schedule.
5. Performs pre-anesthetic evaluation on cases added to the schedule.
6. Notifies the anesthesiologist on-call of any emergency case.
7. Reports to the Anesthesiologist running the schedule at the end of the call period.

OB CALL (HUH pager 41755)
1. Available in-house for emergency cases and “STAT” pages.
2. Carries the OB pager and may carry the pain pager.
3. Covers OB cases; assists with late cases and emergencies as needed.
4. Assists with changes in anesthesia orders dictated by changes in the OR schedule.
5. Performs pre-anesthetic evaluation on cases added to the schedule.
6. Notifies the anesthesiologist on-call of all C-sections and new labor analgesia cases.
7. Reports to the anesthesiologist running the schedule at the end of the call period.

LATE-CALL
1. Stay until released by 1st call faculty anesthesiologist.
2. Perform pre-anesthetic evaluation on cases added to the schedule
3. Complete late cases and emergencies; helps in OB as needed.
4. Available by pager to return to the hospital to help with emergencies.

FACULTY CALL STRUCTURE
The 1st call faculty anesthesiologist remains in house and takes responsibility for
managing the entire call team. The 2nd call faculty anesthesiologist remains in the
hospital until relieved by the 1st call faculty anesthesiologist, and may return at any time
to assist the call team.

On weekdays, 3rd and 4th call faculty anesthesiologists remain in house to assist in
clinical duties until relieved by the 1st call faculty anesthesiologist.

EMPLOYMENT INFORMATION
CERTIFICATE OF SERVICE
At the end of the training period, the hospital Graduate Medical Education office issues a
certificate of service to each trainee demonstrating satisfactory performance during the

19
period of appointment.

LICENSURE
All physicians-in-training must obtain and maintain an active Pennsylvania State Board
of Medicine Training License. The Pennsylvania State Board of Medical Education and
Licensure requires all physicians-in-training at the PGY-3 and higher levels or training be
licensed in the Commonwealth of Pennsylvania (in addition to having an active Medical
Training License).

CONTRACTS
Contracts are signed and renewed each July 1st. For those starting midyear, contracts
expire June 30th.

MALPRACTICE INSURANCE
Residents and Fellows in the Department of Anesthesiology are covered through
Hahnemann University Hospital’s malpractice liability insurance.

POLICIES
SUBSTANCE ABUSE POLICY

Please consult your Hahnemann University Hospital Resident Manual for the details of
this hospital policy. Our department also has a substance abuse policy that addresses
concerns of anesthesiologists specifically. On orientation day and at least once each
year, residents view the “Wearing Masks” video presentation. Additional educational
sessions occur each year. The department Wellness Committee oversees these
activities and the substance abuse policy. We treat substance abuse with the utmost
seriousness. You should always feel free to approach your faculty advisor, Program
Director, or Chair with any concerns you may have about yourself or any other
healthcare provider. Confidential help is readily available.

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/05 POLICY AND PROCEDURE
FOR
Review: 03/07 DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: SUBSTANCE ABUSE POLICY

POLICY:

The Department of Anesthesiology abides in full by the policies of the Graduate Medical
Education Office of Hahnemann University Hospital and those of the Hospital with respect to
controlled substances and other drugs of abuse. In addition, the department strives to detect
substance abuse early, and to direct expeditiously any impaired caregivers to treatment.
The hospital policy prohibits the selling, purchasing, dispensing, manufacturing, distributing,
diverting, stealing, using, possessing and/or being under the influence of non-medically indicated

20
prescription or non-prescription drugs or illegal substances, and/or alcohol on hospital premises,
on breaks, on lunch or while conducting hospital business off premises. Further, the hospital
policy encourages employees with substance abuse problems to voluntarily seek treatment.

PURPOSES

To identify department members who are impaired by use of drugs or alcohol.
To direct any impaired department members to rehabilitative treatment for substance abuse.
To maintain quality patient care, a safe working environment, and the health of department
members.

DEFINITION OF TERMS

Drug: any legal or illegal substance (including over-the-counter medication, prescribed
medication, alcoholic beverages, un-prescribed controlled substances, or any other substances)
which potentially affects one’s ability to perform duties or which potentially affects the safety
and/or well-being of patients, employees, or others.
Substance Abuse: the use or misuse of any drug or alcohol in a manner which may reduce
effectiveness or pose an unsafe condition in the work environment.
Wellness Committee: a group composed of at least one member from faculty, nurse anesthesia,
and residents, not to exceed 7 named members, charged with designing and implementing
strategies for maintaining the health and vigor of departmental members. The chair of the
department serves as an ex officio member of the Wellness Committee and appoints all its
members.

PROCEDURES

1. Detection of impaired caregivers.
• Every member of the department has a responsibility to know the signs of impairment, as
taught at departmental conferences and in videos and publications of the American Society of
Anesthesiologists. The department will provide educational sessions to transmit, reinforce, and
assess knowledge of department members in this regard (see item 5 below). The signs include, but
are not limited to, the following:
i. absenteeism/lateness
ii. always wearing long sleeves or cover-gowns
iii. arriving earlier than others in the morning
iv. volunteering for additional work that provides access to controlled substances
v. noted change in interaction with staff or patients
vi. impairment in job performance
vii. unaccounted drugs missing from hospital stock
viii. indications of inappropriate medication dosing
ix. lethargy, slurred or incoherent speech, or speech which differs from the usual
x. unusual odor on breath
xi. departures from usual behavior
xii. new errors in judgment that jeopardize patient care
xiii. on-the-job accidents
xiv. lack of manual dexterity or unusual trembling
xv. lack of coordination in body movement
xvi. inappropriate response to stimulus
xvii. verbal abuse and boisterous behavior toward others
xviii. threats of physical harm toward self or others
xix. emotional instability and/or hostility
xx. sudden, unprecedented change in mood
xxi. drastic change in dress or appearance.

21
• Department members who suspect another department member, at any position or rank,
of impairment should NOT approach that individual immediately, but rather contact one of the
following individuals immediately:
i. The chair of the department Wellness Committee
ii. Any member of the department Wellness Committee
iii. The clinical service chief of the department
iv. The chair of the department
v. The program director or vice chair of the department
• Any one of the individuals listed above may request an alleged impaired department
member to submit to a witnessed interview for purposes of identifying an alleged impairment.
This action originates from a report of signs of impairment. The interview may result in a request
for urine, blood, or hair sample for subsequent analysis.
• The department Wellness Committee will discuss and implement, if they deem
appropriate, a mechanism by which department members may privately record their legal use of
prescription medications, in order to pre-document this legal use in the event of a subsequent
request for urine, blood, or hair sampling.
2. Responsibilities of Department Members. Please refer to the hospital substance abuse policy
regarding hospital employees’ and supervisors’ responsibilities, all of which apply. The policy covers
requested medical examination, release from duty, disciplinary action, leave of absence, and more.
3. Referral for treatment. The department will strongly advise any impaired member to enter a
treatment program. Impaired caregivers will be referred to the Physicians’ Health Programs of the
Pennsylvania Medical Society for placement. Another equally capable program may be substituted.
4. Return to Work. The department views every impaired physician individually. Some should never
return to anesthesiology, some are fit to do so, and some require additional therapy before a trial period
of return to work. The Wellness Committee, in collaboration with an impaired department member’s
treating physicians, and other engaged parties, if applicable, such as the Graduate Medical Education
office, will determine whether or not a particular individual will be recommended to Human Resources
for return to work.
5. Education Efforts. The Wellness Committee will provide educational sessions for departmental
members at least twice each year, covering scientific and social aspects of addiction, including
detection of impaired physicians, departmental policy, and hospital policy.

VACATION / MEETING POLICY

Please request vacation or time off in writing on the appropriate “Request for Time Off”
form, available in a mailbox slot in the residents’ mailboxes section in the main
anesthesiology mailroom. All vacation requests are handled as outlined in the
Vacation Policy in this manual. Vacations are not approved without the appropriate
signatures.

The American Board of Anesthesiology (ABA) allows a maximum absence of 20 working
days per year, including vacation and all illness, whether unforeseen or known.
Absences, for any reason, beyond those permitted by the ABA, will prolong your training.
Training prolonged by even one day beyond September 30th will, under current ABA
criteria, postpone eligibility for the written examination until the following August. In
addition, the ABA permits up to 5 days each year for attendance at a scientific meeting.
However, only a few trainees will earn this opportunity; awarding time in this category
rests with the Program Director.

Vacation is not appropriate during the first two weeks of the Pediatric Anesthesia or the
PACU rotation, or while on STICU unless otherwise approved.

22
Especially in the CA-2 year, residents are strongly encouraged to distribute their
vacation time amongst rotations by taking at least one week of vacation while serving at
an affiliate institution.

Senior residents should note that time spent interviewing for fellowship or jobs comes
from the vacation time allowance. Dedication to patient care dictates a limit on the
number of trainees taking vacation at any one time. Expect popular times to fill early.
The department will honor family emergencies if appropriately documented; however,
possession of airplane tickets does not justify exceptional treatment. Terminal vacation
is generally not granted.

REPORTING YOURSELF AS SICK

Sick time is granted according to hospital personnel policy (also see above regarding
ABA maximum). If coming to work with a particular medical condition would endanger
you or your patients, you should report yourself as sick. ANY OTHER BASIS FOR
REPORTING YOURSELF AS SICK VIOLATES PROFESSIONAL ETHICS AND MAY
IMPACT POORLY ON YOUR EVALUATIONS. In selected cases, the Program Director
may request independent verification of illness or other reasons for not reporting to work.

Our patients depend on us every day. When we cannot work, our colleagues bear the
burden to lessen the impact on patient care. Early notification allows time to adjust
schedules or obtain additional personnel. Please make every effort to inform the
department as soon as you realize you cannot report to work, as follows:
• Prolonged absence (e.g., parturition, elective surgery): schedule a meeting in
advance via the Academic Coordinator to discuss plans with the Program Director
• Illness developing before 3PM: inform the anesthesiologist running the schedule
• Illness developing between 3 and 11PM: inform the 1st call faculty
anesthesiologist
• All non-prolonged absences: leave a message BEFORE 6AM each day as
follows:
o 215-762-6239. Provide name, date, your illness, and callback telephone
number; call only for all rotations at Hahnemann University Hospital.
o 215-762-7922. Provide the same information; make this call regardless of
your rotation assignment (SCHC, Abington included !).
• DO NOT CALL THE OPERATING ROOM DESK OR THE PACU.

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/05 POLICY AND PROCEDURE
FOR
Review: 03/07 DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: DUTY HOURS AND FATIGUE

23
POLICY:

The Department of Anesthesiology abides in full by the policies of the Graduate Medical
Education Office of Hahnemann University Hospital and institutes additional measures, if needed,
to support and protect residents in the Anesthesiology Training Program and their patients from
the adverse effects of prolonged resident duty hours and fatigue.

PROCEDURES:

1. The Department and all residents in the Anesthesiology Residency Training
Program shall abide by the policy and procedures set forth in GME Policy 19, entitled “Work
hours, on-call, and on-call rooms.”

2. When working at Hahnemann University Hospital, residents shall record the time
each day when they are relieved of duty in the log book in the Anesthesiology Work Room
(8th floor, North Tower). Residents shall respond promptly to departmental staff requests to
clarify, correct, or explain entries in the log book that are inconsistent with on call or other
departmental work schedules.

3. Any changes in the on-call and late duty schedule, regardless of reason, must
not violate any of the following guidelines for duty hour limitations:

• Less than 80 hours per week averaged over 4 weeks;
• At least 1 day in 7 free of patient care responsibilities, averaged over 4 weeks;
• On-call responsibilities less frequently than 1 day in 3, averaged over 4 weeks;
• No more than 24-hours of continuous patient care responsibilities;
• No more than 30-hours of continuous duty;
• 10 hour minimum rest period between duty periods;

4. The Department monitors resident work hours regularly. When an apparent violation of
the work hour policy is detected, the resident, his/her advisor, and Clinical Service Chief of
the department will review the data demonstrating a violation. The advisor will author a
written report from all three participants to the Program Director within one week of the
meeting with the following minimum content:

• the circumstances leading to the apparent violation;
• any impact the event had on subsequent resident performance;
• recommendations to prevent a repeat occurrence.

5. Every year, every resident must complete an at-home study module on resident fatigue,
complete the accompanying 5-question multiple choice quiz, and score at least 80% on that
quiz. Residents scoring less than 80% must re-take the examination until they score at least
80%.

6. Residents who feel drowsy at the conclusion of their duty hours should take a restorative
(30-90 min) nap prior to operating a motor vehicle. Occupation of the call room for this
purpose shall not be considered a violation of GME Policy 19, point 7.

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/07 POLICY AND PROCEDURE
FOR

24
Review: DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: RESIDENT DISMISSAL

POLICY:

The Department of Anesthesiology shall abide by all Hospital GME policies regarding dismissal of
residents from the training program.

PROCEDURES:

1. Per Hospital GME Policy GME 14, the Program Director, with assistance from other
individuals or offices as indicated by GME 14 procedures 2 and 3, will classify the action as
ACADEMIC or EMPLOYMENT.

2. For ACADEMIC ACTIONS, the Program Director will follow the sequence of actions listed in
GME 14 Appendix A.

3. For EMPLOYMENT ACTIONS, the Director in the Office of GME will follow the sequence of
actions listed in GME 14 Appendix B.

4. GME 14 Appendix A item 5(c) permits the Program Director to impose termination (dismissal)
as a disciplinary action. GME 17 details the appeal process available to trainees.

5. The Program Director shall notify the American Board of Anesthesiology and/or the ACGME,
as applicable, of any action involving suspension without pay or termination (dismissal).

REFERENCE: Hahnemann University Hospital Graduate Medical Education Policies GME 14
and GME 17, the policies therein, being incorporated in and considered a part of this
departmental policy.

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/07 POLICY AND PROCEDURE Page 1 of 1
FOR
Review: DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: CHAIN OF RESPONSIBILITY AND SUPERVISION

POLICY:

The Department of Anesthesiology shall abide by all Hospital and University GME policies
governing supervision of residents in training. The chain of responsibility will be determined by
the Program Director, with ratification by the Department Clinical Competency Committee and
Department Education Committee.

PROCEDURES:

1. For all clinical matters, the ultimate supervisors of residents in training shall have clinical

25
privileges as attending physicians in the institution at which clinical work occurs. Therefore, a
resident in training may NEVER take sole responsibility for supervising another trainee.

2. Residents in anesthesia training at all levels may supervise clinical care of a patient by
medical students, student nurse anesthetists, or other personnel in training positions,
including residents in other training programs rotating through the department of
anesthesiology regardless of training level, only with the knowledge and permission of the
attending anesthesiologist responsible for the care of that patient.

3. Senior residents in anesthesia training may supervise clinical care of a patient by junior
residents in anesthesia training only with the knowledge and permission of the attending
anesthesiologist responsible for the care of that patient. Responsibility for care of that patient
ultimately resides with the attending anesthesiologist.

4. Residents in training at any level shall report to the Program Director any instance of potential
or actual compromised patient care resulting from inadequate or inappropriate supervision of
trainees, including themselves. When the Program Director is not available, e.g., nights,
weekends, vacation, etc., report to the attending anesthesiologist in house, who shall report
to the Program Director upon his/her return.

********END OF POLICY*************

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/07 POLICY AND PROCEDURE
FOR
Review: DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: RESIDENT PROMOTION

POLICY:

The Department of Anesthesiology shall promote residents from one level of training to the next
level of training, or withhold such promotion, based on clearly defined criteria and clearly defined
process. Residents shall have access to the criteria and process and be informed of revisions in a
timely manner.

PROCEDURES:

6. The on-line, electronic, resident manual shall list the criteria for promotion of resident trainees
at defined milestones in their training. The Program Coordinator shall maintain the on-line
resident manual current with these criteria.

7. The Department Clinical Competency Committee (“Committee”) shall determine the criteria
for promotion at defined milestones and inform the Program Coordinator whenever these
criteria are revised.

8. The Committee shall meet at appropriate times, based on the milestones the Committee sets,
to determine whether or not each resident meets criteria for promotion.

26
9. The Committee may, at its discretion, set remediation criteria and/or plans to allow a resident
to achieve promotion pending satisfaction of specific criteria. Promotion may be retroactive to
milestone dates or may be delayed until remediation is completed, based on the Committee’s
plan. Whenever possible, remediation plans should try to prevent the need to retract an
action taken with the American Board of Anesthesiology regarding a resident’s clinical
competency status.

10. The Program Director will inform each resident of the decision of the Committee regarding
promotion.

11. Denial of promotion at a milestone constitutes an Academic corrective Action subject to
Policy GME 14 Appendix A. Corrective Action may take the form of written feedback, of a
written corrective action plan, and/or as a formal warning with probation. Corrective Actions
may be grieved according to Policy GME 14 Appendix A part 6.

REFERENCE: Hahnemann University Hospital Graduate Medical Education Policies GME 14,
the policy therein, being incorporated in and considered a part of this departmental policy.

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/03 POLICY AND PROCEDURE
FOR
Revision: 06/06 DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: PRE-OPERATIVE EVALUATIONS

INTRODUCTION AND DEFINITIONS:

Anesthesia care benefits from advanced knowledge of the patient’s co-morbid conditions, a
history and physicial examination, and results of relevant laboratory tests. The patient benefits
from a discussion of the risks and benefits of options for anesthetic care. A pre-operative
interview permits the patient to participate in the choice of anesthesia, and provide informed
consent for that choice and for alternative choices.

POLICY:
1. The responsibility for a pre-operative interview rests with the assigned trainee, even
when post-call or returning from a rotation at another site, or when another caregiver
conducts the interview, even if in accordance with procedure agreed by house staff, faculty,
and CRNAs.
2. Anesthesia faculty exercise their supervisory responsibility for patient care via a
discussion with either the assigned trainee or the caregiver conducting the pre-anesthetic
interview.

PROCEDURE:
1. Whenever possible, the trainee administering anesthesia to a patient will interview the
patient in advance of the procedure on the previous day or before that time.
2. A trainee may ask another anesthesia caregiver (faculty, trainee, or CRNA) to conduct
the pre-anesthesia interview for them. This delegation may occur overtly and individually, or
implicitly by procedures agreed by house staff, CRNAs, and faculty. Regardless, the trainee
must speak with their delegate regarding the patient, and the trainee holds full responsibility
for the quality of the interview.

27
3. The trainee discusses the patient’s status and anesthetic plan with the assigned faculty
anesthesiologist in advance of the procedure, preferably the evening prior.
4. Should a proper pre-operative visit not occur because of lack of attention to this policy,
the faculty anesthesiologist may administer the anesthetic without the trainee’s participation,
i.e., ban the trainee from participation in the case; in this instance, the trainee may be denied
credit for that day of training. Although not a vacation or sick day, the day will not count
towards ABA certification.

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/03 POLICY AND PROCEDURE Page 1 of 1
FOR
Revision: 06/06 DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: POST-OPERATIVE EVALUATIONS

INTRODUCTION AND DEFINITIONS:

Consultant anesthesiologists detect, diagnose, and treat post-operative complications related to
anesthesia. A post-operative visit facilitates these activities.

POLICY:
1. The responsibility for a post-operative interview rests with the trainee who induces
anesthesia, even when another caregiver relieves the trainee prior to the procedure’s
conclusion.
2. Anesthesia faculty exercise their supervisory responsibility for patient care by discussing
the post-anesthetic interview with either the assigned trainee or another caregiver conducting
it.

PROCEDURE:
1. Whenever possible, the trainee administering anesthesia to a patient admitted to the
hospital will interview the patient within 48 hours after the procedure.
a. Patients sent home the day of surgery will be contacted by operating room
personnel.
b. For patients sent home the morning after surgery, before post-operative visits
can occur, assessment of post-operative complications occurs via the PACU discharge
note.
2. A trainee may ask another anesthesia caregiver (faculty, trainee, or CRNA) to conduct
the post-anesthesia interview for them. This delegation may occur overtly and individually, or
implicitly by procedures agreed by house staff, CRNAs, and faculty. Regardless, the trainee
must speak with their delegate regarding the patient, and the trainee holds full responsibility
for the quality of the interview.
3. The caregiver conducting the post-anesthesia interview documents the visit by either:
a. Placing an executed, approved yellow post-operative visit label, in the patient’s
chart; or
b. Writing a note in the Progress Notes section of the patient’s chart.
4. The caregiver conducting the post-operative interview places their signature, their name
printed legibly underneath or beside it, and their pager ID number on their documentation.
5. The trainee discusses the patient’s post-operative status with the faculty anesthesiologist
who supervised them during the conduct of the procedure.
6. The caregiver conducting the post-anesthetic interview will report in writing any

28
anesthetic complications using Departmental morbidity and mortality forms.
7. The caregiver conducting the interview reports any mortality or major morbidity, e.g.,
epidural hematoma, occurring with 24 hours of operation orally to the Chief of Service, or in
his/her absence, to the Chair.

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/07 POLICY AND PROCEDURE
FOR
Review: DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: RESIDENT SELECTION

POLICY:

The Department of Anesthesiology shall abide by all Hospital employment policies and all
Hospital and University GME policies governing selection of residents in the training programs.
The selection process will be determined by the Program Director, with ratification by the
Department Clinical Competency Committee and Department Education Committee.

PROCEDURES:

SECTION A. THE NATIONAL RESIDENT MATCHING PROGRAM

5. The Department shall participate in the National Resident Matching Program (NRMP) each
year. The Program Coordinator shall prepare and file all applications, renewals, invoices,
fees, and correspondences to ensure Departmental participation in the NRMP process.

6. In July of each year, the Program Coordinator, Program Director, and their assistants and
delegates will review and update the content of the Departmental website to ensure that it
presents the Residency Program accurately.

7. The Program Coordinator will update public information regarding the Department’s
Residency training programs at least yearly in a timely fashion to ensure accurate portrayal of
the program to prospective applicants.

8. Beginning in September and occurring no less frequently than every week, the Program
Coordinator will provide a list of applicants to the Program Director and his/her assistants,
including detailed information from each applicant, according to specifications provided by the
Program Director. For example, a spreadsheet containing Name, Date and City of Birth,
Name of Medical School, and United States Medical Licensing Examination scores or
equivalent, might form the requested data for each applicant.

9. The Program Director and his/her assistants shall select from the list of applicants those
individuals invited to appear for an interview. The Program Coordinator shall provide each
prospective interviewee with a list of dates for interview and schedule the candidates for
interview.

10. Each year, the Program Director shall assemble a team of interviewers to conduct interviews
of applicants for a given NRMP cycle. The team shall consist of no less than 4 and no more
than 10 individuals, at least one of whom shall be a resident in good standing in the program.
A subset of this interview team, sized appropriately for the number of candidates appearing,

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shall actively interview on any given interview day.

11. Each interviewer shall provide a rating or ranking of each candidate independent of those
assigned by other interviewers. Details of the process (range of scores, definitions of
categories, rating v. ranking, etc.) shall be determined no later than October 1 of each year.

12. The interview team shall meet as a group to discuss the candidates interviewed for purposes
of identifying candidates the Department will not place on its rank list(s) to the NRMP.

13. The Program Director and his/her assistants shall use the interview scores to create the rank
list(s) for the NRMP; the Program Coordinator will enter the list(s) to the NRMP; the Program
Director will certify the list.

14. The Department will offer an employment contract to the candidates who match to the
program, in accordance with NRMP guidelines, barring extenuating circumstances such as,
but not limited to, undisclosed felony or substance abuse.

SECTION B. SELECTION OF RESIDENTS OUTSIDE THE NRMP PROCESS

1. From time to time, openings in the training programs occur that warrant selection of a
resident at a time not synchronous with the NRMP process or for a level of training other than
entry level. For these circumstances, the department will select residents outside the NRMP
process.

2. The Department may choose to select a subset of residents who enter the training programs
from outside the NRMP process. This choice must be ratified by the Clinical Compentency
Committee.

3. The Program Coordinator will provide a list of applicants for the position(s) to fill outside the
NRMP process, including information specified by the Program Director in fashion similar to
that of item A (4) above. The applicant list derives from unsolicited requests received by the
department, augmented by names provided through professional contacts, word of mouth, or
other means.

4. The Program Director will assemble an interview team of no more than 4 individuals. When
possible, one individual shall be a resident in the training program in good standing. The
interview team shall interview one or more candidates for the open position(s), meet in
conference following the interviews, and provide a ranked list of names for the Program
Director to use in filling the open position(s).

REFERENCE: Hahnemann University Hospital Graduate Medical Education Policy GME 10, the
policies therein, being incorporated in and considered a part of this departmental policy.

********END OF POLICY*************

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/05 POLICY AND PROCEDURE Page 1 of 1
FOR
Revision: 06/06 DREXEL UNIVERSITY COLLEGE OF MEDICINE

30
Subject: AIRWAY MANAGEMENT OF THE TRAUMA PATIENT

INTRODUCTION AND DEFINITIONS:

Trainees in Anesthesiology and those in Emergency Medicine both need experience in managing
the airway of trauma patients. Departmental responsibility depends on the patient’s time of arrival.

POLICY:
1. Level 1 trauma patients receive airway management from attending anesthesiologists,
from CRNAs, from trainees who have completed the clinical continuum in anesthesiology, or
from anesthesiology trainees in their CA3 year of training.
2. Proper patient care requires communication among anesthesia care providers, trauma
attendings and trainees, and emergency room house staff and personnel.

PROCEDURE:
1. The CA3 resident on call or CRNA will respond to pages on the Trauma pager for level-1
trauma, emergency airway management calls, and cardiopulmonary arrest (“code”) calls from
the Emergency Room. When no CRNA or CA3 resident is available to hold the Trauma
pager, an attending anesthesiologist will respond to Trauma pages,
2. Upon arrival in the Emergency Room, the responding anesthesia caregiver will so identify
themselves to the Emergency Medicine (EM) or Trauma Attending in charge.
3. From 1900 to 0700 hrs, the EM senior resident retains primary responsibility for airway
management, under supervision of the EM and/or Trauma Attending. The anesthesia
responder consults and/or assists, as requested by the supervising EM or Trauma Attending.
4. From 0700 to 1900, the anesthesia responder retains primary responsibility for airway
management. The CRNA or CA3 anesthesia resident will establish the airway, as needed.
Should the CRNA or CA3 anesthesia resident require assistance, that person will call the
anesthesia Attending, situation permitting, or stand aside and transfer responsibility for airway
management to the EM or Trauma Attending.

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/05 POLICY AND PROCEDURE Page 1 of 5
FOR
Review: 06/06 DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: CORRECTIVE AND DISCIPLINARY ACTIONS

INTRODUCTION AND DEFINITIONS:

The Department of Anesthesiology follows the policy and procedures of the Hahnemann
University Hospital Graduate Medical Education office. For that reason, that policy appears here.

POLICY:

Hahnemann University Hospital and Drexel University College of Medicine recognize that the
Program Directors, Department Chairs, Hospital administration, and the Directors in the Office of
Graduate Medical Education have authority to take corrective and/or disciplinary action against a
house staff member for academic, behavioral, or clinical care issues as well as issues relating to

31
terms and conditions of employment. This policy establishes the standards and procedures that
will be followed by the Hospital and DUCOM when initiating corrective and disciplinary actions
against a house staff member.

Under this policy, there are two categories of corrective and/or disciplinary action:

(1) Academic Action: A corrective or disciplinary action is considered to be an “Academic
Action” whenever it involves the house staff member’s academic or clinical performance
in the graduate medical education program. Academic Actions are initiated and
processed by DUCOM. Academic Action is determined by the Program Director who
oversees the graduate medical education program. Examples of matters that are
considered Academic Action include, but are not limited to:

• Failure to meet academic or educational requirements and expectations for
house staff members
i. Failure to meet patient care needs appropriately
ii. Not achieving adequate level of medical knowledge
iii. Not behaving in a professional manner
iv. Not communicating with staff, colleagues or patients appropriately
v. Failure to comply with systems based practice
vi. Failure to achieve competency in practice based learning
• Use of inappropriate clinical judgment
• Not meeting research expectations of program
• Not teaching medical students appropriately
• Failure to comply with the program’s administrative requirements such as data
collection, reporting, etc.

(2) Employment Action. A corrective or disciplinary action is considered an “Employment
Action” whenever a house staff member engages in, makes or exhibits acts, statements,
demeanor or professional conduct, either within or outside the Hospital, which is, or is
reasonably likely to be, detrimental to patient safety or to the delivery of quality patient
care, disruptive to the Hospital’s operations or an impairment to the community’s
confidence in the Hospital, and/or is non-compliant with the policies and regulations of
either the Hospital and/or DUCOM’s graduate medical education program. Employment
Actions are initiated and processed by the Hospital. Examples of matters that are
considered Employment Actions include, but are not limited to:

• Disruptive behavior
• Engaging in illegal discrimination or harassment
• Breach of patient confidentiality
• Criminal activity of any sort
• Use of illegal drugs
• Working under the influence of drugs or alcohol
• Reckless endangerment of life, limb or property
• Violent or aggressive behavior
• Theft of hospital materials, supplies or property
• Unprofessional behavior
• Altering medical records

PROCEDURES:

1. All Hospital or DUCOM physicians, faculty, staff and administrators who have concerns about
the academic or employment performance of a house staff member should notify the

32
Program Director or a Director in the Office of Graduate Medical Education (GME Office). The
Program Director and the GME Office will promptly notify each other of concerns that are
received about a house staff member.

2. For any severe incidents (academic, behavioral or clinical) involving a house staff member,
the following individuals or offices will be notified of the incident as well:

a. Program Chair
b. Associate Dean for Graduate Medical Education
c. Director of Human Resources at HUH
d. HUH Legal Department
e. DUCOM General Counsel’s Office

3. The first step in any corrective or disciplinary action is to determine if the problem is an
Academic Action or an Employment Action or both. This determination is made initially by the
Program Director or GME Office Director who initiates. In cases where there is question
about how to classify the action, the Associate Dean for Graduate Medical Education and the
Director of Educational Development and Support will be consulted and determine how the
action should be classified. This determination will dictate which process will be followed.

4. The steps to be utilized for Academic Actions are set forth in Appendix A and for Employment
Actions in Appendix B.

5. Corrective Action. Ordinarily, corrective action is a process intended to inform the house staff
member of deficiencies in academic, behavioral or clinical care performance in order to
provide the house staff member with an opportunity to correct such deficiencies before more
serious disciplinary action is instituted.

a. Single Complaint: Corrective Actions for Academic Actions are determined by
the Program Director and for Employment Actions by a Director in the GME Office.
These informal early interventions should be conducted in private and are designed to
correct and remediate a problem as early as possible. Corrective actions are intended as
an educational experience aimed at improving the house staff member’s performance in
a particular area. All proceedings should be documented and kept in the house staff
member’s permanent department file or GME Office file in accordance with this policy.

b. Multiple Complaints and/or Severe Complaint: A more formal counseling session
should be conducted whenever more than one complaint or a single severe complaint
has been received regarding a house staff member which reflects either a pattern of
unacceptable behavior or action or a severe complaint. The Program Director should
report to the Chair of the Department and review the problem and discuss strategies for
improvement as well as outlining a time period for such improvement. The Office of
Graduate Medical Education should be informed that there is a problem.

c. Acceleration of Disciplinary Process. For multiple complaints or single
complaints of a severe nature, the Program Director or the GME Office may elect to skip
the Corrective Action step and proceed immediately to Disciplinary Action.

d. All proceedings must be documented and kept in the house staff member’s
permanent department file.

6. Disciplinary Action

Disciplinary Action can be imposed when previous Corrective Actions have failed to adequately
remediate deficiencies in academic, behavioral or clinical care performance; when more then one

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Corrective Action has previously been taken against a house staff member; or when a single
severe incident has been reported.

Disciplinary Action may take one or more of four forms:

(a) Written Reprimand: A reprimand will be a written warning to the house staff member
stating that his/her behavior does not meet expectations. This letter will state the
deficiencies for which the house staff member is being reprimanded. It shall further
provide the duration of the reprimand; what, if any, assistance may be made available to
help the house staff member in meeting expectations; detail the mechanism of evaluation
to determine improvement and inform the house staff member of the potential
consequences if expectations are not met. A letter of reprimand should be taken
seriously as an official warning which allows the house staff member an opportunity to
correct behaviors during the period noted. If the behavior is not corrected, the house
staff member’s conduct could ultimately result in his/her suspension or termination.

(b) Suspension without pay: A suspension period without pay may be imposed by the
Program Director or the Director of Educational Development and Support. Time off will
not be credited towards the completion of the residency experience and may result in
temporary suspension of the right to practice medicine in the Commonwealth of
Pennsylvania. This action will become part of the house officer’s permanent record at the
State Licensing Board, an event which must be reported on all future applications and
verifications for training, licensure, or hospital privileges. If at the end of this suspension
designed to resolve the matter, the Director of Educational Development and Support (for
Employment Actions) or the Program Director (for Academic Actions) may extend the
suspension without pay or progress to a termination.

(c) Termination: A termination constitutes that action taken by the Hospital or DUCOM,
through the Program Director (for Academic Actions) or Director of Educational
Development and Support (for Employment Actions), by which the house officer is
entirely and irrevocably relieved of his/her responsibilities within the Hospital and
dismissed from the residency program. After the date of the termination, the house
officer will no longer be a student of the DUCOM program or an employee of the Hospital.
All salary and other employment benefits shall cease immediately on the date of
termination.

(d) Other Penalty or Sanctions: As determined by the Program Director (for Academic
Actions) or GME Office Director (for Employment Actions).

7. The following individuals must be notified of any Disciplinary Action regarding a house staff
member:
a. Program Director
b. Department Chair
c. Director of Educational Development and Support in the Office of Graduate Medical
Education
d. Associate Dean for Graduate Medical Education
e. Director of Hospital Human Resources Department

8. All disciplinary action must be reported to the Graduate Medical Education Committee
(GMEC).

9. Retention of Records: All materials related to a Disciplinary Action and Disciplinary Action
proceedings will remain in the house staff member’s GME Office and department files and
will be reported accordingly where required by the State and when release of information is
granted by the house staff member. All Disciplinary Action obligations must be fulfilled before
the house staff member will receive the official certificate of completion of training.

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APPENDICES: Flow Charts for Corrective and Disciplinary Actions

A. Academic Actions

Sequence: 1. Problem identified by Program Director

2. Corrective Action: Program Director attempts to correct internally by

a. Written feedback to house staff member;
b. Written Corrective Action Plan put into effect;
c. Warning and Departmental Probation: A warning and departmental
probation is a form of Corrective Action and will be in writing to the
house staff member. This letter will state the deficiencies for which
the house staff member has been counseled and given warning. It
shall further state a period of time of probation; what, if any
assistance may be made available to help the house staff member in
meeting expectations; detail the mechanism of evaluation to
determine improvement; and inform the house staff member of the
possible consequences if expectations are not met. A warning letter
should be taken seriously as it allows the house staff member an
opportunity to correct behaviors during the period of probation. If the
behavior is not corrected, the house staff member’s conduct and
behavior could ultimately result in Disciplinary Action with reprimand,
suspension or termination. “Warning and departmental probation”
files are kept in the department only and are not reportable unless
disciplinary action, noted below, is warranted; and/or
d. Other penalty or sanction as determined by the Program Director.

3. If issue is resolved to satisfaction of the Program Director, the matter goes no
farther. If not resolved in the department or repeats, Disciplinary Action may
be taken by the Program Director.

4. Only Disciplinary Action, not Corrective Action, may be appealed by the
house staff member per GME 17. Corrective Action may be grieved by the
house staff member by following the appeal process below.

5. Disciplinary Action at level of Department – Program Director may impose
any of the following:

a. Written reprimand
b. Suspension without pay
c. Termination
d. Other disciplinary penalty or sanction as determined by the Program
Director.

6. Corrective Actions may be grieved by the house staff member to the
Department Chair first and, if not satisfied with the decision, may be further
grieved to the Associate Dean for Graduate Medical Education and then to
the Dean if necessary. The decision of the Dean is final and concludes the
grievance process.

7. Disciplinary Actions may be appealed by the house staff member per the
process outlined in House Staff Manual - Policy and Procedure GME 17.

35
8. The implementation of a Corrective or Disciplinary Action will not be stayed
or halted merely because the action is being grieved or appealed by the
house staff member.

9. All proceedings must be documented and kept in the house staff member’s
file.

B. Employment Actions

Sequence: 1. Problem identified by Hospital personnel

2. Corrective Action:
Hospital attempts to correct internally by Director in the Office of GME
meeting with house staff member to understand problem and give feedback
Written Corrective Action Plan put into effect
Department Program Director and Chair notified
Associate Dean for Graduate Medical Education notified
House staff member may be given written Warning
If issue resolved, goes no farther. If not resolved or house staff member
repeats, Disciplinary Action is required.

2. Disciplinary Action at level of Office of GME – any of the following:

a. Written reprimand;
b. Suspension without pay;
c. Termination;
d. Other disciplinary sanction as determined by a GME Office Director

3. Only Disciplinary Action, not Corrective Action, may be appealed by the
house staff member per process in Fair Treatment Process outlined in the
Hahnemann University Hospital Employee Handbook. House staff members
are encouraged to use the Hospital’s Open Door Policy to discuss any
problems, concerns or disputes regarding Corrective Action.

4. Final recommendation made by the Fair Treatment Committee and sent to
the Hospital CEO.

5. Final decision by the Hospital CEO with a copy to the Associate Dean for
Graduate Medical Education and Dean.

6. End point: If house staff member is not satisfied with final decision by the
Hospital CEO, then house staff member may pursue Final and Binding
Arbitration by the American Arbitration Association using steps as noted in
the Tenet Employee Handbook.

Reference: 2005-6 Hahnemann University Hospital Graduate Medical Education Housestaff Manual

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/05 POLICY AND PROCEDURE Page 1 of 1
FOR

36
Review: 06/06 DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: TEMPORARY ADMINISTRATIVE LEAVE

POLICY:

Both Hahnemann University Hospital and/or Drexel University College of Medicine reserve the
right to temporarily suspend a house staff member from academic or clinical responsibilities in
order to enforce compliance with both the clinical and educational duties of being a house officer
when the presence of the house staff member at the Hospital or DUCOM may pose a threat to
self or others or is appropriate in order to allow an internal investigation into allegations of serious
misconduct against the house staff member pending initiation of Corrective Action or Disciplinary
Action.

PROCEDURES:

The period of Temporary Administrative Leave should normally be no longer than necessary for
the completion of an investigation or until it is determined the house staff member no longer
poses a threat to self or others.

The decision to impose a Temporary Administrative Leave is made by the Program Director for
Academic Actions and by a Director in the GME Office for Employment Actions. In no event may
the period of Temporary Administrative Leave exceed thirty (30) days.

The GME Office shall determine whether the period of Temporary Administrative Leave will be
with or without pay.

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/05 POLICY AND PROCEDURE Page 1 of 1
FOR
Review: 06/06 DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: GRIEVANCES

POLICY:

Hahnemann University Hospital and Drexel University College of Medicine assure an educational
environment in which house staff members may raise and resolve issues or complaints and can
have grievances without fear of intimidation or retaliation applicable to their graduate medical
education programs.

PROCEDURES:

1. Academic Matters. Should a house staff member have a complaint or grievance against the
program or DUCOM concerning an academic or clinical matter, the house staff member shall first
submit a written grievance to his or her Program Director within thirty (30) days of the occurrence

37
of the matter being grieved. If the grievance is not resolved by the Program Director to the
satisfaction of the house staff member within ten (10) days after its submission, then the house
staff member may appeal in writing to the Program Chair. If the grievance is not resolved by the
Program Chair to the house staff member’s satisfaction within ten (10) days after the appeal is
submitted, then the house staff member may appeal in writing to the Associate Dean for
Graduate Medical Education. The Associate Dean for Graduate Medical Education will make a
decision on the appeal within ten (10) days of receipt. The decision of the Associate Dean for
Graduate Medical Education will be the final decision within DUCOM on the grievance.

2. Employment Matters. Non-academic actions of employment, including, but not limited to
salary, benefits, insurance, discrimination and sexual harassment shall be adjudicated through
the Tenet Employee Fair Treatment Process as detailed in the House Staff Employment
Agreement, House Staff Manual and Tenet Employee Handbook. House staff members are
encouraged to use the Hospital’s Open Door Policy to discuss any problems, concerns or
disputes regarding Corrective Action.

3. Confidentiality. Grievance proceedings shall be considered confidential and not disclosed by
the Hospital and DUCOM except to persons with a need to know or to respond to the house staff
member’s disclosure of the proceedings.

DEPARTMENT OF ANESTHESIOLOGY
Original: 05/05 POLICY AND PROCEDURE Page 1 of 2
FOR
Review : 06/06 DREXEL UNIVERSITY COLLEGE OF MEDICINE

Subject: APPEALS OF DISCIPLINARY ACTIONS
AND NON-REAPPOINTMENT

POLICY:

Appeals of Disciplinary Actions imposed by Hahnemann University Hospital or the Drexel
University College of Medicine shall use the procedures set forth in this policy.

PROCEDURES:
1. Appeal of Academic Actions or Non-reappointment Decisions: The following is the
institutional procedure to be used for appeals by a house staff member of Academic
Actions imposed pursuant to GME 14 or for the appeal of a decision to non-renew a
house staff member’s appointment in the program:

a. In order to commence an appeal of an Academic Action or non-reappointment,
the house staff member must submit a signed written request (not e-mail) for an
appeal of the decision to the Department Chair within fifteen (15) business days
from receipt of written notification of the Disciplinary Action or notice of non-
reappointment. The house staff member’s written request must include a full and
detailed explanation of the reason(s) why the decision should be reversed.
b. The appeal shall be submitted to an Ad-Hoc Departmental Hearing Committee
(Ad Hoc Committee). The Ad Hoc Committee will be appointed by the
Department Chair and shall consist of two (2) members of the teaching faculty
from the house staff member’s department, and one (1) senior house staff

38
member from the program. The Committee shall elect a member from the group
to preside at the hearing. A house staff member may challenge the appointment
of a member of the Ad Hoc Committee by proving to the Department Chair that
the member has actual bias or prejudice against the house staff member. If the
Department Chair determines the challenge is merited, he or she shall appoint
another member to serve on the Ad Hoc Committee. However, the mere fact
that an Ad Hoc Committee member has previously worked with, supervised or
evaluated the house staff member shall not prove adequate grounds for removal
of an appointed member.
c. The Committee shall convene the hearing within ten (10) business days of the
house staff member’s written request and shall notify the house staff member in
writing of the date, time and place for the hearing as soon as reasonably
possible, but not less than seventy-two (72) hours in advance of the hearing
unless the house staff member shall waive such requirement in writing.
d. The house staff member and his or her Program Director or designee shall have
the opportunity to be present at the hearing and each shall present such
information or materials (oral or written) as they wish to support their case. Each
party may also request that witnesses be permitted to present information to the
Ad Hoc Committee. Such requests must be made by submitting to the Chair of
the Ad Hoc Committee at least twenty four (24) hours prior to the start of the
hearing a written list of the proposed witnesses and a description of the
information the witnesses are expected to provide. The Ad Hoc Committee shall
rule on such requests and may, on its own initiative, request the attendance of
other persons to give information. However, the Ad Hoc Committee has no
authority to compel the attendance of any witnesses. The Ad Hoc Committee
may limit introduction of documents or information by the parties or witnesses on
grounds of relevancy, repetition or for other good cause. Parties shall be present
at all times during the hearing but are not permitted to directly question each
other or witnesses during the hearing. The Director of Educational Development
and Support will be present to advise the Chair of the Ad Hoc Committee and to
ensure the process is followed. No other representatives for the parties shall be
present during the hearing. Unless the Ad Hoc Committee rules otherwise, each
party must submit all written documents it wishes to present at the hearing to the
Chair of the Ad Hoc Committee at least twenty-four (24) hours prior to the start of
the hearing. Each party shall be permitted to review all materials submitted to
the Ad Hoc Committee prior to and during the hearing. No party shall be
permitted to make a recording or transcription of the hearing. The Ad Hoc
Committee may adjourn a hearing to a later date(s) if it determines such action is
necessary in order to permit a full presentation of information on the appeal.
Any and all procedural matters arising before or during the hearing will be
determined by majority vote of the members of the Ad Hoc Committee.
e. A majority vote of the Ad Hoc Committee shall decide the issue(s) before it. The
Ad Hoc Committee shall render a decision affirming, reversing, or modifying the
action appealed.
f. No party shall be allowed to vote or to participate in the Ad Hoc Committee’s
deliberations.
g. Regardless of the outcome of the hearing, the Ad Hoc Committee will provide the
house staff member and Program Director with a written statement of its decision
and the reason(s) for such decision within ten (10) business days from the date
of the conclusion of the hearing. If written materials are submitted to the Ad Hoc
Committee, such materials shall be appended to the Ad Hoc Committee’s report.
h. The house staff member or Program Director may appeal the Ad Hoc
Committee’s decision to the Graduate Medical Education Committee (GMEC)
within ten (10) business days of receipt of the Ad Hoc Committee’s decision by
written notification to the Associate Dean for GME specifying the reason(s) for
the appeal.

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i. The Associate Dean for Graduate Medical Education or, in his or her absence,
the Chair of the GMEC, will appoint a GMEC Sub-committee (“Sub-committee”)
to be convened to evaluate any such appeal. This Sub-committee shall consist
of two-graduate medical education training Program Directors and a senior
house staff member from programs other than the program involved in the
appeal. The Sub-committee shall elect a member from the group to act as chair.
j. The Sub-committee shall review the findings of the Ad-Hoc Departmental
Hearing Committee and may, at its option, request the house staff member, the
Program Director, and any other persons it deems necessary to appear before
the Sub-Committee or to provide additional written information or documents to
the Sub-committee. The Director of Educational Development and Support will
be present to advise the Chair of the Sub-committee and to ensure the process is
followed. No other representatives of the parties shall be present during any
appearance before the Sub-committee. Any and all procedural matters arising
before or during the review will be determined by majority vote of the members of
the Sub-committee.
k. Upon completing its review, the Sub-committee shall by the majority vote of its
members recommend whether the decision of the Ad Hoc Committee should be
affirmed, reversed, or modified.
l. A written report should be prepared by the Sub-committee chair and submitted to
the GMEC at its next meeting date.
m. The GMEC will review the Sub-committee report and issue its decision in writing
within a reasonable time which will not exceed thirty (30) business days from the
submission of the Sub-Committee report.
n. The opinion and decision of the GMEC will be final.
o. An appeal may be made to the Dean with a briefing by the Associate Dean for
Graduate Medical Education.
2. Appeal of Employment Actions: For Appeals of Disciplinary Actions imposed from
Employment Actions, the house staff member will follow the Tenet Fair Treatment
Process outlined in the Employee Handbook.

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