GMEC Manual Rev 052212 - Greenville Hospital System

GRADUATE MEDICAL EDUCATION COMMITTEE (GMEC) 

Policy Manual 

Reviewed and Amended: September 2009 

Edited: November 2010 

Reviewed and Amended: September 2011

TABLE OF CONTENTS 

I. INSTITUTIONAL ORGANIZATION AND RESPONSIBILITIES ................................................................ 3 

GME Program Overview ................................................................................................................... 4 

GHS Commitment Statement ........................................................................................................... 5 

GHS Policy Compliance .................................................................................................................... 6 

II. INSTITUTIONAL RESPONSIBILITIES FOR RESIDENTS ......................................................................... 7 

Resident Recruitment and Appointment ......................................................................................... 8 

Resident Contracts ........................................................................................................................... 9 

Resident Change of Residency Program ........................................................................................ 10 

Resident Dismissal and Grievance (w/ process) ............................................................................ 11 

Resident Participation in Hospital/OMS Committees and Initiatives ............................................ 13 

Moonlighting .................................................................................................................................. 15 

Duty Hours ..................................................................................................................................... 16 

Resident Duty Hour Compliance Oversight.................................................................................... 17 

House Staff Manual ........................................................................................................................ 19 

Transitions of Care ........................................................................................................................ 24 

Sleep Deprivation and Fatigue ....................................................................................................... 25 

International Electives ................................................................................................................... 26 

III. GRADUATE MEDICAL EDUCATION COMMITTEE (GMEC) ............................................................... 27 

GMEC Role w/ Organization Chart ................................................................................................. 28 

GMEC Responsibilities .................................................................................................................... 32 

DIO Delegation ............................................................................................................................... 34 

Vendor Interactions ....................................................................................................................... 35 

GME Vendor Interactions ............................................................................................................... 36 

Residency Closure/Reduction in Size ............................................................................................. 40 

Disaster and GME ........................................................................................................................... 41 

Program Annual Reports w/ Format .............................................................................................. 42 

GMEC Policy Review ....................................................................................................................... 50 

IV. INTERNAL REVIEW .......................................................................................................................... 51 

Internal Reviews ............................................................................................................................. 52 

2

I. INSTITUTIONAL ORGANIZATION AND RESPONSIBILITIES 

3

GME PROGRAM OVERVIEW 

The Greenville Hospital System (GHS) is a voluntary, community, nonprofit organization owned and operated 

by an independent, self‐perpetuating Board of Trustees. Upon this Board rests the full responsibility for the 

operation of the Hospital, the quality of care rendered, and the relationship with the entire community. 

The Greenville Hospital System is an Accreditation Council for Graduate Medical Education (ACGME) 

accredited Graduate Medical Education (GME) teaching institution. The Greenville Hospital System (GHS) 

Medical Staff accepts responsibility for assuring supervision of all resident educational activities including 

patient care. Through its by‐laws the GHS Medical Staff has delegated this responsibility to Academic Services. 

Academic Services fulfills this responsibility through its full time and volunteer faculty teaching staff. 

Faculty members have the dual obligations of training residents progressively to independence and assuring 

provision of safe patient care. In order to fulfill these obligations all patients admitted to GHS have an 

attending physician who is a member of the Medical Staff. Residents participate in the care of these patients 

with the agreement and at the invitation of the attending physician. It is understood that residents have no 

independent Medical Staff privileges within the Greenville Hospital System. Therefore, a resident may perform 

only those cares and procedures for which the patient’s attending physician has privileges. 

Fundamental to the GME process is the tenant that residents must be supervised in such a manner that allows 

them to assume progressively increasing responsibility and autonomy commensurate with their individual 

levels of education, ability, and expertise. While the resident credentialing process is implicit within the 

program description of resident responsibilities at each year level of training, it is a fact that resident peers 

progress at different rates due to individual abilities and variable experiences determined by timing of 

educational rotations. Consequently, only the attending physician is qualified to determine the capabilities of 

any individual resident at any given time. This requires that the teaching staff on‐call arrangements be 

structured to ensure that appropriate supervision is readily available at all times to residents on duty. 

Accordingly, uncertainty regarding the qualifications of a resident to provide specific care for a patient should 

be addressed to the attending physician or his/her medical staff designee. 

Academic Program descriptions are provided to the residents and are intended to provide an overview of all 

residents’ experiences by year and rotation. All residency programs maintain a departmental manual specific 

to their requirements. This GMEC policy manual defines policies and procedures relative to resident education 

oversight in general. 

4

Institutional Requirements: I.B.2 

Common Program Requirements: I.A 

Graduate Medical Education Institutional Commitment 

Greenville Hospital System recognizes the value of and enthusiastically supports the provisions of medical 

education and, consequently, has included this commitment in the Bylaws of the GHS Board of Trustees under 

Article II, Section 2.6‐1(j) “To provide teaching and instruction programs and schools for nurses, hospital 

technicians, hospital employees, medical students, and physicians during internship and residency.” In accord, 

Greenville Hospital System is committed to providing the necessary educational, financial, and human 

resources support to graduate medical education. Further, Greenville Hospital System is committed to and 

responsible for promoting patient safety and resident well‐being and to providing a supportive educational 

environment. 

Signature on File 

Jerry R. Youkey, M.D. 

Vice President, Medical and Academic Affairs 


Spence M. Taylor, M.D. 

Designated Institutional Official 


Michael C. Riordan 

President and Chief Executive Officer 


Jerry Dempsey 

Chairman, GHS Board of Trustees 

October 21, 2011 

5

GMEC Policy # I‐01‐11 

Institutional Requirements: II.D.4.l | II.D.4.m | II.D.4.n 

Common Program Requirements: N/A 

POLICY TITLE: 

GHS Policy Compliance 

It is the policy of the GHS Graduate Medical Education Committee that all Graduate Medical Education 

programs will adhere to applicable GHS policies; including sexual and other forms of harassment, disabilities 

accommodation, and physician impairment including that due to substance abuse. Applicable GHS policies will 

be highlighted during new resident orientation. 

September 24, 2009 

Date of Initial GMEC Approval 



Graduate Medical Education DIO and 

Chief Academic Officer 


Edward W. Bray III, M.D. 

GMEC Chair and Assistant Dean for 

Graduate Medical Education 


Date of Last GMEC Review 

6

II. INSTITUTIONAL RESPONSIBILITIES FOR RESIDENTS 

7

GMEC Policy # II‐01‐11 

Institutional Requirements: II.A 

Common Program Requirements: III 

POLICY TITLE: 

Resident Recruitment and Appointment 

It is the policy of the GHS Graduate Medical Education Committee that the policy/criteria for acceptance of 

Resident staff at the Greenville Hospital System will be directed as: 

- Criteria for applicant consideration – make proper application through ERAS or universal application 

provided by NRMP, meet criteria as set forth by Essentials of Accredited Residencies and specialty 

boards, complies with application procedures, participates in NRMP, and eligible for licensure in South 

Carolina. It is the policy of Academic Services to employ physician trainees (residents and fellows) 

requiring immigration authorization only under the J‐1 Exchange Visitor Program sponsored by the 

Educational Commission for Foreign Medical Graduates (ECFMG) and permanent visa status. No 

exceptions will be made to this provision except as defined by the Vice President, Medical Services and 

Dean, Academic Services. 

- Criteria for selection – GHS participates in the NRMP program, Selection Committee reviews all 

applications, consideration is given to the applicant’s medical school Dean’s Letter, letters of 

recommendation, grades and class rank, USMLE or ECFMG scores, and recommendations of GHS 

physicians who personally interviewed the applicants. Program Selection Committee reviews the 

applications, develops a rank list in order of preference, and submits a match list to NRMP in 

accordance with the rules and regulations of that organization. Positions available after the Match are 

filled using the same criteria, with appointment being made directly by the program director. 













8


Institutional Requirements: II.D 

Common Program Requirements: 

POLICY TITLE: 

Resident Contracts 

It is the policy of the GHS Graduate Medical Education Committee that residents will be provided a written 

agreement of appointment/contract outlining the terms and conditions of their appointment. The 

agreement/contract will contain and/or reference those institutional policies as required in the ACGME 

Institutional Requirements. No restrictive covenants will be included in any resident or fellow contract. 

Academic promotions and renewal of a resident’s contract will be based upon the performance evaluation 

process of the primary residency program of the resident. Non‐renewal of a contract is an act of termination 

and will be exercised only for unsatisfactory performance. 













9


Institutional Requirements: III.B.7 


POLICY TITLE: 

Resident Change of Residency Program 

It is the policy of the GHS Graduate Medical Education Committee that a resident desiring to change Residency 

Program after commencing his/her residency training must obtain a Change of Residency Form from the office 

of the Designated Institutional Official and follow the applicable rules as detailed in the GHS House Staff 

Manual. 













10


Page 1 

Institutional Requirements: II.D.4(e) 


POLICY TITLE: 

Resident Dismissal and Grievance (w/process) 

It is the policy of the GHS Graduate Medical Education Committee that all resident staff who enter residency 

training programs at GHS should graduate. Non‐renewal of contracts or termination of employment will be 

exercised only for cause. A house staff member may be suspended from duty or terminated from the program 

for cause by the Academic Services Department Chair responsible for the performance of the house officer, or 

by the DIO, Vice President, Medical Services and Dean, Academic Services, or Chief Executive Officer of the 

Greenville Hospital System. Resident Staff are subject to GHS employment policy and procedure standards. 

Due Process 

Non‐renewal of a contract is an act of termination and will be exercised only for unsatisfactory performance. 

Termination of a resident for unsatisfactory performance or for cause will originate with the program involved. 

Each program will have a policy stating acceptable behavior and describe the procedure by which residents are 

evaluated on performance and what corrective actions will be taken when appropriate. When the level of 

performance is determined to warrant termination, a written request will be forwarded to the DIO. The Vice 

President of Medical and Academic Services will then present the findings and recommendations to the 

members of the Academic Services Graduate Medical Education Committee (GMEC) at a called meeting. If a 

majority of the GMEC agrees with the recommendation, the Assistant Dean of Graduate Medical Education will 

notify in writing the resident of his/her termination. 

Appeal Process 

Appeal of this decision by the resident will be in writing to the DIO within ten (10) days of receiving the written 

notice of termination. Such notice will be delivered by registered mail. Upon receipt of an appeal, the DIO will 

appoint a committee consisting of a Professor or Associate Professor from the residency program involved and 

a Professor or Associate Professor from two other residency programs. Within five (5) days of appointment of 

the committee, the committee will meet to review all recorded performances of the resident involved, 

including appropriate personal interviews of the faculty and residents who have been responsible for the 

written evaluations and comments. Upon written request to the DIO, the resident may request that he/she 

and any advocates of his/her position have the opportunity to be heard by the Committee. The Committee will 

determine the extent of involvement in the committee process of any advocate. The minutes of committee 

meetings will be recorded by a court reporter and reflect documentation of the resident’s notification and 

response. 

The Committee will reach a decision within ten (10) days of appointment of the committee. The Committee’s 

majority recommendation will be binding and without recourse. 

11


Page 2 

POLICY TITLE: 

Resident Dismissal and Grievance (w/process) 

If a majority of the committee does agree to termination of the resident, the Assistant Dean of Graduate 

Medical Education will notify the resident of his/her termination. If the majority of the committee does not 

agree to termination of the resident, any recommended course of action or recommended reprimand(s) of the 

resident by the committee will be communicated in writing to the department chairman and program director 

for follow‐through. 

Prior to resident notification, the President & CEO and Chairman of the Board of Trustees will be notified in 

writing of the committee’s final action. The resident will be notified of the committee’s decision in writing 

within five (5) days following the conclusion of the committee meeting. 













12


Institutional Requirements: II.E.2.a 


POLICY TITLE: 

Resident Participation in Hospital/OMS Committees and Initiatives 

It is the policy of the GHS Graduate Medical Education Committee that Residents will be encouraged to be 

membership active on applicable committees that will include: 

Pediatrics Code Stat 

Adult Code Stat 

GMEC (President, Vice President & Secretary – elected Officers) 

Pharmacy & Therapeutics 

Information Technology 

Metabolic Adult Support Task Force 

House Staff Liaison – (Chief Residents and elected Officers) 

Internal Review – (per policy) 

Jackson Award – (per Award description) 

Research Award – (per Award description) 

Simulation Advisory Committee – (per Advisory Committee By‐laws) 

Except for ex officio membership and DIO appointment, resident selection/appointment to specific 

committees will be processed via the GHS House Staff Liaison Committee whose membership consists of each 

program’s Chief Resident, universal elected officers (President, Vice President, and Secretary) and a 

representative from the 3 rd and 4 th year USC Medical Students. 













13

SYSTEM COMMITTEES: RESIDENT REPRESENTATION 

Academic Year 2012 


Committee (GMEC) 

Bethany Bessom, MD (House Staff Pres–(Pediatrics) 

Lionel van der Westhuizen, MD (House Staff VP–(Surgery) 

Deanna Ball, MD (House Staff Secretary‐(Pediatrics) 

Pediatrics Code Stat 

Amanda O’Kelly, MD (Pediatrics) 

Adult Code Stat 

Brett Murphy, MD (Orthopaedic Surgery) 

Chris Vaughan, MD (Med‐Peds) 

Pharmacy & Therapeutics 

Cary A. Sanders, MD (Med/Peds) 

Information Technology 

Ben Barden, MD (Orthopaedic Surgery) 

J. D. Adams, MD (Orthopaedic Surgery) 

Metabolic Adult Support Task Force 

Brandon Smith, MD (Surgery) 

House Staff Liaison Committee 

Chief Residents/Elected Officers/Committee Representatives/ 

3rd and 4th Year Medical Student Representatives 

Simulation Center 

Internal Review 

As selected per policy 

Jackson Award 

As selected per policy 

GHS/UMC Outstanding Faculty and House Staff Research Award ‐ As selected per policy 

14


Institutional Requirements: II.D.4.j 

Common Program Requirements: V1.G.2.a‐c 

POLICY TITLE: 

Moonlighting 

It is the policy of the GHS Graduate Medical Education Committee that GHS residents may moonlight so long 

as a moonlighting obligation does not interfere with that resident’s educational program. In addition, if a 

proposed moonlighting activity is to take place in a GHS facility or in connection with a GHS program, the 

resident must demonstrate competence to furnish the moonlighting services and be granted appropriate GHS 

Medical Staff clinical privileges in accordance with this policy. Resident staff are not required to moonlight. 

Moonlighting activities will be closely monitored by the Department Chairs and Residency Program Directors 

for signs of fatigue and will guarantee sufficient time for rest and relaxation in order to promote the residents’ 

educational experience and safe patient care. Further, resident moonlighting activities will count as part of the 

80‐hour work week. 

Specific qualifications and procedural requirements will be detailed in the GHS House Staff Manual. 













15



Common Program Requirements: V1.A.5.d 

V1.G.1 

POLICY TITLE: 

Duty Hours 

It is the policy of the GHS Graduate Medical Education Committee that, in compliance with ACGME 

Institutional requirements and applicable ACGME RRC requirements, resident working hours shall not exceed 

an average of 80 hours per workweek averaged over a 4 week period. House staff are considered to be on duty 

at all times when in the hospital and are subject to call at all hours. 

Each residency program is responsible for the ongoing monitoring of resident duty hours and must have a 

documented monitoring tool. Each program will specifically address duty hours compliance and 

documentation at the Program’s Annual Report to GMEC and the GMEC Internal Review process. 

The GHS Graduate Medical Education Committee does not recognize exceptions to the ACGME Resident Duty 

Hours guidelines. 













16


Page 1 

Institutional Requirements: II.D.4.i 

Common Program Requirements: V1.A.5.d 

POLICY TITLE: Resident Duty Hour Compliance Oversight 

It is the policy of the GHS Graduate Medical Education Committee that each program will have written policies 

and procedures consistent with the Institutional and Program Requirements for resident duty hours. These 

policies will be distributed to the residents and the faculty. 

Procedures: 

1) Monitoring of duty hours is required with frequency sufficient to ensure an appropriate 

balance between education and service and to meet ACGME Common Program 

Requirements. Those program requirements define duty hours as all clinical and 

academic activities and do not include reading and preparation time spent away from the duty 

site. The requirements state that duty hours be limited to 80 hours per week, and that continuous 

on site duty, including in‐house call, must not exceed 24 consecutive hours. Residents may remain 

on duty for up to six additional hours to participate in didactic activities, transfer care of patients, 

conduct outpatient clinics, and maintain continuity of medical and surgical care. No new patients 

may be accepted after 24 hours of continuous duty. Residents must be provided with one day in 

seven free from all educational and clinical responsibilities, averaged over a four‐week period, 

inclusive of call. Adequate time for rest and personal activities must be provided with adherence of 

10 hours off between duty shifts. 

Residents will use the New Innovations Web‐based System to document duty hours. If 

documented hours exceed the 80 hour compliance and violate the ACGME requirement, the 

resident must use the New Innovations duty hours comments section to document the specifics 

regarding the non‐compliance. Program Directors will use the same New Innovations reporting 

system for weekly duty hours compliance monitoring for their respective programs. GMEC will use 

New Innovations reporting to determine compliance. Programs will be monitored for duty hours 

compliance during the academic year and during annual reporting. Programs out of compliance 

will be monitored with a frequency to be determined by GMEC. 

2) Directors of programs that are out of compliance with the Resident Duty Hours Policy will 

determine a plan and timeline to be in compliance and submit that plan and time line to the GMEC 

for review and approval. 

3) Each resident will be responsible for providing accurate and timely data using New Innovations 

regarding their individual compliance with the GMEC Resident Duty Hour Policy and the ACGME 

Duty Hours requirements. Failure to comply may result in penalty action(s) to include the GHS 

Human Resources discipline cycle of verbal and written warnings, suspension, and dismissal. 

Non‐compliance Discipline: 

Resident duty hours documentation in a timely manner is a requirement. Residents document duty hours 

using the GHS New Innovations Web‐based System. Residents are required to complete duty hours 

17


Page 2 

POLICY TITLE: Resident Duty Hour Compliance Oversight 

documentation daily. When in non‐compliance of duty hours requirements, residents must complete 

documentation regarding the specifics of the situation within New Innovations comments section. Any 

resident unable to complete his/her duty hours documentation because of the following reasons, 1) vacation, 

2) sick, 3) or educational leave, must have approval from their Program Director. 

Failure to complete duty hours documentation is a demonstrated behavior of lack of the ACGME 

Professionalism general competency. Non‐compliance and failure to meet the duty hours documentation as 

required may result in the following disciplinary actions: 

First Offense: 

Second Offense: 

Third Offense: 

Fourth Offense: 

Fifth Offense: 

Process & Procedure Coaching 

Verbal Warning 

Written Warning 

Suspension 

Termination from Residency Program 













18


Institutional Requirements: III.B 


POLICY TITLE: 

House Staff Manual 

It is the policy of the GHS Graduate Medical Education Committee that the GMEC will review and affirm the 

House Staff Manual revisions annually. The House Staff Manual reflects GMEC policy and is incorporated into 

the GMEC Policy Manual by this reference and current Table of Contents attachment. 













19

2011 Manual of Policies and Procedures 

Medical Education Resident Staff 

TABLE OF CONTENTS 

Foreword and Purpose ................................................................................................................................... I 

Graduate Medical Education Institutional Commitment .............................................................................. II 

Resident Physicians/House Staff Teaching‐Learning Commitment ............................................................. III 

Section I: Programs Overview 

GME Program Overview ................................................................................................................................ 1 

Program Policy Manuals ................................................................................................................................ 2 

GHS Mission, Vision, & Values ..................................................................................................................... 3 

Facilities of the Greenville Hospital System ........................................................................................................... 4 

Greenville Hospital System Organizational Structure............................................................................................ 5 

Graduate Medical Education Operational Structure ............................................................................................. 6 

Organizational Chart ‐ Medical Staff Flow Chart ................................................................................................... 7 

Medical Staff ........................................................................................................................................................... 8 

Medical Staff Supervision of Resident/Fellow Patient Care Activities .................................................................. 8 

Patient Care Chain of Command ............................................................................................................................ 9 

Physicians Notification Sequence – Appendix A .................................................................................................. 11 

Teaching Staff ........................................................................................................................................................ 11 

House Staff Liaison Committee ............................................................................................................................. 12 

System Committees: Resident Representation .......................................................................................... 12 

Section II: Education & Competency Requirements 

Licensure ................................................................................................................................................................ 13 

Advanced Cardiac Life Support ............................................................................................................................. 13 

Research Requirements ........................................................................................................................................ 15 

CITI Training ........................................................................................................................................................... 17 

Mandatory Trainings ............................................................................................................................................. 18 

Electronic Clinical Works (eCW) Training ............................................................................................................. 18 

Conferences ........................................................................................................................................................... 19 

Educational Rotations ............................................................................................................................................ 19 

International Electives ........................................................................................................................................... 19 

Patient Simulation Center ..................................................................................................................................... 20 

Performance Evaluations ...................................................................................................................................... 20 

Learning Portfolio .................................................................................................................................................. 20 

Certificates ............................................................................................................................................................. 21 

Section III: Systems‐based Practice / Communication / Medical Information / Other 

Electronic Clinical Works (eCW) Training ............................................................................................................. 18 

System Communication Models ........................................................................................................................... 22 

Hand‐off Communication and Responsibilities .................................................................................................... 23 

Communication and Hand‐offs Policy .................................................................................................................. 23 

Pager Assignments ................................................................................................................................................ 24 

Communication Device ......................................................................................................................................... 24 

Social Media and Social Networking .................................................................................................................... 26 

20

Table of Contents ‐ Page 2 

Telephone Calls ...................................................................................................................................................... 28 

Emergency Code Procedures for House Staff ...................................................................................................... 28 

Emergency Paging Codes for Greenville Hospital System ................................................................................... 30 

Official Abbreviations “Do Not Use” List .............................................................................................................. 31 

Call Schedule .......................................................................................................................................................... 31 

Language Services .................................................................................................................................................. 31 

eNet – Employee Information/Payroll Self‐Service Access ................................................................................. 32 

Keys ........................................................................................................................................................................ 32 

Legibility of Handwriting ...................................................................................................................................... 32 

Loan Deferments ................................................................................................................................................... 33 

Medical Information Procedures for Residents/Fellows ..................................................................................... 33 

Procedure for Completion of Delinquent Medical Records ................................................................................ 34 

Corrections in Medical Records .................................................................................................................. 36 

Transcription Services ................................................................................................................................. 37 

Section IV: Policies & Procedures 

Consultation/Referral Policy ................................................................................................................................. 38 

Selection Criteria .................................................................................................................................................... 38 

Change of Residency/Fellowship Program Procedure ........................................................................................ 39 

Conflict of Interest ................................................................................................................................................. 39 

Controlled Substance Registration ....................................................................................................................... 40 

Promotion .............................................................................................................................................................. 40 

Discipline and Termination ................................................................................................................................... 40 

Resignation and Due Process ................................................................................................................................ 40 

Appeal Process ....................................................................................................................................................... 41 

Educational Leave and Travel Policy ..................................................................................................................... 41 

Lodging ............................................................................................................................................................... 42 

Meals ................................................................................................................................................................. 42 

Air Travel ............................................................................................................................................................ 42 

Automobile Travel ............................................................................................................................................. 42 

Registration Fees ............................................................................................................................................... 43 

Rental Cars ......................................................................................................................................................... 43 

Other Miscellaneous Expenses ......................................................................................................................... 43 

Travel Reimbursement ..................................................................................................................................... 44 

Travel to Present Paper .................................................................................................................................... 44 

Educational Allowance Fund ................................................................................................................................. 44 

Moving Allowance ................................................................................................................................................. 45 

Employee Health Requirements ........................................................................................................................... 45 

Fitness for Duty and Drug Free Work Environment &Testing ............................................................................. 46 

Harassment ................................................................................................................................................. 46 

Hepatitis B Vaccine Policy ..................................................................................................................................... 46 

Infection Prevention and Control ........................................................................................................................ 47 

DHEC Reportable Conditions ................................................................................................................................ 48 

Moonlighting Policy and Procedures for Residents/Fellows ............................................................................... 50 

Patients Rights and Responsibilities ..................................................................................................................... 54 

Patient Safety ......................................................................................................................................................... 56 

Resident Responsibilities During Local Extreme Emergent Situations and Disasters ................................. 56 

House Medical Staff Disaster Response ...................................................................................................... 58 

21


Duty Hours ............................................................................................................................................................. 59 

Sleep Deprivation and Fatigue .............................................................................................................................. 59 

Uniforms ................................................................................................................................................................. 60 

Vendor Policy ......................................................................................................................................................... 60 

Section V: Resources & Benefits 

Credit Union ........................................................................................................................................................... 61 

Direct Deposit of Paycheck ................................................................................................................................... 61 

Employee Accident Report .................................................................................................................................... 61 

Employee Insurance Highlights 

Insurance Highlights .......................................................................................................................................... 62 

Health Insurance Plan ....................................................................................................................................... 62 

Silver and Gold Plans Comparison .................................................................................................................... 62 

Prescription Drug Benefit ....................................................................................................................... 63 

Cost of Health Care Coverage ........................................................................................................................... 63 

Dental Insurance ............................................................................................................................................... 64 

Vision Plan ......................................................................................................................................................... 65 

Flexible Spending Accounts ............................................................................................................................. 65 

Health Services Benefit ..................................................................................................................................... 65 

Basic Group Term Life Insurance/AD&D Insurance ........................................................................................ 65 

Supplemental Group Universal Life Insurance ................................................................................................ 66 

Voluntary AD&D Insurance ............................................................................................................................... 66 

Business Travel Accidental Insurance .............................................................................................................. 66 

World‐wide Travel Assistance .......................................................................................................................... 67 

Pre‐paid Legal Plan and Identity Theft Shield Benefit ..................................................................................... 67 

Long Term Disability Insurance ........................................................................................................................ 67 

Short Term Disability Insurance ....................................................................................................................... 67 

Long Term Care (LTC) Insurance ....................................................................................................................... 67 

Allstate Supplemental Health Options Plan (SHOP) ........................................................................................ 68 

Retirement Savings Plan ................................................................................................................................... 68 

Section 529 Plan “Future Scholar Program” .................................................................................................... 68 

Adoption Benefit Assistance ............................................................................................................................. 68 

Paid Time Off (PTO) ........................................................................................................................................... 68 

Other Benefits ................................................................................................................................................... 68 

Professional Liability ......................................................................................................................................... 69 

Leave & PTO Policies 

Compassionate Leave ....................................................................................................................................... 69 

Court Appearances ............................................................................................................................................ 70 

Family and Medical Leave Act Policy ............................................................................................................... 70 

Jury Duty ............................................................................................................................................................ 78 

Maternity Leave ................................................................................................................................................ 78 

Military Leave .................................................................................................................................................... 78 

PTO‐Paid Time Off (PTO) ................................................................................................................................... 79 

Vacation ............................................................................................................................................................. 79 

Holiday PTO Policy for Resident Staff/Fellows ................................................................................................ 79 

Educational Leave ............................................................................................................................................. 79 

Procedure for Requesting PTO ......................................................................................................................... 79 

Severance Pay ................................................................................................................................................... 80 

22


Illness ................................................................................................................................................................ 81 

Meals ...................................................................................................................................................................... 81 

Personal Problems and Concerns/Reporting Anonymity/Employee Assistance Program ................................ 81 

Risk Management .................................................................................................................................................. 82 

Salary ...................................................................................................................................................................... 82 

Section VI: Forms 

Request for Change of Residency/Fellowship ...................................................................................................... 83 

Education or Vacation Leave Request .................................................................................................................. 84 

Communication Device ........................................................................................................................................ 85 

GME Communication Device(s) Authorization – IPAD ........................................................................................ 86 

GME Communication Device(s) Authorization – Telephone .............................................................................. 87 

Application for Moonlighting Privileges ............................................................................................................... 88 

International Electives Rotation Request Form ................................................................................................... 93 

GHS Resident Waiver Statement .......................................................................................................................... 95 

International Program Letter of Agreement Template ....................................................................................... 96 

23


Institutional Requirements: N/A 

Common Program Requirements: V1.B.1‐4 

POLICY TITLE: 

Transitions of Care 

It is the policy of the GHS Graduate Medical Education Committee that the faculty and resident physicians will 

adhere to the standardized Communication and Hand‐offs policy as reflected in the GHS Medical Staff Policies 

and detailed in the Manual of Policies and Procedures for Medical Education Resident Staff (House Staff 

Manual). 

Specialty‐specific processes that are compliant with the Medical Staff Communication and Hands‐off policy are 

within each of the Residency Program's written policies and procedures. 













24



Common Program Requirements: VI.C.1‐3 

POLICY TITLE: 

Sleep Deprivation and Fatigue 

It is the policy of the GHS Graduate Medical Education Committee that faculty and residents and fellows will be 

educated to recognize the signs of fatigue and sleep deprivation and must adopt and apply policies to prevent 

and counteract its potential negative effects on patient care and learning. 

Each GME Program will assure the GHS GMEC through audit and annual reporting that such curriculum and 

supervision are formalized within the respective GME program. Unique policies and/or procedures per 

program will be in compliance with this policy and the policy and guidance from respective RRC’s and the 

ACGME. 

Education may be unique to the individual program or conducted GME‐wide as the Program Directors 

Committee so directs. 













25


Institutional Requirements: 


POLICY TITLE: International Electives 

It is the policy of the Greenville Hospital System Graduate Medical Education Committee that residency 

programs may provide elective educational opportunities at international sites. Each rotation must be 

acceptable within the individual residency program curriculum and the related ACGME/RRC requirements. 

Approved residents: 

 

 

 

 

 

Must meet minimum competency‐based academic standards as determined by the related residency 

program. 

May be required to present her/his experience to the Department. 

Are responsible for obtaining all appropriate vaccinations as designated by an international health 

clinic and providing certification of emergency of‐of‐country medical care coverage. 

Are responsible for formal medical clearance by their personal physician for travel to the specific area. 

May use their individual education allowance money at the discretion of the Program Director. Any 

remaining finances beyond the education allowance resource will be the responsibility of the resident 

physicians. 

A formal application located in the House Staff Manual (supplied through the residency program office) will be 

completed and will preferably be submitted three (3) months prior to the anticipated beginning of the 

international elective but must be submitted at least one (1) month prior to the rotation. The application must 

receive signatory approval by the Program Director and the Designated Institutional Official. The resident 

physician will not be insured through the Greenville Hospital System malpractice coverage and must obtain 

separate malpractice coverage, if available. 













26

III. GRADUATE MEDICAL EDUCATION COMMITTEE (GMEC) 

27

GMEC ROLE w/ Organization Chart 

The Greenville Hospital System Graduate Medical Education Committee has oversight authority and 

responsibility for all aspects of residency education. Voting membership includes the DIO, Assistant Dean for 

Graduate Medical Education (Chair), Program Directors (Associate Program Directors are non‐voting members 

except by Program Director proxy), the House Staff Officers elected by the House Staff – (President, Vice 

President, Secretary), the Academic Services Administrator, and others as deemed by DIO appointment. 

Departmental Faculty Directors for Education and the Vice President for Academic Development also serve as 

non‐voting members. Other non‐voting faculty or members may be appointed by the DIO. 

The GHS GMEC will establish and implement policies and procedures regarding the quality of education and 

the work environment for the residents and fellows in all programs. 

The GHS GMEC will conduct its oversight responsibilities in compliance with ACGME institutional requirements, 

ACGME common program requirements and applicable RRC guidelines. 

28

GREENVILLE HOSPITAL SYSTEM 

GRADUATE MEDICAL EDUCATION PROGRAMMATIC STRUCTURE 

Organized 

Medical 

Staff 

GHS 

Board of Trustees 

GHS 

President & CEO 

Assistant Dean 

Graduate Medical 

Education 

GHS 

VP, Medical & Academic Services 

(DIO) 

Program Directors 

Committee 


Education Committee 

Academic Services 

Administration 

Family 

Medicine 

Internal 

Medicine 

Medicine‐ 

Pediatrics 

General 

Surgery 

Obstetrics & 

Gynecology 

Orthopaedic 

Surgery 

Pediatrics 

Sports 

Medicine 

Vascular 

Medicine 

Vascular 

Surgery 

Minimal 

Access 

Surgery 

Total Joint 

Arthroplasty 

Dev/Behav 

Pediatrics 

* A dotted line denotes a non‐ACGME accredited program 

Revised: November 2011 

29


PHYSICIAN AFFAIRS OPERATIONAL STRUCTURE 

GHS 


* Associate VP & 

Chief Medical Officer 

(CMO) 

GHS 

VP, Medical & Academic Services 

* Associate VP & 

Designated Institutional 

Official (DIO) 

GHS UMG Chief 

Administrative 

Officer & Executive 

Director, Ambulatory 

Services 

UMG 

Medical 

Director 

Medical 

Staff 

Office 

Department of Clinical 

Integration 

Clinical Integration Responsibilities 

Physician Compensation & 

Service Expansion Responsibilities 

UMG Medical 

Services Offices 

Center for 

Teaching & Learning (CTL) 

Academic Integration Responsibilities 

GHS Chairs 

* Associate VP, Executive VP, or just VP Revised: October 2011 

30


GRADUATE MEDICAL EDUCATION OPERATIONAL STRUCTURE 

GHS 


GHS Executive VP, Medical & Academic Services 

and Dean, USC School of Medicine‐Greenville 

VP & DIO for Academics 

and Executive Medical Director UMG 

GHS Department 

Chairs Academic 

Responsibilities 

Assistant Dean 


Education 

Associate Dean 

USCSOM‐Columbia 

GHS VP, Academic 

Development 

Center for 

Teaching & 

Learning (CTL) 

Offices 

UMG Department 

Operations 

Directors 

1 

GME Residency Program 

Coordinators 

GME Residency 

Program 

Directors 

2 

3 

GMEC 

Administrator 

Academic Services 

Curriculum 

Development 

GME & 

Curriculum 

Development 

Officer 

GME 

Operations 

MedEx 

Academy 

Note 1: This reporting relationship is for daily activities 

of the residency program within the UMG Clinical Department. 

Note 2: Required ACGME reporting relationship for support of 

academic components of the individual program. 

Note 3: This relationship is for the overriding academic corporate 

support activities and ACGME policy and procedure oversight 

requirements. 

* Associate VP, Executive VP, or just VP Revised: May 2012 

31

GMEC RESPONSIBILITIES 

In accordance with the ACGME Institutional Requirements, the Greenville Hospital System Graduate Medical 

Education Committee will: 

1. Annually review and recommend resident stipends, benefits, and funding for resident positions to 

assure an equitable and fair allocation process. 

2. Ensure effective communications between GMEC and appropriate system‐wide committees and the 

effective communication between program directors and clinical teaching sites. 

3. Ensure compliance regarding resident duty hours requirements (see GMEC Policy # II‐07‐11). 

4. Monitor programs’ supervision of residents and assure that supervision is consistent with ACGME 

requirements. 

5. Communicate with the leadership of the Organized Medical Staff regarding the safety and quality of 

patient care. 

6. Provide oversight to assure a curriculum and an evaluation system that ensures that residents 

demonstrate achievement of the ACGME general competencies. 

7. Ensure appropriate oversight for the selection, evaluation, promotion, transfer, discipline, and/or 

dismissal of residents in compliance with the Institutional and Common Program Requirements (see 

GMEC Policy #’s II‐01‐11, II‐02‐11, II‐03‐11). 

8. Review all ACGME program accreditation letters of notification and monitoring of action plans for 

correction of citations and areas of non‐compliance. 

9. Review the GHS ACGME Institutional Accreditation letter of notification from the IRC and monitoring 

of action plans for correction of citations and areas of noncompliance. 

10. Prior to submissions to the ACGME by program directors, provide oversight of program changes 

through review and approval of: 

a. All applications for ACGME accreditation of new programs; 

b. Changes in resident complement; 

c. Major changes in program structure or length of training; 

d. Additions and deletions of participating institutions; 

e. Appointments of new program directors; 

f. Progress reports requested by any Review Committee; 

g. Responses to all proposed adverse actions; 

32

GMEC Responsibilities 

Page 2 

h. Requests for exceptions to resident duty hours requirements; 

i. Voluntary withdrawals of programs accreditation; 

j. Requests for an appeal of an adverse action; 

k. Appeal presentations to a Board of Appeal or the ACGME. 

11. Provide oversight of all phases of educational experiments and innovations that may deviate 

from Institutional, Common, and special/subspecialty‐specific Program Requirements. 

12. Provide oversight of program reductions and closures (see GMEC Policy # III‐04‐11). 

13. Monitor interactions of residents and GME programs with vendor representatives (see GMEC 

Policy # III‐02‐11). 

14. Present an annual report to the organized Medical Staff and the GHS Board of Trustees that reviews 

the activities of the GMEC during the past year with attention to the impact of GME on patient safety 

and quality of care, resident supervision, resident responsibilities, resident evaluation, and 

compliance with duty‐hour standards. 













33

GMEC Policy # III‐01‐11 

Institutional Requirements: I.B.4.a 


POLICY TITLE: 

DIO Delegation 

It is the policy of the GHS Graduate Medical Education Committee that in the absence of the Designated 

Institutional Official, the Assistant Dean for Graduate Medical Education will have the authority and 

responsibility to review and cosign all program information forms and any documents or correspondence 

submitted to the ACGME by Program Directors. 













34




POLICY TITLE: 

Vendor Interactions 

It is the policy of the GHS Graduate Medical Education Committee that each residency program will be in 

compliance with the GHS CME policies regarding education sponsorship and comply with its own program – 

specific vendor interaction policy that is compliant with GHS Vendor policy and procedures. 













35


Page 1 

POLICY TITLE: 

GME Vendor Interactions 

Policy and Guidelines for Interactions between the Faculty, Residents, Medical Students and Educational 

Staff of the Greenville Hospital System University Medical Center and Commercial Vendors. 

Purpose of Policy 

The purpose of this policy is to establish guidelines for interactions with industry representatives for medical 

staff, faculty, staff, students, and trainees of the Greenville Hospital System University Medical Center. 

Interactions with industry occur in a variety of contexts, including marketing of new pharmaceutical products, 

medical devices, and research equipment and supplies on‐site, on‐site training of newly purchased devices, the 

development of new devices, educational support of medical students and trainees, and continuing medical 

education. Faculty and trainees also participate in interactions with industry off campus and in scholarly 

publications. Many aspects of these interactions are positive and important for promoting the educational, 

clinical and research missions of the Greenville Hospital System University Medical Center. However, these 

interactions must be ethical and cannot create conflicts of interest that could endanger patient safety, data 

integrity, the integrity of our education and training programs, or the reputation of either the faculty member 

or the institution. 

Statement of Policy 

It is the policy of the Greenville Hospital System University Medical Center that interactions with industry 

should be conducted according to the highest ethical standards and so as to avoid or minimize conflicts of 

interest. When conflicts of interest do arise they must be addressed appropriately, as described herein. 

Scope of Policy 

This policy incorporates the following types of interactions with industry. It does not include faculty research and 

related activities, which are included in the Greenville Hospital System University Medical Center Medical Staff Policy 

on Conflict of Interest (http://ghsnet.ghs.org/Medstaff/WebDocuments/Policies/Conflict_of_Interest_Policy.pdf). 

I. Gifts and compensation 

II. Site access by sales and marketing representatives 

III. Provision of scholarships and other educational funds to students and trainees 

IV. Support for educational and other professional activities 

V. Disclosure of relationships with industry 

VI. Training of students, trainees, and staff regarding potential conflict of interest in industry interactions 

I. Gifts and Compensation 

A. Personal gifts from industry may not be accepted anywhere at the Greenville Hospital System 

University Medical Center or at any other clinical facility operated by GHS UMC, such as 

physicians’ practices and outlying hospitals. In addition, GHSUMC faculty, staff and trainees 

may also not accept gifts at any non‐GHSUMC clinical facility such as other hospitals, outreach 

clinics and the like. Non‐faculty medical staff members are strongly discouraged from 

accepting gifts at non‐GHSUMC‐operated clinical facilities but are not proscribed by this policy 

from doing so. 

B. Individuals should be aware of other applicable policies, such as the AMA Code of Ethics 

Opinion 8.061 – Gifts to Physicians from Industry 

(http://www.ama‐assn.org/ama/pub/physician‐resources/medical‐ethics/code‐medicalethics/opinion8061.page) 

and the Accrediting Council for Continuing Medical Education 

Standards for Commercial Support (www.accme.org). 

36


Page 2 

POLICY TITLE: 


C. Individuals may not accept gifts or compensation for listening to a sales talk by an industry 

representative. 

D. Individuals may not accept gifts or compensation for prescribing or changing a patient's 

prescription. 

E. Individuals must consciously and actively divorce clinical care decisions from any perceived or 

actual benefits expected from any company. It is unacceptable for patient care decisions to be 

influenced by the possibility of personal financial gain. 

F. Individuals may not accept compensation, including the defraying of costs, for simply 

attending a CME or other activity or conference (that is, if the individual is not speaking or 

otherwise actively participating or presenting at the event). 

G. Textbooks and items of educational value may be provided to the institution if approved by 

the department Chair/ program director and if consistent with department educational goals 

and institutional policies. 

H. Pens, pads, educational brochures which feature specific product names and information are 

not to be accepted and are not to be left on the premises. 

II. 

III. 

Site Access by Sales and Marketing Representatives 

A. Sales and marketing representatives are not permitted in any patient care areas except to 

provide in‐service training on devices and other equipment and then only by appointment. 

B. Sales and marketing representatives are permitted in non‐patient care areas by appointment 

only. Appointments will normally be made for such purposes as: 

1. In‐service training of GHSUMC personnel for research or clinical equipment or devices 

already purchased. 

2. Evaluation of new purchases of equipment, devices, or related items. 

C. Appointments to obtain information about new drugs in the formulary will normally be issued 

by the hospital pharmacy or by Pharmaceutical and Therapeutics Committees. The acceptance 

of pharmaceutical samples will be governed by the GHS Pharmacy policy. 

D. Appointments may be made on a per visit basis at the discretion of the faculty member, his or 

her division or department, or designated hospital personnel issuing the invitation and with 

the approval of appropriate Department Chair. 

Provision of Scholarships and Other Educational Funds to Students and Trainees 

A. Industry support of students and trainees should be free of any actual or perceived conflict of 

interest, must be specifically for the purpose of education and must comply with all of the 

following provisions: 

1. The educational department, program or division selects the fellow, student or 

trainee. 

2. The funds are provided to the department, program, or division and not directly to 

student or trainee. 

3. The department, program or division has determined that the funded conference or 

program has educational merit. 

4. The recipient is not subject to any implicit or explicit expectation of providing 

something in return for the support, i.e., a "quid pro quo." 

37


Page 3 

POLICY TITLE: 


B. This provision may not apply to national or regional merit‐based awards, which are considered 

on a case‐by‐case basis. 

IV. 

Support for Educational and Other Professional Activities 

A. Individuals should be aware of the ACCME Standards for Commercial Support. They provide 

useful guidelines for evaluating all forms of industry interaction, both on and off campus and 

including both GHSUMC‐ sponsored and other events. The Standards may be found by going to 

the website: www.accme.org. 

B. All education events sponsored by the Greenville Hospital System University Medical Center 

must be compliant with ACCME Standards for Commercial Support whether or not CME credit 

is awarded. 

1. Educational grants that are compliant with the ACCME Standards may be received 

from industry but must be administered by departments or divisions and not by 

individual faculty. 

2. Divisions and departments must maintain records of compliance with the ACCME 

Standards. 

C. Vendors shall not sponsor any educational programs without approval by the Department 

Chair, Program Director or Section Chief. In all cases the selection of speakers and assurance of 

the educational integrity of the program is the responsibility of the GHS faculty member, 

program director or department chair. While the support of venders may be acknowledged 

vendors may not speak or present product information in conjunction with educational time. 

There can be no activities to promote or market specific products in educational time. 

D. Meals or other types of food directly funded by industry may not be provided at the Greenville 

Hospital System University Medical Center or for GHS educational events off campus. 

E. Faculty and medical staff should evaluate very carefully their own participation in meetings 

and conferences that are fully or partially sponsored or run by industry because of the high 

potential for perceived or real conflict of interest. This provision does not apply to meetings of 

professional societies that may receive partial industry support, meetings governed by ACCME 

Standards, and the like. 

F. Individuals who actively participate in meetings and conferences supported in part or in whole 

by industry (e.g., by giving a lecture, organizing the meeting) should follow these guidelines: 

1. Financial support by industry is fully disclosed by the meeting sponsor. 

2. The meeting or lecture content is determined by the speaker and not the industrial 

sponsor. 

3. The lecturer is expected to provide a fair and balanced assessment of therapeutic 

options and to promote objective scientific and educational activities and discourse. 

4. The GHSUMC participant is not required by an industry sponsor to accept advice or 

services concerning speakers, content, etc., as a condition of the sponsor's 

contribution of funds or services. 

5. The lecturer makes clear that content reflects individual views and not the views of 

Greenville Hospital System University Medical Center. 

6. The use of the GHSUMC name in non‐GHSUMC event is limited to the identification of 

the individual by his or her title and affiliation. 

38


Page 4 

POLICY TITLE: 


V. Disclosure of Relationships with Industry 

A. Individuals are prohibited from publishing articles under their own names that are written in 

whole or material part by industry employees. 

B. In scholarly publications, individuals must disclose their related financial interests in 

accordance with the International Committee of Medical Journal Editors 

(http://www.icmje.org). 

C. Faculty with supervisory responsibilities for students, residents, trainees or staff should ensure 

that the faculty's conflict or potential conflict of interest does not affect or appear to affect his 

or her supervision of the student, resident, trainee, or staff member. 

D. Individuals having a direct role making institutional decisions on equipment or drug 

procurement must disclose to the purchasing unit, prior to making any such 

decision, any financial interest they or their immediate family have in companies that might 

substantially benefit from the decision. Such financial interests could include equity 

ownership, compensated positions on advisory boards, a paid consultancy, or other forms of 

compensated relationship. They must also disclose any research or educational interest they 

or their department have that might substantially benefit from the decision. The purchasing 

unit will decide whether the individual must excuse him/herself from the purchasing decision. 

1. This provision excludes indirect ownership such as stock held through mutual funds. 

2. The term "immediate family" includes the individual's spouse or dependent children. 

E. For disclosure requirements related to educational activities, see the ACCME Standards for 

Commercial Support (www.accme.org). 

VI. 

Training of Students, Trainees, and Staff Regarding Potential Conflict of Interest in Interactions with 

Industry 

B. All students, residents, trainees, and staff shall receive training regarding potential conflicts of 

interest in interactions with industry. 













39


Institutional Requirements: II.D.5 


POLICY TITLE: 

Residency Closure/Reduction in Size 

GHS is committed to facilitating completion of training by any resident who has matriculated. GHS will inform 

the GMEC, the DIO, and residents as soon as possible when it intends to reduce the size of or close one or 

more programs, or when GHS intends to close. In practice this means that closure of residencies, reduction of a 

resident complement, or institutional closure is done in a proactive planned manner such that the reductions 

are timed with program completion. Reductions are to be accomplished during the recruiting phase rather 

than through elimination of matriculated residents. In the event that crisis would preclude such an approach, 

GHS would be committed to maintain the program until the residents were enrolled in an ACGME accredited 

program elsewhere to continue their education. This approach is in conformity with the institutional 

requirements of the ACGME. 

In the event that GHS intends to reduce the size or close either a program or the Institution itself, GHS will 

inform the GMEC, the DIO, and the residents as soon as possible. 













40


Institutional Requirements: 1.B.8 


POLICY TITLE: 

Disaster and GME 

It is the policy of the GHS Graduate Medical Education Committee that in the event of a local extreme 

emergent situation, natural disaster or cataclysm that all appropriate steps will be made to continue 

compliance with all applicable ACGME and RRC rules. GME will be in compliance with the GHS disaster policy 

and procedures (GHS Emergency Operations Plan ‐ EOP). In the event that such disaster prohibits timely 

continuance of Graduate Medical Education programs at the Greenville Hospital System, the ACGME and RRC’s 

will be contacted to ensure an orderly transaction to other ACGME accredited residency programs. 













41




POLICY TITLE: 

Program Annual Reports w/Format 

It is the policy of the GHS Graduate Medical Education Committee that each program will present to the GHS 

GMEC a written annual report per the attached outline and schedule. The Annual Reports will become a part 

of the GMEC meeting minutes. 













42

Annual Report Presentation Schedule 

SEPTEMBER 

OCTOBER 

NOVEMBER 

DECEMBER 

Orthopaedics Surgery 

OB/GYN 

General Surgery 

Vascular Surgery 

Minimal Access Surgery 

Internal Medicine 

Vascular Medicine 

Family Medicine 

Sports Medicine 

Pediatrics 

Developmental Pediatrics 

Combined Internal Medicine/Pediatrics 

43

Greenville Hospital System 

Residency Program 

Annual Report: 

[Type Name of Program] 

Program Director: 

2011 

Academic 

Year 

44

2011 Residency Program Annual Report Template 

Program: 

Department Chair: 

Program Director: 

Program Coordinator: 

RRC accreditation status: 

Date of last RRC site visit: 

Date of last internal review: 

Date of next RRC review: 

Faculty: List all faculty members with USCSOM – G faculty appointments (* - the asterisk 

indicates new faculty since last report). Indicate core faculty members as designated within 

the Program’s RRC PIF guidelines. Document average hours per week applied to each 

performance item below. 

Name (Position) 

Core 

Faculty 

(Y/N) 

Based 

Mainly 

at Site 

Primary and Secondary 

Specialties / Fields 

Original 

Specialty Cert Cert Cert 

Field (Y/N) Year Status 

Re-cert 

Year 

No. of 

Years 

Teaching 

in This 

Specialty 

Average Hours Per Week Spent On 

Clinical 

Supervision 

Didactic 

Admin Teaching 

Research 

45

Faculty awards/recognition: 

National/Regional Committees & Positions of Recognition: 

Hospital Committees: 

Other: 

House Staff: 

Resident positions by year: 

Number of positions filled by year: 

Residents terminated during prior year: 

Status of any other disciplinary/probation action: 

Awards/recognition: 

In-training exam results: 

Graduating resident plans: 

Specialty Board Pass Rate: 

Hospital Committees: 

Match results: 

Total positions: 

Rank order matched: 

Open positions: 

# IMG matched: 

# Minority matched: 

# Positions filled outside of match: 

Scholarly Activity: (Faculty & Residents) 

46

Faculty & Resident/Fellow Scholarly Productivity Chart 

Complete summative chart and list citations of scholarly activities below. 

Publications: 

Peer Reviewed: 

Non-Peer Reviewed: 

Books & Book Chapters Published: 

Members of Nat’l Study Sections or Committees: 

Journal Editors: 

Faculty 

Number of: Number of: Number of Departmental Members Who Are: 

Articles in Books & Members of 

Members 

Peerreviewed 

Chapters Sections or 

Extramural 

Book Nat’l Study 

working on 

Journal Editors 

Journals Published Committees 

Grants 

Residents/ 

Fellows 

Regional/national presentations: 

Local presentations: 

Extramural Grants: PI’s, Description, Funding Agency, Funding Amount, and Length 

Ongoing research initiatives: 

Other: 

Issues/concerns: 

Status of RRC citations: 

Status of Internal Review concerns: 

Other: 

47

Documentation Requirements with Comments 

Written Recruitment Policy: (provide policy) 

Written Competency-based Goals and Objectives: (provide curriculum 

documentation) 

General Competencies Curriculum and Measurement Compliance: (provide one 

example per ACGME general competency of curricula and assessments) 

Simulation Center Activities: (list learning modules used and numbers participating 

with each activity) 

Resident Responsibilities: (describe the process for graduated responsibility and 

autonomy with supervision appropriate to the level of resident expertise and seniority) 

Resident Supervision: (provide a narrative describing relationships and levels of 

resident supervision within the program) 

Formal Resident and Faculty Evaluation Policy and Process: (provide policy and 

describe processes) 

Formal Rotation Evaluations: (with examples) 

Learning Portfolio: (describe the tool(s) used to document an organized collection of 

past and current learning accomplishments and scholarly activities used to reflect and 

assess general competencies and progressive practice capabilities. Provide one 

learning portfolio example and describe the process for reviewing resident/faculty 

academic performance) 

Residents/Fellows: 

Faculty: 

Master Affiliation Agreements & PLA’s: Provide a copy of each ACGME-defined 

required agreement. 

Definition: There must be a program letter of agreement (PLA) between the program and 

each participating site providing a required assignment. The PLA must be renewed at least 

every five years. 

48

For each required PLA complete the following table by marking an “X” in the appropriate 

column. Copy and repeat table as needed. 

Agreement with: 

Does the agreement identify faculty with 

supervisory responsibilities? 

Does the agreement specify responsibilities for: 

Teaching 

Supervision 

Formal Evaluation 

Does the agreement specify the duration and 

content of the educational experience? 

Does the agreement state the policies and 

procedures that will govern resident education 

during the assignment? 

Please answer the following question by 

inserting the word Yes, No, or N/A in the 

appropriate column. 

Has the program made all RRC required 

additions or deletions through ACGME ADS? 

Explain below. 

Last renewal 

Date: 

YES 

YES/NO 

NO 

N/A 

Duty Hours Compliance with Documentation: Provide description of process 

through which you monitor compliance with duty hour standards. Include New 

Innovations summative report including list of exceptions and responses) 

Resident Fatigue Policy, Monitoring, and Education: (provide departmental policy 

and list training initiatives) 

Patient Safety & Quality of Care Education: (provide a narrative describing resident 

participation in patient safety and quality of care education) 

Hand-off Process: (provide a narrative describing transition of care and attach written 

policy regarding hand-offs) 

Department Evaluation & Plan: (provide evaluation summary and improvement 

plans) 

Future Initiatives Based Upon Department Evaluation and Plan: 

49




POLICY TITLE: 

GMEC Policy Review 

It is the policy of the GHS Graduate Medical Education Committee that the GMEC Policy Manual and policies 

will be reviewed for affirmation and/or amendment at least every two years. 













50

IV. INTERNAL REVIEWS 

51

GMEC Policy #: IV‐01‐11 

Page 1 

Institutional Requirements: IV.A‐B 


POLICY TITLE: 

Internal Reviews 

It is the policy of the GHS Graduate Medical Education Committee that an internal programmatic review of 

each graduate medical education residency program will be conducted on a regular basis by the Graduate 

Medical Education Committee (GMEC) through an appointed internal review committee. 

Procedures: 

1. Internal reviews must be in process and documented in the GMEC minutes by 

approximately the midpoint of the accreditation cycle. The accreditation cycle is 

calculated from the date of the meeting at which the final accreditation action was taken to the 

time of the next site visit. The internal review is considered complete when the report is accepted 

by GMEC. Probation‐designated or programs with significant RRC deficiencies may be reviewed 

with required action plans more frequently. 

2. When a program has no residents enrolled at the mid‐point of the review cycle, the 

following circumstances apply: 

a. The GMEC will demonstrate continued oversight of those programs through a 

modified internal review that ensures the program has maintained adequate 

faculty and staff resources, clinical volume, and other necessary curricular 

elements required to be in substantial compliance with Institutional, Common and 

specialty‐specific Program Requirements prior to the program enrolling a resident. 

b. After enrolling a resident, an internal review will be completed within the second sixmonth 

period of the resident's first year in the program. 

3. The residency program's Program Director is notified by Academic Services 

Administration that an internal review will be scheduled. The Academic Services 

Administration will coordinate all appropriate logistics for the internal review process. 

4. The internal review committee is appointed by the GHS GMEC Chairperson. (See 

Internal Review Format.) 

5. The designated Residency Program will be provided a copy of the specific steps for the internal 

review process. (See Internal Review Format.) 

6. Upon the resolve of the review process, the results will be reported to the GMEC. (See Internal 

Review Format.) 

7. Upon identification of program deficiencies and/or issues, the residency program will 

submit a written action plan within 60 days to the GMEC. 

8. The designated residency program may be required to provide periodic action plans to 

the GMEC. 

52


Page 2 

POLICY TITLE: 


GHS Graduate Medical Education Review Format 

1. For each internal review, the GMEC chairperson will appoint an Internal Review 

Committee consisting of: 

a. A Department Chair or Program Director from a residency program other than the 

program under review. 

b. Faculty member(s) from residency programs not being reviewed. 

c. Resident(s) from residency programs not being reviewed. 

d. A Residency Program Coordinator from a program not being reviewed. 

e. Designated Institutional Official is an ex‐officio member without vote. 

f. The Administrator for Academic Services will serve as the process coordinator and a voting 

member. 

g. Manager, GME Curriculum is an ex‐officio member without vote. 

h. The Assistant Dean for Graduate Medical Education serves as Chair .... unless 

the program reviewed is within his/her discipline. In that event, the Academic 

Services Administrator will serve as process coordinator and Chair. 

i. Additional internal or external reviewers may be included on the internal review 

committee. Administrators from outside the program may be included. 

2. Review protocol: 

A. The Internal Review Committee will study, review applicable documentation, and assess 

the following: 

1. Compliance with the Common, specialty/subspecialty‐specific Program, and 

Institutional Requirements; 

2. Educational objectives and effectiveness in meeting those objectives; 

3. Educational and financial resources; 

4. Effectiveness in addressing areas of non‐compliance and concerns in previous 

ACGME accreditation letters of notification and previous internal reviews; 

5. Effectiveness of educational outcomes in the ACGME general competencies; 

6. Effectiveness in using evaluation tools and outcome measures to assess a 

resident's level of competence in each of the ACGME general competencies; 

Annual program improvement efforts in: 

a) Resident performance using aggregated resident data; 

b) Faculty development; 

c) Graduate performance including performance of program graduates on 

the certification examination; and 

d) Program quality. 

7. Policies on selection, evaluation, and promotion of residents, disciplinary action, 

supervision of residents, duty hours, and moonlighting. 

53


Page 3 

POLICY TITLE: Internal Reviews 

Materials and data to be used in the review process will include: 

a. The ACGME Common, specialty/subspecialty‐specific Program, and 

Institutional Requirements in effect at the time of the review; 

b. Procedures and documentation regarding compliance with duty hours 

requirements. 

c. Accreditation letters of notification from previous ACGME reviews and 

progress reports sent to the respective RRC. 

d. Reports from previous internal reviews of the program; 

e. Resident evaluations of the faculty and the overall program; 

f. Previous annual program evaluation; and 

g. Results from internal and external resident surveys, if available. 

B. The Internal Review Committee will conduct interviews with the program director, key 

faculty members, at least one peer‐selected resident from each level of training in the 

program, and other individuals deemed appropriate by the committee. 

C. Interview session(s) with the residents and faculty of the program being reviewed will be 

conducted and documented on behalf of the committee. 

D. Questionnaires will be developed and distributed separately to the reviewed 

program's faculty and residents. 

E. The Internal Review Committee will discuss and analyze the results of the faculty and 

resident interviews and received questionnaires. 

F. Internal Review Report 

1. The written reports of the internal review committee for each program will 

contain, at a minimum: 

a. The name of the program reviewed, the date of the assigned midpoint, the 

status of GMEC oversight of the internal review at the midpoint, and the 

date the written report is approved by the GMEC; 

b. The names and titles of the internal review committee members; 

c. A brief description of how the internal review process was conducted, 

including the list of the groups/individuals interviewed and the documents 

reviewed; 

d. Sufficient documentation to demonstrate that a comprehensive review 

followed the GMEC's internal review protocol; and 

54


Page 4 

POLICY TITLE: 


e. A list of the citations and areas of non‐compliance or any concerns or 

comments from the previous ACGME accreditation letter of notification 

with a summary of how the program and/or institution subsequently 

addressed each item. 

2. The DIO and the GMEC will monitor the response by the program to actions 

recommended by the GMEC. 

3. The GMEC may request follow‐up progress reports at specified intervals. 













55

GMEC Manual Rev 052212 - Greenville Hospital System

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?