House Staff Manual - Winthrop University Hospital

Graduates of medical schools outside the United States who have completed a Fifth Pathway programprovided by an LCME-accredited medical school.Residents who have completed their basic residency and are applicants for residency in subspecialtyprograms shall be graduates of ACGME-accredited programs.SELECTION CRITERIAThe Program Director is responsible for selecting from among eligible applicants on the basis of theirpreparedness, ability, academic credentials, communication skills, personal qualities such as motivation andintegrity and professionalism. Each Program Director has program-specific policies which provide greaterspecificity to the above criteria.APPOINTMENT PROCEDURES/REAPPOINTMENTSThe Program Director reviews applicant credentials and qualifications to determine eligibility forappointment at WUH. Applicants are responsible for providing all the required credentials andemployment eligibility requirements to WUH prior to their appointment.Once the Program Director has selected an applicant for a residency position, the Office of AcademicAffairs reviews all academic credentials to ensure that the eligibility requirements have been met.Contracts are issued for one year.Reappointments are made based on satisfactory completion of the current post-graduate year. Exceptunder extraordinary circumstances, notification of intent not to renew is given no later than four monthsprior to the end of the current contract year.39. ESCALATION POLICYThe following policy delineates the responsibility of the healthcare provider in recognizing and reportingconcerns, problems and emergencies in the health care delivery system that threaten the welfare and safetyof the patient, patient’s family or hospital personnel. It defines the chain of command to be followed forescalation.POLICY1. The following is a list of conditions that might require escalation. It is not totally inclusive of allconditions or situations that require escalation. Each situation must be evaluated independently.Changes in medical condition that need prompt attentionInappropriate or questionable medical or nursing practiceDiscrepancy in medical or nursing judgmentEthical or legal issues needing prompt resolutionEquipment failureFacility emergenciesEnvironmental emergenciesFailure of clinical or ancillary department to respond to defined needsSuspected Terrorism2. It is the responsibility of all healthcare providers to be knowledgeable about the escalation process andto implement it appropriately.3. Implementation of the escalation process will not result in punitive action toward the initiatingindividual.Rev. 1/08