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EMPLOYMENT 2.1
Employment
Advanced Cardiac Life Support/
Basic Life Support Training
Current ACLS Provider status is mandatory for all fel-
lows and residents. The Office of Graduate Medical Edu-
cation will maintain records for the house staff. A current
copy of an ACLS/BLS certification card must be provided
to the Office of Graduate Medical Education. Re-certifi-
cation classes will be offered on a quarterly basis on cam-
pus at the Washington Hospital Center. To register for a
course, contact Jeff Scheulen at 7-3006 or 7-5421.
Business Ethics and Conduct
The successful business operation and reputation of the
Washington Hospital Center is built upon the principles of
fair dealing and ethical conduct of our employees. Our
reputation for integrity and excellence requires careful
observance of the spirit and letter of all applicable laws and
regulations, as well as a scrupulous regard for the highest
standards of conduct and personal integrity.
The continued success of the Washington Hospital Center
is dependent upon our patients’ trust and we are dedicated
to preserving that trust. Employees owe a duty to the
Washington Hospital Center, its customers, and sharehold-
ers to act in a way that will merit the continued trust and
confidence of the public.
The Washington Hospital Center will comply with all
applicable laws and regulations and expects its directors,
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2.2 EMPLOYMENT
officers, and employees to conduct business in accordance
with the letter, spirit, and intent of all relevant laws and to
refrain from any illegal, dishonest, or unethical conduct.
In general, the use of good judgment, based on high ethical
principles, will guide you with respect to lines of acceptable
conduct. If a situation arises where it is difficult to deter-
mine the proper course of action, the matter should be dis-
cussed openly with your immediate supervisor and, if nec-
essary, with the Office of Graduate Medical Education for
advice and consultation.
Compliance with this policy of business ethics and conduct
is the responsibility of every Washington Hospital Center
employee. Disregarding or failing to comply with this stan-
dard of business ethics and conduct will lead to disciplinary
action, up to and including possible termination of
employment.
Check Out Procedure
House staff are responsible for items issued to them by the
Washington Hospital Center or in their possession or
control, including the following:
I identification badges
I keys
I pagers
I uniforms
All house staff are required to complete a House Officer
Check Out List prior to leaving the Hospital. Check out
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EMPLOYMENT 2.3
forms can be picked up in the Office of Graduate Medical
Education or in the Departments.
All Washington Hospital Center property must be returned
by house staff on or before their last day of work. Final
paychecks will be distributed through the Office of
Graduate Medical Education. Where permitted by applic-
able laws, the Washington Hospital Center may withhold
from the employee’s check or final paycheck the cost of any
items that are not returned when required. The
Washington Hospital Center may also take all action
deemed appropriate to recover or protect its property.
Committees
House staff are assigned to the committees of the Hospital
and Medical Board as appropriate. Committee member-
ship includes, but is not limited to:
I Bioethics
I Pharmacy Therapeutics
I Medical Records
I Code Blue
I Disaster
I Cancer
I Critical Care
I Operating Room
I Research Quality Transfusion Clinical Effectiveness
Steering Committee
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2.4 EMPLOYMENT
Continuity of Care
Graduate Medical Education
Institutional Policy
Approved by GMEC: August 3, 1999
House Staff Continuity Of Care Policy
I. Purpose
To establish a policy for all post-graduate training programs
at the Washington Hospital Center to maintain continuity
of care for our patients and the house staff.
II. Scope
This policy will apply to all post-graduate training pro-
grams at the Washington Hospital Center. All information
contained in this policy shall be used as minimum criteria.
More detailed selection criteria shall be delineated by each
clinical department in its respective departmental policy.
III. Definitions
House Staff or House Officer - refers to all interns, resi-
dents and fellows participating in the Washington
Hospital Center’s post-graduate training program.
IV. Responsibilities/Requirements
A. Duty hours and on-call schedules must be structured in
order to focus on the needs of the patient, continuity of
care and education of the resident.
B. In programs that offer both teaching and non-teaching
services, detailed guidelines must be established by the
program indicating instructions for patient admissions,
procedures for each service and transfer between services.
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EMPLOYMENT 2.5
C. Residents will not normally have responsibility for
patients on the non-teaching service except for emergency
medical response or in the best interest of the patient.
D. Attendings will supervise all patient care responsibilities
and the departments will assume responsibility for ensuring
that residents have easy access to attendings.
Disability Accommodation
The Washington Hospital Center is committed to comply-
ing fully with the Americans with Disabilities Act (ADA)
and ensuring equal opportunity in employment for quali-
fied persons with disabilities. All employment practices and
activities are conducted on a non-discriminatory basis.
Post-offer medical examinations are required only for those
positions in which there is a bona fide job-related physical
requirement. They are given to all persons entering the
position only after conditional job offers. Medical records
will be kept separate and confidential.
Reasonable accommodation is available to all disabled
employees, where their disability affects the performance of
job functions. All employment decisions are based on the
merits of the situation in accordance with defined criteria,
not the disability of the individual.
This policy is neither exhaustive nor exclusive. The
Washington Hospital Center is committed to taking all
other actions necessary to ensure equal employment oppor-
tunity for persons with disabilities in accordance with the
ADA and all other applicable federal, state, and local laws.
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2.6 EMPLOYMENT
Dress Code
Dress, grooming, and personal cleanliness standards
contribute to the morale of all employees and affect the
business image the Washington Hospital Center presents to
its patients and visitors. House staff are expected to pre-
sent a clean and neat appearance and to dress according to
the requirements of their positions. All house staff must
wear a long, white lab coat. Men must wear shirts with
ties, and women, shirts, blouses or sweaters with skirts or
pants. Hospital identification cards and Patient First pins
are issued to all new employees, and must be worn when-
ever on duty.
Graduate Medical Education
Institutional Policy
Approved by GMEC: April 26, 2000
House Staff Scrub Suits
I. Purpose
To establish a policy for all post-graduate training programs
at the Washington Hospital Center for the use and distrib-
ution of Washington Hospital Center scrub suits by the
house staff.
II. Scope
This policy will apply to all house staff who participate in a
graduate medical education (GME) training program at
the Washington Hospital Center.
III. Definitions
House Staff or House Officer - refers to all interns, resi-
dents and fellows enrolled in a MedStar Hospital post-
graduate training program.
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EMPLOYMENT 2.7
Washington Hospital Center Scrub Suits - Hospital
purchased tops and pants bearing the Hospital insignia,
which are routinely worn in areas where surgical and/or
invasive procedures are performed.
IV. Responsibilities/Requirements
A. All employed house staff are authorized to wear
Washington Hospital Center scrub suits while carrying out
their clinical responsibilities.
B. House staff are authorized to wear scrub suits through-
out the Hospital, unless otherwise specified by departmen-
tal policy.
C. House staff are issued a bar code by Linen Distribution
during their orientation process, and are assigned to access
scrub suits from one or more of the Scrub Exchange
Systems.
D. House staff on rotation from other institutions must
request access to the Scrub Exchange System through
Linen Distribution. All scrub suits must be returned prior
to the end of the rotation.
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2.8 EMPLOYMENT
Duty Hours
Graduate Medical Education
Institutional Policy
Policy Number: 2-2
Issued: July 1, 1999
Revised: May 2004
I. Purpose
To establish a policy for all post-graduate training programs
at Washington Hospital Center in order to monitor and
schedule appropriate work/duty hours of house officers,
ensuring that the educational goals of the program and
learning objectives of the residents are not compromised by
reliance on residents to fulfill institutional service obliga-
tions.
II. Scope
This policy will apply to all ACGME-accredited training at
Washington Hospital Center. All information contained in
this policy shall be minimum criteria for house officer duty
hours. More detailed duty hour information shall be delin-
eated by each clinical department in its respective
Departmental Policy for House Officer Duty Hours. The
Graduate Medical Education Committee of each Hospital
must approve all policies.
III. Definitions
House Staff or House Officer - refers to all interns, resi-
dents and fellows enrolled in a MedStar Hospital post-
graduate training program.
Post-Graduate Training Program - refers to a structured res-
idency or fellowship educational program, accredited by
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EMPLOYMENT 2.9
the ACGME, CPME, ADA or other recognized accredit-
ing body, or a non-accredited program which is recognized
by its specialty board, for purposes of clinical education.
Duty Hours - Defined as work time scheduled for all clini-
cal and academic activities related to the residency pro-
gram, including, but not limited to patient care (both
inpatient and outpatient), administrative duties related to
patient care, the provision for transfer of patient care, time
spent in-house during call activities, scheduled academic
activities such as conferences and moonlighting. Duty
hours do not include time for a program of self-study, e.g.,
reading and preparation time spent away from the duty
site.
IV. Responsibilities/Requirements
A. The Program Director is responsible for the duty sched-
ules in his/her respective department. The Program
Director is responsible for making the ultimate decisions
regarding scheduling of all duty hours for residents within
their scope of supervision.
B. On-call rooms are provided for residents with night-
time duty hours.
C. House staff schedules will be tailored to be consistent
with the residency requirements set forth by the
Accreditation Council for Graduate Medical Education
(ACGME) in the Institutional Requirements, Common
Program Requirements and Program Requirements.
1. Duty hours must be limited to 80 hours per week,
averaged over a four-week period, inclusive of all in-
house activities.
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2.10 EMPLOYMENT
2. Residents must be provided with 1 day in 7 free from
all educational and clinical responsibilities when aver-
aged over a four-week period, inclusive of call.
3. A 10-hour time period should be provided between
all daily duty periods and after in-house call.
4. In-house call must occur no more frequently than
every third night, averaged over a four-week period.
5. 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 (for a
total of 30 continuous hours) to participate in didactic
activities, transfer care of patients, conduct outpatient
clinics, and maintain continuity of medical and surgical
care as defined in Specialty and Subspecialty Program
Requirements.
6. No new patients, as defined in Specialty and
Subspecialty Program Requirements, may be accepted
after 24 hours of continuous duty.
7. At-home call must be monitored to ensure that house
staff have 1 day in 7 free from duty as defined above in
IV.C.2 and should a house officer be called into the
hospital from home those hours spent in-house must
counted toward the 80-hour limit.
D. On a periodic basis, Program Directors will be asked to
review their duty hour schedules and processes for ensuring
compliance of their schedules with the Graduate Medical
Education Committee.
E. Any house officer working in excess of the hours men-
tioned in item IV. C.1-7 above should, and is strongly
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EMPLOYMENT 2.11
encouraged to report the situation to their Chief Resident,
Program Director, Department Chair, Director, Medical
Education, or the Senior Vice President, Medical Affairs.
F. Each department must have its own Policy for House
Officer Duty Hours, which is approved by the Graduate
Medical Education Committee.
Duty Hour Extension Policy
Graduate Medical Education
Institutional Policy
Approved by GMEC: November, 2003
I. Purpose
To establish a policy for all post-graduate training
programs the Washington Hospital Center to request insti-
tutional endorsement for duty hour extension applications
to the Residency Review Committees (RRC).
II. Scope
This policy will apply to all ACGME-accredited training
programs at Georgetown University Hospital.
III. Definitions
House Staff or House Officer – refers to all interns, resi-
dents and fellows enrolled in a Washington Hospital
Center post-graduate training program.
Post-Graduate Training Program – refers to a structured
residency or fellowship educational program, accredited by
the ACGME, CPME, ADA or other recognized accredit-
ing body, or a non-accredited program which is recognized
by its specialty board, for purposes of clinical education.
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2.12 EMPLOYMENT
Duty Hours – Defined as work time scheduled for all
clinical and academic activities related to the residency
program, including, but not limited to patient care (both
inpatient and outpatient), administrative duties related to
patient care, the provision for transfer of patient care, time
spent in-house during call activities, scheduled academic
activities such as conferences and moonlighting. Duty
hours do not include time for a program of self study, e.g.,
reading and preparation time spent away from the duty
site.
Duty Hour Extension – refers to the ACGME’s exception
to the Duty Hour Requirement whereby individual resi-
dency programs may request up to a 10 % addition to the
80-hour limit based on a sound educational rationale.
Prior permission of the GMEC is required.
IV. Responsibilities/Requirements
A. All requests for duty hour extensions must be reviewed
and approved by the Graduate Medical Education
Committee (GMEC). In order to be placed on the agenda
for the GMEC meeting, the following information must
be submitted to the Graduate Medical Education Office
(GME Office) at least 2 weeks’ prior to the next meeting.
1. Documentation that the program is accredited and in
good standing (continued full accreditation or full
accreditation) without a warning or a proposed or con-
firmed adverse action.
2. Information that describes how the program and
institution will monitor, evaluate, and ensure patient
safety with extended resident work hours.
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EMPLOYMENT 2.13
3. The educational rationale in relation to the program’s
stated goals and objectives for the particular assign-
ments, rotations, and level(s) of training for which the
increase is requested.
4. Specific information regarding the program’s moon-
lighting policies for the periods in question.
5. Specific information regarding the resident call sched-
ules during the times specified for the exception.
6. Evidence of faculty development activities regarding
the effects of fatigue and sleep deprivation.
The GMEC will review all of the documentation for edu-
cational justification of a duty hour extension. The
GMEC will not endorse any extension that is not com-
pletely warranted for educational reasons.
B. Procedure: If approved by the GMEC, all of the above
information should be sent to the GME Office in addition
to:
1. A written statement of institutional endorsement of
the requested duty hour extension signed by the
Designated Institutional Official (DIO).
2. A copy of this policy.
3. The current accreditation status of the program and
of the sponsoring institution.
The Director of Graduate Medical Education will forward
the request to the respective RRC.
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2.14 EMPLOYMENT
Evaluation Policy
Graduate Medical Education
Institutional Policy
Approved by GMEC: April 26, 2000
Revised: May 2004
Evaluation of House Officers
I. Purpose
To establish a policy for all post-graduate training programs
at the Washington Hospital Center to use in the formal
evaluation of house officers’ performance and for the house
officers’ evaluation of the hospital and the program.
Evaluation is utilized to enhance the educational process.
II. Scope
This policy will apply to all Graduate Medical Education
(GME) training programs at the Washington Hospital
Center. All information contained in this policy shall be
used as minimum criteria for evaluation. More detailed
evaluation criteria shall be delineated by the clinical depart-
ments in their respective Departmental Evaluation Policies.
III. Definitions
House Staff or House Officer – refers to all interns,
residents and fellows participating in a MedStar Hospital
post-graduate training program.
Post-Graduate Training Program – refers to a residency or
fellowship educational program.
Remediation – the act or process of remedying or correct-
ing; see Policy for Fair Hearing
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EMPLOYMENT 2.15
Probation – A formal level of academic or professional
discipline; see Policy for Fair Hearing
IV. Responsibilities/Requirements
A. Evaluation of House Officers
1. To enhance the educational process and keep all
house officers apprised of their educational progress/
advancement, all Program Directors (or designees) must
formally evaluate each house officer at six (6) month
intervals. These evaluations shall be in writing, dated,
and signed by the Program Director, attesting that
he/she has verbally discussed the evaluation with the
house officer.
2. All formal evaluations must be kept as part of the
House Officer’s personnel file and be available upon
request of the house officer at all times.
3. At the conclusion or termination of each house
officer’s training, a formal summation of performance
during the duration of training will be completed by the
Program Director and maintained as permanent docu-
mentation of the program. A copy of this final evalua-
tion will be forwarded to the Office of Graduate
Medical Education for permanent archiving.
4. All documentation of house officers’ performance by
the faculty, formal or informal, must be maintained as
permanent documentation by the department.
5. The Program Director shall be responsible for com-
municating the Departmental Policy for Evaluation to
all house staff and faculty.
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2.16 EMPLOYMENT
6. Evaluations will be one of the tools utilized in deter-
mining promotion, as specified in the Policy for the
Promotion of House Officers.
B. Evaluation by House Officers
1. Each Program Director shall assure that at least annu-
ally, each house officer formally evaluates the teaching
faculty and the program in writing.
2. These evaluations should be anonymous and confi-
dential. Program Directors must assure house officers
are free to comment frankly and openly without fear of
intimidation or retaliation.
3. In addition to the departmental evaluation process,
the Office of Graduate Medical Education will conduct
an annual end-of-the-year summary evaluation of the
program, the institution and the overall educational
experience. All house officers are required to complete
the institutional evaluation. Reports of the evaluation
will be communicated to the Program Directors and the
Graduate Medical Education Committee.
C. Disciplinary Action
1. House Officers are expected to meet and adhere to
academic, clinical and professional standards set forth
by the Institutional and Program Requirements, as well
as the Institution and the Department. If at any time a
house officer exhibits unsatisfactory performance, reme-
diation is necessary. In most circumstances, the house
officer will continue to perform his/her daily duties dur-
ing the remediation process. If, however, it is felt that
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EMPLOYMENT 2.17
patient care may be compromised, the resident may be
removed from clinical responsibilities pending the Fair
Hearing.
2. Inadequate performance should be clearly communi-
cated, in writing, to the house officer as early as possi-
ble, and at minimum, at the six-month formal evalua-
tion.
3. If the Program Director deems it necessary, the house
officer may be placed on one of two levels of interven-
tion:
a. Departmental Remediation: Any house officer
whose performance is assessed to be unsatisfactory
by the Program Director may be placed on
Departmental Remediation.
—The Program Director shall inform the house
officer in writing of the deficiencies noted in
academic, clinical, or professional performance.
An improvement program will be developed to
include: the duration of the remediation pro-
gram, the definition of successful completion of
the program, and the consequences of failure to
successfully complete the remediation program.
Improvement is the responsibility of the house
officer. This documentation will be maintained in
the house officer’s departmental file.
—Departmental Remediation must be assigned
for a specific period of time, not to exceed twelve
(12) months in duration.
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2.18 EMPLOYMENT
—Upon successful completion of Departmental
Remediation, the house officer will be removed
from this disciplinary status. Documentation will
remain part of the house officer’s departmental
file, but will only be disclosed upon written
authorization of the house officer or through legal
process, unless otherwise required by a specialty
organization.
—If the Departmental Remediation is not suc-
cessfully completed, the Remediation may be
repeated for up to another six (6) month period,
or the Program Director may increase the level of
discipline to Institutional Probation (see below).
—Departmental Remediation is not considered
to be a reportable disciplinary action, unless oth-
erwise required by a specialty organization.
—Assignment of Departmental Remediation is
not grounds for a house officer to request a Fair
Hearing.
b. Institutional Probation: If a house officer fails
to meet the requirements as set forth in
Departmental Remediation, or it has been deter-
mined that the house officer has committed an
egregious act, Institutional Probation, may be
assigned.
—The Program Director shall inform the house
officer in writing of the decision to place him/her
on Institutional Probation status. This letter
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EMPLOYMENT 2.19
must be copied to the Director of Medical
Education/VPMA for the house officer’s perma-
nent file.
—This letter should contain a very specific pro-
gram for remediation, as well as criteria (goals and
objectives) for successful completion of the
probation.
—Institutional Probation must be assigned for a
specific period of time, not to exceed one (1) year
in duration.
—Upon successful completion of Institutional
Probation, the house officer will be removed from
this disciplinary status. Documentation will
remain part of the house officer’s permanent file,
but will only be disclosed upon written authoriza-
tion of the house officer or through legal process,
unless otherwise required by a specialty organiza-
tion.
—If the Institutional Probation is not successfully
completed, the Probation may be repeated for
another six (6) month period, or the house officer
may be recommended for termination (Refer to
the Policy for Termination and the Policy for
Promotion).
—Assignment of Institutional Probation is
considered to be grounds for a house officer to
request a Fair Hearing.
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2.20 EMPLOYMENT
General Responsibilities
Graduate Medical Education
Institutional Policy
Approved by GMEC:
General Responsibilities of House Staff
I. Purpose
To establish a policy for all post-graduate training programs
at the Washington Hospital Center providing guidelines to
house staff regarding their general responsibilities as post-
graduate trainees.
II. Scope
This policy will apply to all house officers participating in
post-graduate training programs at the Washington
Hospital Center. More specific guidelines may be devel-
oped by each Program, and approved by the Graduate
Medical Education Committee.
III. Definitions
House Staff or House Officer - refers to all interns, resi-
dents and fellows participating in a MedStar Hospital
post-graduate training program.
Post-Graduate Training Program - refers to a residency or
fellowship educational program.
IV. Responsibilities/Requirements
A. Each house officer is expected to avail himself/herself of
the educational opportunities offered within the institu-
tion, provide medical treatment to the hospital’s patients in
a competent and caring manner, and conduct himself/her-
self in a moral, ethical and professional manner at all times.
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EMPLOYMENT 2.21
B. To meet these responsibilities, the house officer is
expected to:
1. Attend and actively participate in all conferences and
teaching rounds within the assigned department.
2. Render appropriate medical care to our patients in a
kind and caring manner under the supervision of the
attending physician.
3. Attend assigned clinics.
4. Participate in the evaluation of the program, his/her
peers and teaching faculty as requested by the Program
Director.
5. Do independent study using the services and
resources offered through the medical library.
6. Participate in research projects and quality improve-
ment activities of the Hospital.
7. Document care and complete/sign patient medical
records in a timely manner.
8. Volunteer to serve as a member of various staff and
hospital committees.
9. Be on time and present for all assignments.
10. Respond to pages promptly.
11. Conduct himself/herself in an ethical and moral
manner.
12. Maintain a professional appearance and comport-
ment.
13. Assume progressive responsibilities as he/she gains
experience.
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2.22 EMPLOYMENT
14. Contribute to the successful operation of the
Hospital.
15. Provide supervision to less senior residents and
medical students.
16. Document completion of procedures and submit
information to program director’s office.
17. “Sign out” before leaving the hospital.
18. Accept “Sign out” from departing house officers.
19. Cooperate with nursing and other staff.
20. Report to the Program Director any event that may
expose you and/or the Hospital to liability.
21. Comply with all departmental policies.
Immigration Law Compliance
Washington Hospital Center is committed to employing
only United States citizens and aliens who are authorized to
work in the United States for any employer on a full-time
basis, and does not unlawfully discriminate on the basis of
citizenship or national origin.
In compliance with the Immigration Reform and Control
Act of 1986, each new house officer, as a condition of
employment, must complete the Employment Eligibility
Verification Form I-9 and present documentation establish-
ing identity and employment eligibility. Former employees
who are rehired must also complete the form if they have
not completed an I-9 with the Washington Hospital
Center within the past three years, or if their previous I-9 is
no longer retained or valid.
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EMPLOYMENT 2.23
House staff with questions or seeking more information on
immigration law issues are encouraged to contact the
Office of Graduate Medical Education. Employees may
raise questions or complaints about immigration law com-
pliance without fear of reprisal.
Levels of Educational Training
Graduate Medical Education
Institutional Policy
Approved by GMEC: May 14, 1996
Revised: December 7, 2004
I. Purpose
To establish a policy for all educational training within
the MedStar Health System, (Washington Division) to
document appropriate types and levels of training in the
institution.
II. Scope
This policy will apply to all graduate medical education
teaching programs within the MedStar Health System
(Washington Division).
III. Definitions
House Staff or House Officer – refers to all interns,
residents and fellows participating in a MedStar Hospital
post-graduate training program.
Post-Graduate Training Program – refers to a residency or
fellowship educational program.
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2.24 EMPLOYMENT
IV. Responsibilities/Requirements
A. Medical Students: American medical students rotate
through the Washington Hospital Center on one of two
levels:
1. Clerkship: Rotation during the third year of
medical school, to fulfill core clerkship or elective
clerkship requirements. Will require the following
documentation:
– Authorization Form signed by the Department
Chairman or designee
– Evaluation of clinical ability during rotation—
forms supplied by the supporting medical school
– Dean’s letter of approval
– Proof of recent physical examination (within one
year)
– Malpractice coverage provided by the supporting
medical school
2. Elective: Rotation during the fourth year of
medical school, to fulfill academic requirements.
Requirements are the same as clerkship.
Institutional Benefits for medical students will include:
I Meal ticktets - $25.00 per month
I Free Parking
I Access to MEDSNET
B. Resident: A physician enrolled in an ACGME-
accredited post-graduate training program. All residents
will be issued one-year contracts at the beginning of the
academic year, July 1.
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EMPLOYMENT 2.25
Admission: Prior to admission and contract, the office
of Graduate Medical Education must have received the
following original documents:
– MedStar/ERAS/Universal Application
– Personal Statement
– Letters of Recommendation (2)
– Official Dean’s Letter
– Official Medical School Transcript
– Copy of DC License or Postgraduate Physician
Enrollment
– ECFMG Certificate if applicable
Residents rotating from other hospitals (JCAHO
accredited): Must provide the office of Graduate
Medical Education with the following items:
– A letter from the Director of Medical Education at
the sponsoring hospital stating that the resident is in
good standing
– Copy of ECFMG certificate (if applicable)
– Proof of recent physical examination (within one
year)
– Copy of DC License or Postgraduate Physician
Enrollment
– Proof of recent immunizations (within one year)
– Proof of malpractice coverage
Institutional Benefits for Residents will include:
I Meal tickets for on-call
I Free parking
I Access to MEDSNET
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2.26 EMPLOYMENT
C. Fellow: A physician enrolled in post-graduate sub-
specialty training. All fellows will be issued one-year
contracts at the start of the academic year, July 1. Two
categories of “Fellow” exist:
1. Clinical Fellow: Regular patient contact is
involved.
Admission: Prior to admission and contract, the office
of Graduate Medical Education must have received the
following original documents:
– Proof of satisfactory completion of approved
residency training from an ACGME-accredited
residency program
– MedStar/ERAS/Universal Application
– Personal Statement
– Letters of Recommendation (2)
– Official Dean’s Letter
– Official Medical School Transcript
– Copy of DC License or Postgraduate Physician
Enrollment
– ECFMG Certificate (if applicable)
2. Research Fellow: Involves incidental or no patient
contact. The purpose of this fellowship is to conduct
research-based studies at the Washington Hospital
Center/MedStar Research Institute.
Admission: Prior to admission and contract, the office of
Graduate Medical Education must have received the
following original documents:
– Satisfactorily completed doctoral degree. (Must
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EMPLOYMENT 2.27
have a degree of either MD, DO, DDS, DPM, or
PhD)
– Satisfactorily completed an approved residency
training program
– ECFMG Certificate (if applicable); not required
for observational only
Fellows rotating from other hospitals (JCAHO
accredited): Must provide the office of Graduate
Medical Education with the following items:
– A letter from the Director of Medical Education at
the sponsoring hospital stating that the fellow is in
good standing
– Copy of ECFMG certificate (if applicable)
– Proof of recent physical examination (within one
year)
– Copy of DC License or Postgraduate Physician
Enrollment
– Proof of recent immunizations (within one year)
– Proof of malpractice coverage
Institutional Benefits for fellows will include:
I Meal tickets for on-call
I Free parking
I Access to MEDSNET
D. Extern: International Medical Graduates or
Medical Students completing one-month training
blocks. Patient contact will be on an observational basis
only.
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2.28 EMPLOYMENT
The following items must be received for approval:
– Approval by Department Chairman and/or
Program Director
– ECFMG Certificate (if applicable); not required
for observational only
– Letter from institution (medical school or hospital)
stating satisfactory status
Institutional Benefits for Externs will include:
I Meal tickets for on-call
I Free parking
I Access to MEDSNET
Medical Licensure
Graduate Medical Education
Institutional Policy
Approved by GMEC: May 2, 2000
Revised: May 2004
Medical Licensure for House Staff
I. Purpose
To establish a policy for all post-graduate training programs
within the MedStar Health System (Washington Division)
to be used in the determination of medical licensure for
house officers.
II. Scope
This policy will apply to all house staff in the MedStar
Health System (Washington Division). All information
contained in this policy shall be used as criteria for medical
licensure.
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EMPLOYMENT 2.29
III. Definitions
House Staff or House Officer – refers to all interns, resi-
dents and fellows enrolled in a MedStar Hospital post-
graduate training program.
Post-Graduate Training Program – refers to a residency or
fellowship educational program.
Practice of Medicine – as defined by the Department of
Health, the application of scientific principles to prevent,
diagnose, and treat physical and mental diseases, disorders,
and conditions and to safeguard life and health. Court
decisions and board policy do not limit the above to
patient care.
IV. Responsibilities/Requirements
A. House staff in the following categories must have a DC
License:
• 4 years past medical school (for US graduates);
• 4 years from the beginning of postgraduate training
(for international graduates)
• enrolled in unaccredited programs
• licensed in another jurisdiction.
House staff are exempt from DC licensure if they are
less than 4 years past medical school (US graduates) or
are less than 4 years from the beginning of their accred-
ited US training (international graduates), are enrolled
in ACGME-accredited programs, and have never been
licensed in another jurisdiction.
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2.30 EMPLOYMENT
B. All house officers who are not exempt from DC licen-
sure regulations must obtain and hold a current D.C.
license for the duration of their training program. Failure
to apply for licensure within a reasonable timeframe prior
to the contract period shall result in termination of the
employment agreement. Failure to renew an existing
license, resulting in an expiration of license, shall result in
termination of the employment agreement.
C. GME Office Responsibilities:
• Maintain current licensure information on all resi-
dents and fellows, including copies of all applicable
licenses.
• Determine annually which house officers require
applications for DC licensure.
• Contact house officers to pick up applications.
• Notify program directors of their house staff who
require licensure.
• Pay license application or renewal fee when a license
is mandated by law, not for moonlighting purposes.
• Mail all applications.
• Follow-up on all applications to ensure that licenses
are received, and secure copies for house staff files.
D. The GME Office will not be responsible for house
officers who do not submit licensure applications in a
timely manner.
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EMPLOYMENT 2.31
E. House Staff Responsibilities:
• Obtain DC license application from the GME
Office.
• Complete licensure applications in full and return to
the GME Office in a timely fashion.
• Submit copies of all licenses to the GME Office.
• House staff are ultimately responsible for submit-
ting their licensure applications within the time
limits, and will be held responsible for fines
incurred as a result of late application.
Moonlighting and Outside Professional
Employment
Graduate Medical Education
Institutional Policy
Policy Number: 2-1
Issued: July 1, 1999
Revised: May 2004
I. Purpose
To establish guidelines for employment outside of the
MedStar Health System employment agreement for
residency and fellowship training.
II. Scope
This policy will apply to all house officers participating in
post-graduate training programs in the MedStar Health
System Washington Division Hospitals.
III. Definitions
House Staff or House Officer - refers to all interns,
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2.32 EMPLOYMENT
residents and fellows enrolled in a MedStar Hospital
post-graduate training program.
Post-Graduate Training Program - refers to a structured res-
idency or fellowship educational program, accredited by
the ACGME, CPME, ADA or other recognized accredit-
ing body, or a non-accredited program which is recognized
by its specialty board, for purposes of clinical education.
Moonlighting - refers to any and all clinical activities
outside of the scope of the defined post-graduate training
program.
Outside Professional Employment - refers to any non-
clinical employment the house officer engages in outside
of the defined post-graduate training program.
IV. Responsibilities/Requirements
A. House Officers are not required to engage in moonlight-
ing; however, moonlighting is permissible as long as, in the
judgment of the Program Director, such activity does not
interfere with the house officer’s ability to meet his/her
educational obligations in a satisfactory manner.
B. The Program Director must prospectively approve, in
writing, all moonlighting of house officers within their
scope of supervision. This written approval will be noted
in the house officer’s file.
C. Moonlighting must be monitored by the program direc-
tor to ensure no adverse effect on house staff performance.
If the program director determines that moonlighting is
negatively impacting house staff performance, the approval
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EMPLOYMENT 2.33
should be rescinded in writing, and documented in the
department file.
D. As a part of the credentialing process, house Officers
who moonlight must obtain, at their own cost, an unre-
stricted state license prior to commencing any moonlight-
ing activity.
E. A house officer who moonlights outside of the MedStar
Health System is not provided coverage of professional lia-
bility insurance by MedStar Health or its affiliates. It is the
responsibility of the moonlighting house officer to obtain
appropriate professional liability insurance for any moon-
lighting activity outside of the MedStar Health System.
Additionally, the house officer must report to the hiring
institution’s medical staff office for credentialing.
F. Any moonlighting occuring within the residency
program or the sponsoring institution must be counted
towards the 80-hour weekly limit on duty hours.
G. Outside professional employment must not interfere
with the house officer’s ability to meet educational objec-
tives in a satisfactory manner.
H. Any house officer holding an H-1B or J-1 visa, by
virtue of INS regulations and ECFMG sponsorship, is not
allowed to accept work or receive income in any capacity
other than that of a resident physician in the specific resi-
dency identified on the DS2019 issued by the ECFMG or
the Labor Conditions Application approved by the INS.
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2.34 EMPLOYMENT
Personnel Data Changes
It is the responsibility of each employee to promptly notify
the Washington Hospital Center of any changes in person-
nel data. Personal mailing addresses, telephone numbers,
number and names of dependents, individuals to be con-
tacted in the event of an emergency, and other such status
reports should be accurate and current at all times. If any
personnel data has changed, notify the Office of Graduate
Medical Education.
Personnel Files of House Officers
Graduate Medical Education
Institutional Policy
Approved by GMEC: September 17, 1996
I. Purpose
To establish a policy for all post-graduate training programs
at the Washington Hospital Center outlining the mainte-
nance and retention of house staff personnel files.
II. Scope
This policy will apply to the management of all personnel
files for the house staff who are enrolled in a graduate med-
ical education (GME) training program at the Washington
Hospital Center.
III. Definitions
House Staff or House Officer - refers to all interns,
residents and fellows participating in a MedStar Hospital
post-graduate training program.
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EMPLOYMENT 2.35
Post-Graduate Training Program - refers to a residency or
fellowship educational program.
IV. Responsibilities/Requirements
A. The Office of Graduate Medical Education serves as
the personnel office for the house officers. To that end, all
employment documents and verifications shall be received,
reviewed, and filed by the GME Office in the house staff
personnel files.
B. Residents shall have access to their files upon request.
C. The following information will be contained in each
personnel file:
CURRENT HOUSE OFFICER Files:
SECTION 1: Personal History/Personnel Information
SECTION 2: Contracts & Diplomas in chronological
order
SECTION 3: All correspondence to, from, or about
the house officer D.C. License, when
obtained
SECTION 4: Loan Deferment forms
Check requests
(travel, educational expenses)
SECTION 5: All ECFMG/Visa paperwork (if
applicable)
SECTION 6: Application Materials:
– Washington Hospital Center Application or
Universal Application
– Official (original) Transcripts
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2.36 EMPLOYMENT
– Personal Statement
– Dean’s Letter
– Letters of Recommendation:
– Residents - 2
– Fellows - 3
– USMLE Step 1 & 2 Scores (if applicable)
Each department may keep photocopies of any and all
personnel materials. In addition, each Program
Director or Chairman is responsible for maintaining
departmental files with the following original docu-
ments:
– Evaluations of house officers
– House officer evaluations of faculty
– Correspondence between the house officer and the
program director
– Procedure logs
Upon conclusion of the training period, the Office of
Graduate Medical Education shall house all alumni files.
Each program director is responsible for transferring
departmental files on the house staff to GME for perma-
nent storage. Upon request, files will be available to the
Program Director or Chairman within one (1) working
day. All requests for verification of residency that requires
the Program Director or Chairman’s comment on clinical
performance will be forwarded to the appropriate person
with the respective file. The following information shall be
maintained in the alumni file:
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EMPLOYMENT 2.37
ALUMNI Files:
SECTION 1: Final Statement of Resident Status
Personal History/Personnel Information
SECTION 2: Contracts & Diplomas in chronological
order
SECTION 3: Pertinent correspondence
– D.C. License, when obtained
– Final loan deferment papers
– Any additional departmental information
SECTION 4: Department Evaluation Forms
SECTION 5: ECFMG Certificates, VISA
(if applicable)
SECTION 6: Application Materials:
– Washington Hospital Center Application Form
– Universal Application
– Official Transcripts
– Personal Statement
– Dean’s Letter
– Two Letters of Recommendation
– USMLE Step 1 & 2 Scores (if applicable)
Physical Examinations and Drug Testing
To help ensure that house staff are able to perform their
duties safely, physical examinations and drug screen are
required.
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2.38 EMPLOYMENT
Prior to the first day of work, a physical examination will
be performed either through Occupational Health at the
Washington Hospital Center or through a private physi-
cian. A completed health attestation form is required from
your private physician. The offer of employment and
assignment to duties is contingent upon satisfactory com-
pletion of the exam. If the physical examination reveals
any physical or mental disorder that would prevent the
house officer from completing the essential duties of the
position and reasonable accommodation cannot be made,
then the contract may be terminated.
All house staff are also required by the District of Colum-
bia to have a yearly physical examination and tuberculosis
screening. Physicals and lab tests can be performed by
appointment in Occupational Health or by a private physi-
cian with a completed attestation form. Failure to com-
plete the annual physical will result in disciplinary action.
Current employees may be required to take medical exami-
nations to determine fitness for duty. Such examinations
will be scheduled at reasonable times and intervals and per-
formed in Occupational Health.
Information on medical condition or history will be kept
separate from other house staff information and main-
tained confidentially. Access to this information will be
limited to those who have a legitimate need to know.
It is the Washington Hospital Center’s desire to provide a
drug-free, healthful, and safe workplace. To promote this
goal, all employees are required to report to work in appro-
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EMPLOYMENT 2.39
priate mental and physical condition to perform their jobs
in a satisfactory manner.
To help ensure a safe and healthful working environment,
all new house staff will be asked to provide body substance
samples (such as urine and/or blood) to determine the illic-
it or illegal use of drugs and alcohol.
While on Washington Hospital Center premises and while
conducting business-related activities off Washington
Hospital Center premises, no employee may use, possess,
distribute, sell, or be under the influence of alcohol or ille-
gal drugs. The legal use of prescribed drugs is permitted on
the job only if it does not impair an employee’s ability to
perform the essential functions of the job effectively and in
a safe manner that does not endanger other individuals in
the workplace.
Promotion of House Officers
Graduate Medical Education
Institutional Policy
Approved by GMEC: April 26, 2000
I. Purpose
To establish a policy for all post-graduate training programs
at the Washington Hospital Center to use in the promo-
tion and appointment of house officers to the next level of
post-graduate training.
II. Scope
This policy will apply to all post-graduate training pro-
grams at the Washington Hospital Center. All information
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2.40 EMPLOYMENT
contained in this policy shall be used as minimum criteria
for promotion. More detailed promotion criteria shall be
delineated by each clinical department in its respective
Departmental Promotion Policy.
III. Definitions
House Staff or House Officer - refers to all interns, resi-
dents and fellows participating in a MedStar Hospital
post-graduate training program.
Post-Graduate Training Program - refers to a residency or
fellowship educational program.
Remediation - the act or process of remedying or correct-
ing; see Policy for Fair Hearing.
Probation - A formal level of academic or professional dis-
cipline; see Policy for Fair Hearing.
IV. Responsibilities/Requirements
Promotion:
A. The decision as to whether or not to re-appoint and
promote a house officer to the next level of post-graduate
training shall be made annually by the Program Director
upon review of the house officer’s performance.
B. The Program Director shall consider all evaluations of
the house officer’s performance (refer to the Policy for
Evaluation of House Officers) and any other criteria
deemed appropriate by the Program Director.
C. Program Directors will communicate promotional deci-
sions to the Office of Graduate Medical Education, in
writing, no later than February 1 of each year. If a
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EMPLOYMENT 2.41
Program Director fails to promote a house officer by
February 1, the Program Director is required to officially
notify the house officer in writing of the reason for with-
holding the promotion. The Office of Graduate Medical
Education should be notified immediately upon the
Department’s decision to not renew an employment con-
tract.
D. Any house officer pending promotion due to unsatis-
factory academic performance should be placed on either
Departmental Remediation or Institutional Probation
(refer to the Policy for Evaluation of House Officers and
the Policy for Fair Hearing).
E. In the event that a house officer is on Departmental
Remediation or Institutional Probation at the time of con-
tract renewal, the Program Director may choose to extend
the existing contract for the length of time necessary to
complete the remediation process, not to exceed six
months, or to promote the house officer to the next level.
If the house officer’s performance continues to be unsatis-
factory, he/she may either be placed on the next level of
discipline or terminated.
F. If a house officer is promoted, but then fails to perform,
he/she will be placed on Departmental Remediation or
Institutional Probation, and will follow the guidelines as set
forth in the Evaluation and Fair Hearing Policies.
G. A house officer may request a Fair Hearing in the case
of contract extension or non-renewal (refer to the Policy
for Fair Hearing).
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2.42 EMPLOYMENT
Non-Renewal of Contract:
A. Failure to progress academically or professionally may
be cause for a Program Director (or designated peer review
group) to not renew a house officer’s contract.
B. Evaluations by the teaching faculty must be considered
when the Program Director decides that a contract will not
be renewed for academic reasons.
C. The house officer should have been placed on either
Departmental Remediation or Institutional Probation prior
to a decision of non-renewal of the contract.
D. When a decision is made not to renew a contract, the
House Officer’s status on either Departmental Remediation
or Institutional Probation should be extended to cover the
remainder of the employment period.
E. When a house officer is notified of the decision not to
renew his/her contract, the house officer should also be for-
mally apprised of the right to a Fair Hearing, as detailed in
the Policy for Fair Hearing.
F. The Office of Graduate Medical Education should be
notified immediately upon the Department’s decision not
to renew an employment contract.
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EMPLOYMENT 2.43
Reduction in Force
Graduate Medical Education
Institutional Policy
Approved by GMEC:
I. Purpose
To establish a policy for all post-graduate training pro-
grams at the Washington Hospital Center to state the
intentions of the Center regarding the potential for reduc-
tion or elimination of the resident physician work force
II. Scope
This policy will apply to all post-graduate training
programs at the Washington Hospital Center.
III. Definitions
House Staff or House Officer - refers to all interns,
residents and fellows enrolled in a MedStar Hospital post-
graduate training program.
Post-Graduate Training Program - refers to a residency or
fellowship educational program, accredited by the
ACGME, for purposes of clinical education.
IV. Responsibilities/Requirements
A. There are no planned closures of post-graduate training
programs; however, national debates concerning the excess
number of physicians in the United States continue. It is,
therefore, important to have a policy in place to protect
and assist residents if unforeseen changes occur.
1. All current contracts will be honored.
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2.44 EMPLOYMENT
2. House staff will be notified in writing at least three
months prior to any major change in the residency
program.
3. Every effort will be made to ensure residency pro-
grams will only be eliminated or downsized at the end
of the academic year.
4. Every effort will be made to help each house officer
find alternative training in an ACGME-accredited
program
Restrictive Covenants
I. Purpose
To outline the institution’s position on the use of restrictive
covenants in resident employment contracts.
II. Policy
In accordance with ACGME requirements, the institution
prohibits the use if restrictive covenants in any resident
employment contract. This includes the official contract
offered by the GME Office as well as any communications
from the residency program.
Selection and Credentialing of House Officers
Graduate Medical Education
Institutional Policy
Approved by GMEC: April 26, 2000
I. Purpose
To establish a policy for all post-graduate training programs
within the MedStar Health System (Washington Division)
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EMPLOYMENT 2.45
to use in the selection of house officers. To further estab-
lish a procedure for the credentialing of house officers.
II. Scope
This policy will apply to all post-graduate training pro-
grams in the MedStar Health System (Washington
Division). All information contained in this policy shall be
used as minimum criteria for selection. More detailed
selection criteria shall be delineated by each clinical depart-
ment in its respective Departmental Selection Policy.
III. Definitions
House Staff or House Officer - refers to all interns, resi-
dents and fellows enrolled in the Washington Hospital
Center’s post-graduate training program.
Match - refers to the formal process of matching residents
to hospitals, administered by the National Residency
Matching Program (NRMP).
IV. Responsibilities/Requirements
A. All applicants for a house staff position must be (pend-
ing) graduates of:
1. An LCME (Liaison Committee on Medical Educa-
tion) accredited medical school; or
2. An AOA (American Osteopathic Association)
accredited medical school; or
3. An accredited college for specialty training in
Podiatric Medicine or Oral Surgery; or
4. A medical school listed in the World Health Organi-
zation Directory of Medical Schools; or
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2.46 EMPLOYMENT
5. Completion of a Fifth Pathway program provided by
an LCME-accredited medical school.
B. All applications for House Staff positions must be sub-
mitted by one of the following methods:
1. The Electronic Residency Application Service
(ERAS); or
2. The Universal Application for Residency Training; or
3. Approved Hospital employment application for
residency training.
Department specific policies may designate other means of
application during a post-match period; however, original
applications must still be submitted.
C. The Program Director, or designee, will evaluate
and select the candidates he/she believes to be the most
qualified for the positions available within the training pro-
gram.
D. PROCEDURE. Once an applicant is selected for an
interview, the following procedure must be employed by all
programs:
1. The following credentials must be collected for each
candidate:
a) Application and Personal Statement, completed
and signed.
b) Original Dean’s letter
c) Original (certified) Medical School Transcript
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EMPLOYMENT 2.47
d) Verification of graduation from the Medical
School. (Appointments to PGY-1 positions may be
made prior to graduation, however, it is the respon-
sibility of each Program Director to verify gradua-
tion before the intern begins in the program and file
documentation in the personnel file.)
e) Two (2) letters of reference from attending physi-
cians familiar with the individual’s performance. If
the candidate has previously been in a post-graduate
training program, one letter must be from the can-
didate’s former Program Director.
2. Candidates of medical schools that are not accredited
by the LCME, the AOA or other accredited college for
specialty training must have the following additional
documentation:
a) Official certified translations of all documents list-
ed above in English; and
b) Certification by the Educational Commission of
Foreign Medical Graduates (ECFMG).
3. All candidates should interview with the Program
Director (or designee) and one or more members of
the faculty. Telephone interviews will only be granted
in lieu of a personal interview in the event of business
necessity.
4. All residency programs are expected to participate in
the National Residency Matching Program (NRMP)
and to follow all rules and requirements as set forth by
that organization.
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2.48 EMPLOYMENT
5. All candidates should be evaluated based on the
following minimum criteria:
a) Preparedness
b) Ability
c) Aptitude
d) Academic credentials
e) Communication skills
f ) Personal qualities, such as motivation and
integrity
6. All candidates invited for interviews must be given
the following information in written format:
a) Salary and benefits information
b) Explanation of the Professional Liability coverage
for house officers
c) Any conditions of employment
7. Upon selection (or after the Match), contracts shall
be prepared by the Office of Graduate Medical
Education, and signed by the Director, Graduate
Medical Education.
8. If any of the required credentials documentation, as
identified above, is missing on the effective date of the
contract, the contract may be void.
9. If a prospective house officer fails to graduate, the
contract will be made null and void.
10. MedStar Health is an equal opportunity employer.
Residency programs will not discriminate with regard
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EMPLOYMENT 2.49
to sex, race, age, religion, color, national origin, disabili-
ty, or veteran status.
Supervision of House Officers
Graduate Medical Education
Institutional Policy
Approved by GMEC: January 6, 2004
Revised: May 2004
I. Purpose
To establish a policy for all post-graduate training pro-
grams at the Washington Hospital Center to ensure
increasing amounts of responsibility, appropriate supervi-
sion and procedural competency of house officers and
other educational trainees.
II. Scope
This policy will apply to all post-graduate training pro-
grams at the Washington Hospital Center. All informa-
tion contained in this policy shall be used as minimum
criteria for supervision. More detailed supervision criteria
shall be delineated by each clinical department in its
respective Departmental Supervision Policy.
III. Definitions
Licensed Independent Practitioner – a physician with an
unrestricted license to practice medicine in the appropriate
state.
House Staff/House Officer – refers to all interns, residents
and fellows enrolled in a Washington Hospital Center
post-graduate training program.
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2.50 EMPLOYMENT
PGY – refers to “Post Graduate Year”, or the year of train-
ing the house officer is currently enrolled in past comple-
tion of medical school.
IV. Responsibilities/Requirements
Supervision of Overall Clinical Competency:
A. Every house officer is assigned to a designated clini-
cal service. On call schedules and rotation schedules
are developed by each service to provide residents with
a variety of service and patient mix.
B. Residents are provided increased responsibility for
patient care as they progress through each year level,
but remain under the direct supervision of their attend-
ings and more senior house staff.
C. Chief residents in their senior year of training may
direct their own clinical service under the supervision
of an attending physician.
D. Chief residents who have completed their training
program are licensed independent practitioners who do
not require supervision by attending physicians.
E. In all resident care cases, the ultimate responsibility
for patient care activities rests with the attending physi-
cian, who supervises all resident activities.
F. The requirements for on-site supervision are estab-
lished for and by each department in accordance with
sub-specialty guidelines.
G. It is the responsibility of each Program Director to
establish detailed written policies for supervision in
their respective program. All departmental policies
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EMPLOYMENT 2.51
must be reviewed and approved by the Graduate
Medical Education Committee.
Supervision of Procedural Competency:
A. Residents must be instructed and evaluated in proce-
dural techniques by a licensed independent practitioner
(LIP) who is certified by their training Program
Director as competent to independently perform that
procedure or who has been credentialed by Washington
Hospital Center to perform that procedure.
B. The Department Chair or Program Director is
responsible for identifying the number of procedures
which must be completed successfully prior to the resi-
dent receiving the designation of competence in that
procedure. For procedures performed by residents in
multiple departments, there should be a uniform policy
for the minimum number of procedures necessary to
achieve competence.
C. The Program Director for each department will be
responsible for maintaining an up to date list of resi-
dents who have been certified as competent to perform
procedures independent of direct supervision. This list
will also be maintained in the nursing office for review
by nurses.
D. The program director must also develop a method
for surveillance of continued competency after it is ini-
tially granted.
E. Once the resident has been evaluated as competent
to perform a specific procedure or set of procedures by
an LIP, s/he may perform that procedure independently
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2.52 EMPLOYMENT
after consultation with the patient’s treating physi-
cian. A resident who is determined to be competent
in a specific procedure (the senior resident) may also
teach the procedure to another resident (the junior
resident) and provide immediate supervision. This
immediate supervision by the senior resident; however,
does not replace the required, but not necessarily
immediate, supervision by an LIP.
F. The ability to obtain and document informed con-
sent is an essential component of procedural competen-
cy. The supervising LIP must also supervise and attest
to the trainee’s competence in obtaining and docu-
menting informed consent. Until a trainee is judged
competent in obtaining informed consent, s/he may
only obtain informed consent while supervised by an
individual with credentials in that procedure. It is
recommended that a minimum of five observed IC
discussions be the criteria for each different procedure.
G. Eligible residents should be licensed by the District
of Columbia, as soon as possible. This requirement
will be directed at a departmental level.
Termination/Dismissal of Employment
Graduate Medical Education
Institutional Policy
Approved by GMEC: April 26, 2000
I. Purpose
To establish a policy for all post-graduate training pro-
grams at the Washington Hospital Center for use in the
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EMPLOYMENT 2.53
termination of house staff employment prior to the date of
contract expiration.
II. Scope
This policy will apply to all house staff at the Washington
Hospital Center. All information contained in this policy
shall be used as absolute criteria for dismissal. More
detailed termination/dismissal criteria can be found in the
Departmental Policy for Termination/Dismissal.
III. Definitions
House Staff or House Officer - refers to all interns, resi-
dents and fellows enrolled in a Washington Hospital
Center post-graduate training program.
Remediation - the act or process of remedying or correct-
ing; see Policy for Fair Hearing
Probation - A formal level of academic or professional dis-
cipline; see Policy for Fair Hearing
Termination - the act of severing employment prior to the
date of expiration of the house officer’s contract
IV. Responsibilities/Requirements
A. Termination of a house officer’s employment prior to
the established expiration date of the contract may be nec-
essary due to just cause.
B. Voluntary Termination/Resignation
1. If the house officer desires a termination of employ-
ment, a letter of resignation must be submitted to the
Program Director, at least 30 days in advance, stating
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2.54 EMPLOYMENT
the reason for the action. The 30 days’ notice may be
waived at the discretion of the Program Director.
2. An interview may be requested by the Program
Director and/or the Director of Medical
Education/VPMA (or designee).
3. Termination may be granted with the concurrence of
the Program Director, Department Chairman, the
Director of Medical Education, and the Vice President
of Medical Affairs of the Hospital.
C. Involuntary Termination
1. The Hospital may elect to terminate a house officer’s
employment prior to the established contract expiration
date due to:
a) Academic or Professional (Gross) Misconduct
b) Endangerment of the health or safety of others,
including patients, employees, or other persons.
c) Unsatisfactory performance
d) Abandonment of position/employment
2. The Program Director, with approval of the
Department Chairman, and the Director of Medical
Education, and the Vice President for Medical Affairs,
shall notify the house officer in writing of the decision
to terminate employment.
3. Upon notice of termination, the house officer has
the right to request a Fair Hearing, as described in the
Policy for Fair Hearing.