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					DEPARTMENT OF OPHTHALMOLOGY
Rhode Island Hospital




    2004ResidentManual:
    Policies&Procedures
                                           RHODE ISLAND HOSPITAL


            2004 Resident Manual: Policies &
                      Procedures




                                             Department of Ophthalmology
                                                   Rhode Island Hospital
                                                 593 Eddy Street, APC 712
                                                   Providence, RI 02903
                                         Phone (401) 444-4669 • Fax (401) 444-6187




Disclaimer. This manual is strictly for the use of residents in the Department of Ophthalmology at Rhode Island Hospital only.
                   The use and distribution of this manual outside the Department is strictly prohibited.
Table of Contents
                                                                                           A.        Meetings ........................................................... 23
                                                                                                1.    NEOS ............................................................ 23
                                                                                                2.    AAO .............................................................. 24
    I.          PROGRAM OVERVIEW .............................3                                 3.    ARVO............................................................ 28
                                                                                                4.    Resident Attendance at Meetings ................ 29
    A.          Mission Statement ............................................. 3
                                                                                           B.        Departmental Curriculum ............................ 29
    B.          Program Description ........................................ 3                  1.     Grand Rounds ............................................... 30
          1.      FREIDA Online Program Information .......... 5                                2.     Lectures......................................................... 30
          2.      Contact Information........................................ 6                 3.     BSCS ............................................................. 30

    B.          List of Faculty .................................................... 6     C.        Examinations ................................................... 31
                                                                                                1.     OKAP ............................................................ 31
                                                                                                2.     Board Certification ....................................... 32
    C.          List of Residents ................................................ 7

                                                                                           D.        Resident Daily Responsibilities..................... 33
    *THROUGH AUGUST 6, 2004II.                              GOALS AND                           1.     Schedule ........................................................ 33
    OBJECTIVES                                              7                                   2.     Communication ............................................ 34
                                                                                                3.     Staff. .............................................................. 34
                                                                                                4.     Surgical logs ................................................. 34
    II.         GOALS AND OBJECTIVES.......................8                                    5.     Clinic ............................................................. 34
                                                                                                6.     Consultations ................................................ 35
                                                                                                7.     Documentation.............................................. 36
    A.          Resident Goals and Objectives........................ 8
                                                                                                8.     Resident Advocacy....................................... 36

    B.          Goals and Objectives Based on Site ............... 9
                                                                                           E.        Other................................................................. 36
          1.     Rhode Island Hospital (RIH).......................... 9
                                                                                                1.     Useful Links.................................................. 36
          2.     Providence VA Medical Center (VAMC)...10
                                                                                                2.     Awards and Grants ....................................... 37

    C.          Goals and Objectives Based on Year ...........10
                                                                                           F.        Medical Student Clerkship............................ 37
          1.     Objectives for First Year (PGY-2)...............10
          2.     Objectives for Second Year (PGY-3) ..........11
          3.     Objectives for Third Year (PGY-4) .............12                         G.        To Come? ......................................................... 37
                                                                                             1.        Faculty Mentor.............................................. 37
                                                                                             2.        Resident Bags ............................................... 37
    D.          Subspecialty Goals and Objectives...............12
          1.      Cataract..........................................................12
          2.      Retina .............................................................13   IV.       VA MEDICAL CENTER POLICIES..........39
          3.      Glaucoma.......................................................14
          4.      Cornea and External Disease........................15
          5.      Pathology.......................................................16       A.        Orientation....................................................... 39
          6.      Neuro-Ophthalmology..................................17
          7.      Oculoplastics .................................................18        B.        Policies .............................................................. 39
          8.      Pediatric Ophthalmology..............................19
          9.      Uveitis............................................................20    C.        Surgeries........................................................... 40
          10.     Optics, Refraction, CL, and Low Vision .....21                                1.     Preoperative Evaluation ............................... 40


    III. DEPARTMENT OF OPHTHALMOLOGY                                                       V.        GME POLICIES ........................................41
    POLICIES .............................................................23
A.         GME Organization .........................................41                   1.       Deaths/Autopsy ............................................ 86
     1.     GME Office ...................................................41              2.       Clinical Documentation ............................... 86
     2.     GME Committee Members ..........................41                            3.       Isolation Precautions .................................... 87
     3.     Institutional Commitment.............................42                       4.       OR Scheduling Guidelines........................... 88
     4.     ACGME.........................................................42              5.       Organ and tissue Donation........................... 88
                                                                                          6.       Pathology ...................................................... 88
B.         General Residency Information....................43                            7.       Physician-Patient Communication .............. 89
     1.     Benefits..........................................................43          8.       Lifespan's Joint Privacy Policy.................... 90
     2.     Cafeteria Hours/Services ..............................45
     3.     Certificates.....................................................45      C.         Support Services & Resources...................... 92
     4.     House Officer's Contract ..............................45                     1.      Bloodborne Pathogen Exposure .................. 92
     5.     Uniforms/Laundry.........................................45                   2.      Clinical Social Work .................................... 92
     6.     Loan Deferment/Forbearance.......................46                           3.      Interpreter Services....................................... 93
     7.     Mail and Notices ...........................................46                4.      Chaplain services.......................................... 94
     8.     Malpractice ....................................................47            5.      Counseling Support Services....................... 94
     9.     Medical Licensure.........................................47                  6.      Ethics Committees........................................ 94
     10.    Controlled Substance Registration...............47                            7.      Risk Management......................................... 95
     11.    Extracurricular Employment........................48                          8.      Lifespan Intranet........................................... 96
     12.    Notary Public.................................................49              9.      Lifespan Library ........................................... 97
     13.    Paging ............................................................49         10.     Pharmacy Services at Lifespan.................... 98
     14.    On-Call Sleep Rooms ...................................49                     11.     OnCall Data. Prescription Services ............. 98
     15.    On-Call Meals Policy ...................................50                    12.     Bioterrorism .................................................. 98
     16.    Parking...........................................................50          13.     Security ......................................................... 99
     17.    Payroll............................................................50         14.     Dictations ...................................................... 99
     18.    Stipends .........................................................50
     19.    Vacation Policy .............................................51
     20.    Absenteeism ..................................................52         APPENDIX A. MINIMUM NUMBERS ...............103
     21.    On site day care center..................................52
     22.    Banking facility & ATM ..............................52
     23.    Employee Health Services............................52                   APPENDIX B. VACATION REQUEST FORM .104
     24.    Employee assistance program ......................53
     25.    Employee activities.......................................54
     26.    Fitness & Wellness Center ...........................54                  APPENDIX C. RESIDENT EVALUATIONS .....105

C.         Graduate Medical Education Policies..........54
                                                                                     APPENDIX D. RESIDENT SCHEDULE............113
     1.     Compensation................................................54
     2.     Inspection of House Staff Files:...................54
     3.     Leave of absence...........................................55
                                                                                     APPENDIX E. SURGICAL EVALUATION .......115
     4.     Selection for House Officers ........................55
     5.     Promotion/Advancement of House Officers57
     6.     Evaluation of House Officers.......................58
     7.     Supervision of House Officers.....................61
     8.     Due Process of House Officers ....................62
     9.     Visas...............................................................70
     10.    Resident Work Hours ...................................71


VI.        HOSPITAL POLICIES ..............................74

A.         Hospital Policies ..............................................74
     1.     Affirmative Action........................................74
     2.     Bereavement/Funeral Leave.........................74
     3.     Identification Badge Policy ..........................75
     4.     Jury Duty and Related Absence ...................76
     5.     Leave of Absence..........................................77
     6.     Mandatory Training/Education ....................78
     7.     Smoke-Free Policy........................................79
     8.     Sexual Harassment........................................79
     9.     Solicitations on RIH Premises .....................80
     10.    Drug-Free Workplace ...................................80
     11.    Holidays.........................................................82
     12     Internet Email Usage ....................................83
     13.    Emergency Preparedness..............................85

B.         Patient Care Policies .......................................86
                                                                             1
                                                                              Chapter




I. Program Overview

A.     Mission Statement


T
       he primary purpose of the program is to produce superior clinical, surgical and
       academic ophthalmologists who are trained in all areas of modern clinical and
       surgical skills. The residents are afforded a rich clinical and surgical experience due
       to the volume and diversity of ophthalmic diseases at Rhode Island Hospital and the
Veteran’s Administration community.
The clinical and surgical experience of the program is complemented by a rigorous academic
lecture schedule designed to promote resident advancement in medical and surgical
knowledge and to develop fine presentation skills. The residents are urged to pursue research
and scholarly activities and to participate in the development of new knowledge, learn to
evaluate research findings and develop habits of inquiry as a continuing professional
responsibility. The responsibility for establishing and maintaining an environment of inquiry
and scholarship rests with our faculty.
The residents’ growth should parallel their personal development. During their training,
many will form lifelong relationships both professionally and socially. We encourage our
residents to pursue their extracurricular interests to bring about compassionate and well-
balanced physicians.
The ophthalmology training program will provide each resident the support and resources
needed to help maintain and develop these relationships, to meet family obligations and
handle personal issues they may encounter during their three years with us.
The quality of education offered by the Brown program ranks highly among its peers, yet a
committed faculty continuously searches for new ways to improve upon its structure. Your
participation and feedback regarding your experience is welcome.
                                                        William G. Tsiaras, M.D, Chairman


B.     Program Description


L
       ifespan, Rhode Island’s first health system, was founded in 1994 and it’s partners include
       the region’s best names in health care: The Rhode Island Hospital (RIH), Miriam
       Hospital, Bradley Hospital, and Newport Hospital. In 2001, Lifespan reported 1,174 beds,


                                               3
9,852 employees, 2,407 affiliated physicians, 173,403 emergency department visits, and 48,050
patient discharges.
RIH is a private, not-for-profit acute care hospital. Founded in 1863, RIH has grown to become
the oldest and largest hospital in Rhode Island, the fourth largest in New England and a nationally
recognized research and academic medical center. It serves as the level one trauma center for
southeastern New England with both pediatric and adult capabilities. The emergency department
sees more than 100,000 patients a year; more than 22,000 of them are trauma patients. This makes
the emergency department at Rhode Island Hospital one of the five busiest in the United States.
The RIH medical center encompasses Women & Infants Hospital, which is the state’s largest
obstetric and women’s health facility and Hasbro Children’s Hospital, which is RIH’s pediatric
division and the state’s only pediatric referral center. RIH provides a full range of diagnostic and
therapeutic services to patients, with particular expertise in cardiology, oncology, neurosciences,
orthopedics, pediatrics, and ophthalmology. RIH is affiliated with and serves as the major
teaching hospital for Brown Medical School.
The core of the Department of Ophthalmology at RIH is the resident eye clinic. The department
began in 1967 and continues to grow as an academic department. Under the current direction of
William G. Tsiaras, MD the department provides a broad educational experience for its residents
and recognizes that the programs success depends as much on the quality of its residents as much
as it does on the quality of the faculty.
The residency program is a three-year program with two positions annually. Six ophthalmology
residents staff the clinic: two in each postgraduate year (PGY) at the PGY-2, PGY-3, and PGY-4
levels.
Although most of the residency training is at RIH, for the majority of the second year the resident
is assigned to the Providence Veterans Administration Medical Center (VAMC) ophthalmology
clinic. The VAMC is dedicated to providing high quality comprehensive outpatient and inpatient
healthcare to veterans residing in Rhode Island and southeastern Massachusetts. Each veteran
who comes to the Medical Center for care is assured personalized care by a team of health care
providers. A Primary Care Provider coordinates each patient's medical care, patient education
needs and referrals to any of the medical centers 32 subspecialty clinics that include
ophthalmology. The Medical Center's Ambulatory Care Program is supported by a general
medical and surgical inpatient facility that delivers a broad range of services in medicine, surgery,
and behavioral sciences. The medical center has approximately, 199 beds, 150 board certified
physicians, and a total of 740 full-time employees who complete the healthcare delivery team of
professional, technical, administrative and support personnel. Nationally and internationally
recognized clinical research activities enhance patient care in: oncology, heart and lung diseases,
hypertension and psychological disorders. The VAMC is also affiliated with the Brown University
School of Medicine.
The residency program is constructed based on a three-year training program model. These
guidelines are inclusive of both didactic knowledge acquisition and acquired skills transfer, and are
set forth in broad terms on a year-by-year and a subspecialty-by-subspecialty basis. Resident
learning and development is provided through a combination of lectures, supervised patient care,
graduated hands-on procedural and surgical experience, research, and independent study. The
goal of the curriculum is to train ophthalmologists who are capable of providing “state of the art”
comprehensive ophthalmologic care and to help interested residents prepare for additional
fellowship training. Through the eye clinics at RIH and the VAMC, the residents are exposed to a


                                                 4
variety of clinical ophthalmologic problems in a diverse patient population comprised of both
children and adults. Resident education is supplemented by a wide variety of patients examined
each day as part of the ophthalmology consultation service and emergency room coverage. Due
to the number of residents in the program, in lieu of assigning a resident to a subspecialty rotation,
the residents staff subspecialty clinics attended by an ophthalmologist that has completed
fellowship training in that discipline. Subspecialty clinics are dedicated to retina, glaucoma, cornea,
oculoplastics, neuro-ophthalmology, and pediatric ophthalmology. Upon completion of the
residency, graduates should possess the knowledge and experience necessary for membership in
the American Board of Ophthalmology (ABO).
Lifespan Affiliated hospitals
Rhode Island Hospital         Memorial Hospital of RI      Bradley Hospital
The Miriam Hospital           Butler Hospital              Women & Infants Hospital
Providence VA Medical Center Roger Williams Medical Center

1. FREIDA Online Program Information

    FREIDA Online is a database that lists information for all the graduate medical education
    programs (over 7,800) accredited by the ACGME. The AMA and the AAMC collect the
    program data via an annual survey called the National GME Census. Available at:
    http://www.ama-assn.org/ama/pub/category/2997.html.
                         Brown University Program
     Specialty                            Ophthalmology
     Identifier                           240-43-11-142
     Program Director                     William G. Tsiaras, M.D.
     Contact Person                       Sally A. Martone
     Address                              Rhode Island Hospital
                                          593 Eddy Street, APC-712
                                          Providence, RI 02903
     Telephone                            (401) 444-4669
     Fax                                  (401) 444-6187
     E-mail                               samartone@lifespan.org
     Accredited/Required Length           3 Years
     Program Start Date                   July 1
     Participates in ERAS                 No
     Affiliated with US Government        No
     Sponsor                              Rhode Island Hospital
     Participant                          VA Medical Center




                                                    5
2. Contact Information

     Rhode Island Hospital              Providence VA Medical Center
     593 Eddy Street                    830 Chalkstone Avenue
     Providence, RI 02903               Providence, RI 02908-4799
     (401) 444-4000                     (401) 273-7100
     www.rhodeislandhospital.org        www.visn1.med.va.gov/providence

B.      List of Faculty
     CHAIRMAN
        WILLIAM G. TSIARAS, M.D.
     Contact Lens                            Retina
        Dennis Karambelas, O.D.                   Lory Snady-McCoy, M.D.
                                                  Arthur I. Geltzer, M.D.
     Cornea
                                                  Paul Greenberg, M.D.
        Elliot M. Perlman, M.D.                   Robert Janigian, M.D.
        Kent L. Anderson, M.D., Ph.D.             Magdalena G. Krzystolik, M.D.
        Ezra L. Galler, M.D.                      Salvatore Loporchio, M.D.
        Paul S. Musco, M.D.                       Caldwell W. Smith, M.D.
        Richard Rodman, M.D.                      William G., Tsiaras, M.D.
     Glaucoma                                     Timothy You, M.D.
                                                  Harold A. Woodcome, M.D.
        Joseph F. Ducharme, M.D.
        Peter F. DeBlasio, Jr., M.D.
     Neuro-Ophthalmology                     General Attendings
        Marjorie A. Murphy, M.D.                  Mitra Ayazifar, M.D.
                                                  Robert L. Bahr, M.D.
     Oculoplastic
                                                  Peter C. Brasch, M.D.
        Michael E. Migliori, M.D.                 Robert E. Curran, M.D.
        Yoash Enzer, M.D.                         Giulio Diamonte, M.D.
        R. Jeffrey Hofmann, M.D.                  Francis Figueroa, M.D.
        Philip R. Rizzuto, M.D.                   Kendall A. Gibbs, M.D.
     Pathology                                    Thomas P. Lang, M.D.
                                                  Thomas McCauley, M.D.
        King W. To, M.D.                          Dugald H. Munro, M.D.
     Pediatric Ophthalmology                      Stephen J. Richman, M.D.
                                                  Karl F. Stephens, M.D.
        David Robbins Tien, M.D.                  Paul E. Sydlowski, M.D.
        Glenn Bulan, M.D.                         Safa F. Wagdi, M.D.
        John Donahue, M.D.                        Dominick Zangari, Jr., M.D.




                                              6
C.     List of Residents
           PGY1                       PGY2                     PGY3

Molly Ritsema, M.D.             Gaurav Gupta, M.D.   Howard Amiel, M.D.

Theodoros Filippopoulos, M.D.   Xiaoquin Lu, M.D.    Panchal Lavkumar, M.D.
                                                     Svetlana Borohovich, M.D.*
*Through August 6, 2004




                                             7
                                                                                 2
                                                                                  Chapter




II. Goals and Objectives

A.        Resident Goals and Objectives
1) Knowledge. Development of a broad fund of basic science and clinical knowledge
   through lecture, reading, and interactive conference and review sessions.

2) Develop a personal program of self-study and professional growth with guidance from
   the teaching staff.

3) Participation fully in the educational activities such as the regularly scheduled conferences,
   which cover the following subspecialty areas: retina, glaucoma, cornea, oculoplastics,
   neuro-ophthalmology, pediatric ophthalmology, uveitis, low vision, and ophthalmic
   pathology.

4) Participate in safe, effective, and compassionate patient care under supervision,
   commensurate with his/her level of advancement and responsibility.
5) Participate in institutional programs and activities involving the medical staff, and adhere
   to established practices, procedures, and policies of the other institutions participating in
   activities and rotations assigned as part of the specific training program.
6) Conform to Hospital bylaws, policies, procedures, and regulations and applicable federal
   and state laws.
7) Complete all patients’ medical records within the time period specified by the Hospital.
8) Supervised direct patient care experience which allows the resident to:
     a)   Master ophthalmologic examination skills,
     b)   Formulate and workup differential diagnoses,
     c)   Manage clinical problems of increasing complexity,
     d)   Develop and exercise clinical and ethical decision making abilities,
     e)   Develop patient communication techniques, and
     f)   Work effectively as a member of the medical care team.

9. Skills- Graduated supervised procedural and surgical experience including:
     a.) Modern cataract and anterior segment techniques including strabismus and
         oculoplastic techniques,
     b.) Anterior and posterior segment laser surgery,


                                                   8
     c.) Exposure to all areas of subspecialty surgery, and
     d.) Completion of the minimum numbers for operative experience as mandated by the
         Residency Review Committee (RRC) for Ophthalmology (see Appendix A).

10. Development of teaching skills by assuming responsibility for teaching and supervising
    other junior house officers and medical students.

11. To provide residents with exposure to research, to teach them to knowledgeably assess
    research results, and to motivate residents to pursue academic research projects.

12. Participation in the annual Ophthalmology Knowledge Assessment Program (OKAP).
    The OKAP is administered annually in mid-April.

13. Preparation for ABO written and oral board certification exams.

14. Preparation for ophthalmic practice.

     a.) Apply cost containment measures in the provision of patient care.
     b.) Ethics:
         i. Patient care responsibilities and
        ii.      Ethics of inter-collegial relations.
     c.) Risk management.
     d.) Policies of sexual harassment, discrimination, and substance abuse.
     e.) Practice management:
            i) Contractual negotiations,              v. Third party payers,
            ii) Hiring/supervising employees,         vi. Managed care,
            iii) Financial management,                vii. Medicare/Medicaid, and
            iv) Working with associates,              viii. Private insurance.

B.       Goals and Objectives Based on Site
1. Rhode Island Hospital (RIH)

     Each resident will spend the majority of their time at RIH. The resident is expected to
     perform the goals and objectives based on their level of training.
     a.) Outpatient Eye Clinic. Under faculty supervision the resident is expected to:
        i.   See patients with appointments in the eye clinic,
       ii.   See consultations from the emergency department and inpatient settings,
      iii.   Teach and supervise medical students and other residents rotating through the
             Department,
      iv.    Manage patients through medical and/or procedural intervention as indicated,
       v.    To interact professionally with patients, staff, faculty, and other residents, and
      vi.    Obtain experience with the Electronic Medical Records Information System at
             the RIH.
     b.) Operating Room. Under direct faculty supervision the resident is expected to:




                                                  9
        i.     Perform and assist in the surgical intervention of patients seen through the
               General Eye Clinic,
       ii.     Directly coordinate the pre- and postoperative management of the surgical
               patient, and
      iii.     Communicate with operative anesthesia and staff to arrange for the surgical
               management of patients.

2. Providence VA Medical Center (VAMC)

     Each resident will spend the part of his or her time at the VA during his or her PGY-2
     and PGY-3 years. The resident is expected to perform the goals and objectives based on
     their level of training.
     a.) Outpatient Eye Clinic. Under faculty supervision the resident is expected to:
        i.     See patients with appointments in the eye clinic,
       ii.     See consultations from the emergency department and inpatient settings,
      iii.     Manage patients through medical, procedural, and surgical intervention as
               indicated,
      iv.      To interact professionally with patients, staff, faculty, and other residents, and
       v.      Obtain experience with the Electronic Medical Records Information System at
               the VAMC.
     b.) Operating Room. Under direct faculty supervision the resident is expected to:
        i.     Perform and assist in the surgical intervention of patients seen through the
               General Eye Clinic,
       ii.     Directly coordinate the pre- and postoperative management of the surgical
               patient, and
      iii.     Communicate with operative anesthesia and staff to arrange for the surgical
               management of patients.


C.           Goals and Objectives Based on Year
1. Objectives for First Year (PGY-2)

     a.) Development of a core knowledge base through attendance of daily didactic lectures
         in the department’s curriculum, use of the American Academy of Ophthalmology
         (AAO) Basic and Clinical Science Course (BCSC), and presentation and attendance at
         clinical conferences and grand rounds.
     b.) Learning of elementary refraction and contact lens fitting techniques.
     c.) Development of proper techniques involved in a thorough ophthalmologic
         examination of the anterior and posterior segment.
     d.) Acquire a basic understanding of ocular diseases and their medical management.




                                                  10
    e.) Assisting in the supervision, teaching, and evaluation of medical students and
        residents from other specialties rotating through ophthalmology (e.g., emergency
        medicine, etc.).
    f.) To workup and manage general eye clinic patients on initial and subsequent follow-up
        evaluations in the department of ophthalmology at RIH where most of their time is
        spent.
    g.) Performance of supervised minor surgical procedures (e.g., chalazion excision, etc.).
    h.) Development of facility with management of most ophthalmic emergencies via
        emergency room coverage and inpatient consultations.
    i.) Exposure to patients on the subspecialty service with an introduction to examination
        techniques and management of basic problems in the areas of retina, glaucoma,
        cornea, ophthalmic plastics, neuro-ophthalmology, pediatric ophthalmology, and
        uveitis.
    j.) Exposure to ophthalmic pathology with emphasis on clinicopathological correlation.
    k.) Identification of an area of research interest and pursuit of an original project with
        faculty guidance.

2. Objectives for Second Year (PGY-3)

    a.) Reinforcement of their core knowledge base through attendance of daily didactic
        lectures in the department’s curriculum, use of the AAO BCSC, and presentation and
        attendance at clinical conferences and grand rounds.
    b.) Increasing clinical decision making in management of general clinic and emergency
        patients.
    c.) Assisting in supervision and teaching of first year residents.
    d.) To workup and manage general eye clinic patients on initial and subsequent follow-up
        evaluations in the department of ophthalmology at the VAMC where most of their
        time is spent. While at VAMC the second–year resident assumes responsibility for the
        medical and surgical care of these patients.
    e.) Introduction to cataract surgery; the second-year residents will begin performing large
        excision extracapsular cataract surgery with intraocular lens implantation and then
        modify their technique to include scleral tunnel phacoemulsification later in the year
        as they develop more proficiency with intraocular surgery.
    f.) Training in and performance of ophthalmic plastic and strabismus surgery.
    g.) Training in techniques of anterior and posterior segment laser surgery (e.g., YAG
        laser capsulotomy and panretinal photocoagulation).
    h.) Development of interpretative skills in assessing diagnostic tests such as fluorescein
        angiograms, radiologic images, etc.
    i.) Performance of ophthalmic consultations in a general medical hospital and
        emergency room setting.



                                                 11
3. Objectives for Third Year (PGY-4)

     a.) Expanding their core knowledge base through attendance of daily didactic lectures in
         the department’s curriculum, use of the AAO BCSC, and presentation and
         attendance at clinical conferences and grand rounds.
     b.) Increasing clinical and surgical decision making in management of general clinic and
         emergency patients.
     c.) Assisting in the teaching and supervision of first and second year residents.
     d.) Training in the indications for, performance of, and complications of anterior
         segment surgery, including basic techniques and advanced procedures.
     e.) Training on the indications for, performance of, and complications of surgery in the
         subspecialty disciplines of glaucoma, retina, cornea, ophthalmic plastics, and pediatric
         ophthalmology. By the completion of the third year, the number of surgical cases in
         each subspecialty area is expected to far exceed the minimum requirements suggested
         by the residency review committee of the Accreditation Council for Graduate
         Medical Education (ACGME) (See Appendix A.).
     f.) Supervising coverage of the ocular trauma service and learning of the medical and
         surgical management of ocular trauma.
     g.) Most of their time is at RIH with some time spent at the VA Medical Center.
     h.) Act as Chief Resident when assigned:
        i.    Submit call schedule,
       ii.    Submit presentation schedule for Grand Rounds,
      iii.    Responsible for the continuity of care in the eye clinic,
      iv.     Manage the clinic and surgical service and ensure that both are adequately
              covered,
       v.     Set the standard for morale among the house staff and thereby promote the
              highest delivery of quality care to our patients and institute good team spirit, and
      vi.     Ensure that vacation requests are submitted per vacation policy.


D.          Subspecialty Goals and Objectives
1. Cataract

     Although no formal rotation or subspecialty clinic in cataract is arranged, the resident is
     exposed to the diagnosis and management of the cataract as part of the general
     ophthalmology clinic. The summary of the educational goals and objectives for the residents
     in managing cataract include the following:
     a.) Establish a fundamental knowledge of cataract as outlined in the objectives for Section 11
         of the AAO BCSC.
        i.    Describe the normal anatomy, embryologic development, physiology, and
              biochemistry of the crystalline lens.


                                                  12
      ii.   Identify congenital anomalies of the lens.
     iii.   Distinguish types of congenital and acquired cataract.
     iv.    Describe the association of cataracts with aging, trauma, medications, and systemic
            and ocular diseases.
      v.    Appropriately evaluate and manage patients with cataract and other lens
            abnormalities.
     vi.    Explain the principles of cataract surgery techniques and associated surgical
            technology.
    vii.    Develop an appropriate differential diagnosis and management plan for intra-
            operative and postoperative complications of cataract surgery.
    viii.   Identify special circumstances in which cataract surgery techniques should be
            modified and develop appropriate treatment plans.
   b.) To attend didactic lecture sessions on cataract and cataract surgery.
   c.) To receive basic examination techniques, diagnostic testing, and history and physical
       examination methods in the context of cataract; e.g., potential acuity and glare meter
       testing.
   d.) Attend surgical laboratory introductive course to cataract surgery.
   e.) Introduction to the operating room, prepping and draping techniques, forms of
       anesthesia, operating microscope, and immediate postoperative care in the context of the
       cataract patient.
   f.) To understand phacodynamics              and    the    variously      commonly   employed
       phacoemulsification techniques.
   g.) To master A-scan ultrasonography and intraocular (IOL) calculations.
   h.) Mastery of surgical techniques occurs by observation and assisting and when experience
       has been accumulated to perform actual surgical cases as primary surgeon under direct
       supervision by the faculty.
   i.) To understand and perform YAG laser capsulotomy for management of posterior
       capsular opacification.

2. Retina

   The summary of the educational goals and objectives for the resident in the retina
   subspecialty include the following:
   a.) To establish a fundamental knowledge of retina as outlined in the objectives for Section
       12 of the AAO BCSC.
       i.   Describe the basic structure and function of the retina and its relationship to the
            vitreous and choroids.
      ii.   Recognize specific pathologic processes that affect the retina or vitreous.
     iii.   Choose appropriate methods of examination and ancillary studies for the diagnosis of
            vitreoretinal disorders.
     iv.    Incorporate data from major prospective clinical trials in the management of selected
            vitreoretinal disorders.
      v.    Explain the principles of medical and surgical treatment of vitreoretinal disorders.


                                               13
   b.) To attend didactic lecture sessions and clinics attended by board certified
       ophthalmologists who have completed fellowship training in retina.
   c.) To receive basic examination techniques, diagnostic testing, and history and physical
       examination methods in the context of retina.
   d.) To acquire the following examination skills:
      i.   Macula examination through the use of 60 or 90 diopter lens and contact lenses (e.g.,
           macular, three mirror, and goniolens);
     ii.   Indirect ophthalmoscopy with the 20 diopter lens; and
    iii.   Advanced examinations techniques; e.g., color fundus drawings.
   e.) To be familiar with the indications and interpretations of ancillary testing:
      i.   Color fundus photos;
     ii.   Fluorescein angiography (FA) and indocyanine green (ICG) angiography;
    iii.   A and B scan ultrasonography; and
    iv.    Electroretinogram (ERG).
   f.) To recognize and manage the emergent treatments of ancillary testing such as FA.
   g.) To observe and perform laser treatments of the macula and peripheral retina.
   h.) To know key points from landmark studies such as the following:
      i.   Early Treatment Diabetic Retinopathy Study (ETDRS);
     ii.   Diabetic Retinopathy Study (DRS); and
    iii.   Diabetic Retinopathy Vitrectomy Study (DRVS).
   i.) To obverse and assist the diverse group of surgical vitreoretinal procedures and to be
       familiar with their indications. To perform as primary surgery procedures such as core
       pars plana vitrectomy (PPV), vitreous tap/injection, indirect laser photocoagulation, and
       scleral buckle procedures under direct faculty supervision as experience is gained.

3. Glaucoma

   The summary of the educational goals and objectives for the residents in the glaucoma
   subspecialty include the following:
   a.) To establish a fundamental knowledge of glaucoma as outlined in the objectives for
       Section 10 of the AAO BCSC.
      i.   Identify the epidemiologic features of glaucoma, including the social and economic
           impacts of the disease.
     ii.   Summarize recent advances in the understanding of hereditary and genetic factors in
           glaucoma.
    iii.   Outline the physiology of aqueous humor dynamics and the control of intraocular
           pressure (IOP).
    iv.    Review the clinical evaluation of the glaucoma patient, including history and general
           examination, gonioscopy, optic nerve examination, and visual field.
     v.    Describe the clinical feature of the patient considered a “glaucoma suspect”.
    vi.    Summarize the clinical features, evaluation, and therapy of primary open-angle
           glaucoma and normal-tension glaucoma.


                                                14
     vii.   List the various clinical features of and therapeutic approaches for the primary and
            secondary open-angle glaucomas.
    viii.   Explain the underlying causes of the increased IOP in various forms of secondary
            open-angle glaucoma and the impact these underlying causes have on management.
     ix.    Review the mechanisms and pathophysiology of primary-angle glaucoma.
      x.    Review the pathophysiology of secondary angle-closure glaucoma, both with and
            without pupillary block.
      xi.   Outline the pathophysiology and therapy of infantile and juvenile-onset glaucoma.
     xii.   Differentiate among the various classes of medical therapy for glaucoma, including
            efficacy, mechanism of action, and safety.
    xiii.   Compare the indications and techniques of various laser and incisional surgical
            procedures for glaucoma.
    xiv.    Describe cyclodestructive treatment for refractory glaucoma.
     xv.    Summarize the indications for and use of low-vision aids in glaucoma patients.
    b.) To attend didactic lecture sessions and clinics attended by board certified
        ophthalmologists who have completed fellowship training in glaucoma.
    c.) To be familiar with basic examination techniques and diagnostic testing in the context of
        glaucoma; e.g., measurement of IOP.
    d.) To gain experience with interpreting optic discs and visual fields in the context of
        glaucoma.
    e.) Mastery of surgery and laser techniques occurs by observation and assisting and when
        experience has been accumulated to perform actual surgical cases as primary surgeon
        under direct supervision by the faculty.
    f.) To obtain experience in the medical applications of initial and continuing glaucoma
        therapy in children and adults.
    g.) To be familiar with combined surgeries and their respective indications; e.g., cataract
        surgery and trabeculectomy.

4. Cornea and External Disease

    a.) The summary of the educational goals and objectives for the residents in the cornea and
        external disease subspecialty include the following:
       i.   To establish a fundamental knowledge of cornea and external disease as outlined in
            the objectives for Section 8 of the AAO BCSC.
      ii.   Describe the anatomy and molecular biology of the cornea.
     iii.   Explain the pathogenesis of common disorders affecting the eyelid margin,
            conjunctiva, cornea, and sclera.
     iv.    Recognize the distinctive signs of specific disease of the ocular surface and cornea.
      v.    Describe how the environment can affect the structure and function of the ocular
            surface.
     vi.    Outline the steps in an ocular examination for corneal or external eye disease and
            choose the appropriate laboratory and other diagnostic tests.
     vii.   Summarize the developmental and metabolic alterations that lead to structural
            changes of the cornea.


                                               15
    viii.   Identify topographical changes of the cornea and describe the risks and benefits of
            corrective measures.
     ix.    Assess the indications and techniques of surgical procedures for managing corneal
            disease, trauma, and refractive error.
      x.    Apply the results of recent clinical research to the management of selected disorders
            of the conjunctiva and cornea.
     xi.    Integrate the discipline of corneal and external eye disease into the practice of
            ophthalmology.
   b.) To attend didactic lecture sessions and clinics attended by board certified
       ophthalmologists who have completed fellowship training in cornea and external disease.
   c.) To receive basic examination techniques, diagnostic testing, and history and physical
       examination methods in the context of cornea and external disease.
   d.) To learn advanced slit lamp biomicroscopy of the ocular surface, cornea, and anterior
       segment.
   e.) To learn the use of the keratometer, topographer, and pachymeter and to be familiar with
       their applications.
   f.) To be familiar with the use and applications of bandage contact lenses, cyanoacrylate glue,
       and amniotic membrane.
   g.) To appropriately utilize the microbiology laboratory with corneal cultures and smears.
   h.) To be familiar with the appropriate use of antimicrobials and the appropriate use of
       immunosuppression for anterior segment inflammatory diseases.
   i.) To evaluate and manage penetrating injuries to the eye as well as foreign body removal,
       chemical injuries, and corneal abrasions.
   j.) To recognize the basic mechanisms underlying a dry eye, utilize basic diagnostic
       techniques, and devise appropriate treatment strategies.
   k.) To establish a basic fundamental knowledge of the following:
       i.   Photorefractive Keratectomy (PRK);
      ii.   Phototherapeutic Keratectomy (PTK); and
     iii.   Laser in situ Keratomileusis (LASIK).
   l.) To be proficient with the surgical technique of tarsorrhaphy and to understand the basic
       principles of penetrating keratoplasty.
   m.) To be familiar with the etiology and management of corneal perforations.

5. Pathology

   The summary of the educational goals and objectives for the residents in the pathology
   subspecialty include the following:

   a.) To establish a fundamental knowledge of pathology as outlined in the objectives for
       Section 4 of the AAO BCSC.
       i.   Explain the functioning, capabilities, and limitations of an ophthalmic laboratory.


                                                16
      ii.   Summarize the histopathology of common ocular conditions in order to improve
            diagnostic acumen.
     iii.   Explain the basic histopathology of common ocular conditions as viewed by light
            microscopy.
     iv.    Correlate clinical and pathologic findings.
      v.    Identify characteristics that differentiate intraocular tumors.
     vi.    Describe the basic principles of immunohistochemistry, flow cytometry, and
            polymerase chain reaction (PCR).
     vii.   Communicate with the ocular pathologist.
    viii.   Select from the many textbooks available on ocular pathology.
      ix.   Identify ophthalmic lesions that indicate systemic disease.
       x.   Summarize new information about the most common primary tumors of the eye.
      xi.   Identify those lesions that are life threatening to patients.
     xii.   Assess modern treatment modalities for ocular tumors that offer the patient the best
            possible survival and that minimize disfigurement and loss of function.
    xiii.   Describe new and current treatment modalities for intraocular tumors.
    xiv.    Provide useful genetic data to those at risk for developing retinoblastoma.
     xv.    Describe useful ancillary tests that help the clinician to differentiate the various ocular
            tumors.
   b.) To attend didactic lecture sessions and clinicopathological conferences attended by board
       certified ophthalmologists who have completed fellowship training in pathology.
   c.) To obtain intramural laboratory experience in gross and microscopic examination of
       pathological specimens with a qualified pathologist.
   d.) To appropriately utilize the pathology laboratory with surgical specimens.

6. Neuro-Ophthalmology

   The summary of the educational goals and objectives for the residents in the neuro-
   ophthalmology subspecialty include the following:
   a.) To establish a fundamental knowledge of neuro-ophthalmology as outlined in the
       objectives for Section 5 of the AAO BCSC.
       i.   Explain the importance of an accurate and detailed history to the differential
            diagnosis of neuro-ophthalmic disease.
      ii.   Describe the critical importance of follow-up and its potential for modifying the
            diagnosis.
     iii.   Outline the necessity of tailoring the neuro-ophthalmic examination.
     iv.    Select the most appropriate test in order to manage the neuro-ophthalmic problems
            in a cost-effective manner.
     v.     Explain possible systemic implications of ophthalmic disorders.
    vi.     Appraise the anatomy of the visual pathway in order to localize lesions.
    vii.    Define the anatomy of the vascular system and the importance of it to neuro-
            ophthalmic pathology.
    viii.   Describe the association between pupil and eyelid position and ocular motor
            pathology.



                                                 17
      ix.    Review pathophysiology and management of diplopia and central ocular motor
             disorders.
      x.     Assess eye movement disorders and the ocular motor system.
      xi.    Review anatomy of other cranial nerves.
     xii.    Identify the effects of systemic disorders on visual and ocular motor pathways.
    b.) To attend didactic lecture sessions and clinics attended by board certified
        ophthalmologists who have completed fellowship training in neuro-ophthalmology.
    c.) To receive basic examination techniques, diagnostic testing, and history and physical
        examination methods in the context of neuro-ophthalmology.
    d.) To gain experience with interpreting optic discs and visual fields in the context of neuro-
        ophthalmology (Kinetic Goldman, Automated Humphrey, Confrontation, and Amsler
        Grid).
    e.) To learn the physiology and neuroanatomy of the pupil, cranial nerves, and the visual
        sensory and ocular motor pathways.
    f.) To acquire the following examination skills:
        i.   Visual sensory: Visual acuity, pinhole vision, color vision testing, and visual fields;
       ii.   Pupillary examination: afferent pupillary defects and pharmacologic testing;
      iii.   Ocular motor examination: cover/uncover, cross-cover, Lancaster red green, red
             glass and light, deviations (Krimsky, Hirschberg, and prism cover), forced ductions,
             and tests for myasthenia gravis (ice test, Tensilon, and Prostigmin); and
      iv.    Cranial nerve examination.
    g.) To appropriately utilize the laboratory and radiology department with neuro-
        ophthalmologic testing.
    h.) To be familiar with the interpretations of the following radiological images:
       i.    Computed Tomography (CT) and
      ii.    Magnetic Resonance Imaging (MRI), etc.

7. Oculoplastics

    The summary of the educational goals and objectives for the residents in the oculoplastics
    subspecialty include the following:
    a.) To establish a fundamental knowledge of oculoplastics as outlined in the objectives for
        Section 7 of the AAO BCSC.
       i.    Describe the normal anatomy and function of orbital and periocular tissues.
      ii.    Identify general and specific pathophysiological processes (including congenital,
             infectious, inflammatory, traumatic, neoplastic, and involutional) that affect the
             structure and function of these tissues.
      iii.   Choose appropriate examination techniques and protocol for diagnosing disorders of
             the orbit, eyelids, and lacrimal system.
      iv.    Select from among the various imaging and ancillary studies available those that are
             most useful for the particular patient.



                                                18
       v.    Develop appropriate differential diagnoses for disorders of the orbital and periocular
             tissues.
     vi.     Compare the indications for enucleation, evisceration, and exenteration.
     vii.    Distinguish between functional and cosmetic indications in the surgical management
             of eyelid and periorbital conditions.
    viii.    Outline the principles of medical and surgical management of conditions affecting the
             orbit, eyelids, and lacrimal system.
      ix.    Recognize the major postoperative complications of orbital, eyelid, and lacrimal
             system surgery.
    b.) To attend didactic lecture sessions and clinics attended by board certified
        ophthalmologists who have completed fellowship training in oculoplastics.
    c.) To receive basic examination techniques, diagnostic testing, and history and physical
        examination methods in the context of oculoplastics.
    d.) To acquire the following examination skills of the eyelids and orbit:
        i.   Hertel exophthalmometry and ptosis measurements.
    e.) To appropriately utilize the radiology, photography, and pathology departments with
        evaluation of orbital fractures and lesions.
    f.) To be familiar with the interpretations of radiological images: e.g., CT, MRI, etc.
    g.) To acquire skills to appropriately manage orbital trauma.
    h.) To observe, assist, and subsequently perform supervised minor surgical procedures; e.g.,
        lid lesion excision, lateral canthotomy, nasolacrimal duct probing, tarsorrhaphy, etc.
    i.) To observe, assist, and subsequently perform faculty supervised major surgical
        procedures; e.g., lid laceration repair, nasolacrimal duct intubation, ptosis surgery,
        enucleation, etc.
    j.) To be familiar with the indications and technique for blowout fracture repair,
        evisceration/exenteration, decompression, eyelid reconstruction, and cosmetic eyelid
        surgery.
    k.) To appropriately manage the anophthalmic socket.

8. Pediatric Ophthalmology

    The summary of the educational goals and objectives for the residents in the pediatric
    ophthalmology subspecialty include the following:
    a.) To establish a fundamental knowledge of pediatric ophthalmology as outlined in the
        objectives for Section 6 of the AAO BCSC.
        i.   Describe evaluation techniques for young children that provide the maximum of
             information with the least trauma and frustration.
       ii.   Outline the anatomy and physiology of the extraocular muscles and their fascia.
      iii.   Explain the classification, diagnosis, and treatment options for ambylopia.
      iv.    Describe the commonly used diagnostic and measurement tests for strabismus.




                                                 19
      v.     Classify the various esodeviations and exodeviations and describe the management of
             each type.
     vi.     Identify vertical strabismus and special forms of strabismus and formulate a treatment
             plan for each type.
     vii.    List the possible complications of strabismus surgery and describe guidelines to
             minimize them.
    viii.    Differentiate among various causes of congenital and acquired ocular infections in
             children and formulate a logical plan for the diagnosis and management of each type.
     ix.     List the most common disease and malformations of the cornea, lacrimal drainage
             system, anterior segment, and iris seen in children.
      x.     Describe the diagnostic findings and treatment options for childhood glaucoma.
      xi.    Identify common types of childhood cataracts and other lens disorders.
     xii.    Outline a diagnostic and management plan for childhood cataract.
    xiii.    Identify appropriate diagnostic tests for pediatric uveitis.
    xiv.     Differentiate among various vitreoretinal diseases and disorders found in children.
     xv.     List the characteristics of ocular tumors and phakomatoses seen in children.
    xvi.     Describe the characteristic findings of accidental and non-accidental childhood
             trauma.
   xvii.     Outline the current joint policy statement regarding the role of vision in learning
             disabilities and dyslexia.
   b.) To attend didactic lecture sessions and clinics attended by board certified
       ophthalmologists who have completed fellowship training in pediatric ophthalmology.
   c.) To receive basic examination techniques, diagnostic testing, and history and physical
       examination methods in the context of pediatric ophthalmology.
   d.) To acquire the following examination skills:
       i.    Assess vision in the neonate, infant, and child;
      ii.    Basic measurements of strabismus: Hirschberg, Krimsky, cover/uncover, and
             alternate cover; and
     iii.    Advanced examinations techniques: stereo acuity testing, cycloplegic refraction,
             retinoscopy, binocularity testing, and special motor testing.
   e.) To be familiar with the indications, techniques, and complications of extraocular muscle
       surgery.
   f.) To appropriately manage ambylopia and retinopathy of prematurity.
   g.) To observe, assist, and perform faculty supervised extraocular muscle surgery and to be
       familiar with other advanced pediatric surgical techniques; e.g., cataract and glaucoma
       surgery.

9. Uveitis

   Although no formal rotation or subspecialty clinic in uveitis is arranged, the resident is
   exposed to the diagnosis and management of the uveitic patient as part of the general and
   subspecialty clinics. The summary of the educational goals and objectives for the residents in
   the uveitis subspecialty include the following:



                                                20
    a.) To establish a fundamental knowledge of uveitis as outlined in the objectives for Section
        9 of the AAO BCSC.
        i.   Outline the immunologic and infectious mechanisms involved in the occurrence and
             complications of uveitis and related inflammatory conditions, including acquired
             immunodeficiency syndrome.
       ii.   Identify general and specific pathophysiological processes that affect the structure and
             function of the uvea, lens, intraocular cavities, retina, and other tissues in acute and
             chronic intraocular inflammation.
      iii.   Choose appropriate examination techniques and relevant ancillary studies.
      iv.    Develop appropriate differential diagnosis for ocular inflammatory disorders.
       v.    Describe the principles of medical and surgical management of uveitis and related
             intraocular inflammation, including indications for and complications of
             immunosuppressive agents.
    b.) To attend didactic lecture sessions on uveitis.
    c.) To receive basic examination techniques, diagnostic testing, and history and physical
        examination methods in the context of uveitis.
    d.) To be familiar with the classification of the uveitic syndromes.
    e.) To understand the basic immunology of the eye.
    f.) To appropriate utilize the laboratory in the diagnostic uveitic algorithm.
    g.) To recognize the specific signs and complications of uveitis.
    h.) To be familiar with the medical and surgical management of uveitis and the side effects of
        therapy.
    i.) To be aware of the surgical considerations in the diagnoses of uveitis (e.g., conjunctival
        biopsy and anterior chamber paracentesis) and in operating on the uveitic patient (e.g.,
        cataract surgery, vitrectomy, etc.).

10. Optics, Refraction, CL, and Low Vision

    The summary of the educational goals and objectives optics, refraction, contact lenses, and
    low vision include the following:
    a.) To establish a fundamental knowledge of optics, refraction, contact lenses, and low vision
        as outlined in the objectives for Section 3 of the AAO BCSC.
        i.   Outline the theory and terminology of physical optics.
       ii.   Discuss the clinical and technical relevance of such optical phenomena as
             interference, coherence, polarization, diffraction, and scattering.
      iii.   Review the basic properties of laser light and how they affect laser-tissue interaction.
      iv.    Outline the principles of light propagation and image formation and work through
             some of the fundamental equations that describe or measure such properties as
             refraction, reflection, magnification, and vergence.
       v.    Explain how these principles can be applied diagnostically and therapeutically.
      vi.    Identify optical models of the human eye and how to apply them.



                                                 21
  vii.   Define the various types of visual perception and function, including visual acuity,
         brightness sensitivity, color perception, and contrast sensitivity.
 viii.   Summarize the steps for performing streak retinoscopy.
  ix.    Summarize the steps for performing a manifest refraction using a phoropter or trial
         lenses.
   x.    Describe the use of the Jackson cross cylinder.
   xi.   Describe the indications for prescribing bifocals and common difficulties
         encountered in their use.
 xii.    Review the materials and fitting parameters of both soft and rigid contact lenses.
 xiii.   Explain the optical principles underlying various modalities in refractive correction:
         spectacles, contact lenses, intraocular lenses, and refractive surgery.
 xiv.    Discern the differenced among these types of refractive correction and how to apply
         them most appropriately to the individual patient.
  xv.    Discuss the basic methods of calculating intraocular powers and the advantages and
         disadvantages of the different methods.
 xvi.    Describe the conceptual basis of multifocal IOLs and how the correction of
         presbyopia differs between these IOLs and spectacles.
xvii.    Recognize the visual needs of low vision patients and how to address these needs
         through optical and nonoptical devices and/or appropriate referral.
xviii.   Describe the operating principles of various optical instruments in order to use them
         more effectively.
b.) To attend didactic lecture sessions and contact lens clinics attended by ophthalmologists
    and/or optometrists experienced in contact lens fitting.
c.) To demonstrate the knowledge, understanding, and skills required to perform the fitting
    of both soft contact lenses and rigid gas permeable (RGP) lenses.
d.) To understand the indications for and uses of low vision aids.




                                            22
                                                                               3
                                                                                Chapter




III. Department of Ophthalmology
Policies

A.       Meetings
1. NEOS
     The New England Ophthalmological Society (NEOS) is a nonprofit group of more than 700
     ophthalmologists (medical and surgical eye physicians) throughout New England. Our
     mission is to provide for the study and advancement of ophthalmology, including the
     education of our members.
     NEOS is the oldest specialty society in the United States in continuous existence since it’s
     founding in 1884. The mission of NEOS is to promote excellence in eye care in the New
     England states through education of ophthalmologists, residents, fellows, allied ophthalmic
     personnel and the public.
     The goals of NEOS are:
     a.) To advance patient centered ethical standards for the delivery of eye care
     b.) To provide effective membership communication and education through meetings and
         the NEOS web site: www.neos-eyes.org
     c.) To make the public more aware that the NEOS is a public foundation for education in
         ophthalmology and to establish the NEOS as the leading New England source of
         information abut eye care with the public and the media.
     d.) To insure adequate endowment to insure ophthalmic education in the new millennium.
     e.) To insure for the education of ophthalmologists as the preferred providers of
         comprehensive eye care.
     Meetings. NEOS offers five ophthalmologic educational meetings per year. Each meeting
     typically runs from 8 AM to 4 PM on a Friday and is divided into morning and afternoon
     sessions. The morning and afternoon sessions cover different topics. Each session has 8-10
     talks and a panel discussion. Most of the talks are clinically oriented and are often given by
     experienced ophthalmologists from the New England area. Each session also has talks given
     by a Guest of Honor--a nationally or internationally recognized expert not from the New
     England area.



                                                23
  To see abstracts of previous meetings in past years, including audio-visual presentations of
  many previous talks, visit the NEOS Online Journal. You will find abstracts from previous
  NEOS meetings starting from 1999.
  For NEOS meetings the clinics are canceled at both sites; i.e., RIH and the VAMC so that
  residents are able to attend this meeting. Residents are expected to attend unless they are on
  vacation. Only the first on-call resident is expected to remain behind to cover emergencies
  and consultations. The call coverage should be shared among all residents taking first call so
  that each resident may attend as many of the meetings as possible. Residents that operate the
  day before (on Thursday) will be required to stay to see their postoperative patients as
  arranged before leaving to attend the meeting.
  Residents are encouraged to participate and submit an abstract for presentation at NEOS.
  Abstract are accepted from resident for the 5th meeting near the end of each academic year.
  The meeting is at no cost to the resident.
  The Dates for the 2004/2005 academic year are as follows:
  October 15, 2004                     March 4, 2005                   May 20, 2005
  November 19, 2004                    April 8, 2005

2. AAO
  The American Academy of Ophthalmology (AAO) is a voluntary organization whose
  membership comprises 90% of US ophthalmologists, and is open to all ophthalmology
  residents. The Academy provides advocacy, assistance with practice management, and clinical
  education programs for the benefit of its members.
  The Academy has more than 27,000 members worldwide. Academy members are Eye M.D.s
  or D.O.s, doctors of medicine or osteopathy who specialize in the eyes and vision. The
  majority of Academy members are practicing physicians, who are comprehensive Eye M.D.s.
  These Eye M.D.s provide the full spectrum of eye care, from prescribing glasses and contact
  lenses to the medical and surgical treatment of a wide variety of eye conditions. In addition,
  many Eye M.D.s are subspecialists, physicians who have special training and focus their
  practices in specific areas of ophthalmology, such as glaucoma, cataract or pediatric
  ophthalmology.
  The Academy is your best resource for ophthalmic education, meetings, advocacy and global
  eye care. Membership in the Academy is open to any ophthalmologist worldwide as well as
  medical doctors currently enrolled in an ophthalmology-training program.
  a.) About the Academy. www.aao.org
      i.   Who We Are
           The AAO is the largest national membership association of Eye M.D.s. Eye M.D.s
           are ophthalmologists, medical doctors who provide comprehensive eye care,
           including medical, surgical and optical care. More than 90 percent of practicing U.S.
           Eye M.D.s are Academy members, and the Academy has more than 7,000
           international members.
      ii. The Academy's Mission



                                               24
         The mission of the AAO is to advance the lifelong learning and professional interests
         of ophthalmologists (Eye M.D.s) to ensure that the public can obtain the best
         possible eye care.
    iii. Academy History
         The Academy evolved as part of the American Academy of Ophthalmology and
         Otolaryngology (AAOO), which was founded in 1896 primarily to provide
         continuing education to eye, ear, nose and throat doctors. The AAO was
         incorporated as an independent organization in 1979 when the AAOO was divided
         into separate academies for each specialty.
    iv. The Academy Today
         The AAO is an association of Eye M.D.s dedicated to enhancing the quality of life
         for every individual they treat by helping each to see his or her best and by protecting
         their patients' vision and eye health throughout life. Academy members are
         committed to responding compassionately to their patients' individual needs and to
         advancing the highest standards of comprehensive eye care. To enable its members
         to meet these goals, the Academy provides a wide variety of programs, products and
         services to Eye M.D.s and the patients they serve.
b.) Key Activities
    i.   Education
         •   Education is a primary focus of Academy activities and the Academy offers a
             number of programs to meet the educational needs of Eye M.D.s and other
             members of the eye care team.
         •   The Academy's Annual Meeting is one of the largest and most important
             ophthalmic meetings in the world. This outstanding four-day event offers
             symposia, scientific papers, instruction courses, films, posters and exhibits
             designed to educate Eye M.D.s and others about the practical applications of new
             advances in eye care.
             The Annual meeting is held in late October each year and the deadline for
             abstract submission is early April. Residents are strongly encouraged to submit
             abstracts for presentation at this meeting.

         •   The Academy also develops and produces a wide range of print and electronic
             educational materials, including reference books, audio and videotapes, CD-
             ROMs, self-assessment programs and an online education center. These materials
             provide ongoing education for practicing Eye M.D.s, residents and other health
             professionals, and many programs and materials carry CME credit.
    ii. Eye Care Information
         •   The Academy is the premiere provider of eye care information to the public.
             Through a variety of materials and programs, including patient education
             publications, public information campaigns to promote eye health and safety, as
             well as relationships with news media, the Academy provides balanced, credible
             and timely information on preserving and protecting vision. Through its
             partnership with Medem, an e-health network made up of members of leading


                                             25
            medical societies, the Academy provides the public with trustworthy eye care
            information on the Internet.
   iii. Advocacy
        •   The Academy's Government Affairs Division in Washington D.C. represents
            Eye M.D.s and their patients before federal and state policy makers. Academy
            staff and physician leaders regularly meet with government officials to provide
            input on legislative and regulatory issues that affect the delivery of quality eye
            care. The Academy also works with state ophthalmic organizations to represent
            the interests of Eye M.D.s and their patients in state legislatures and with
            managed care organizations.
   iv. Ophthalmic Practice
        •   Practicing medicine today requires knowledge and skills that extend beyond
            clinical expertise. The Academy offers a variety of managed care and practice
            management programs to assist its members in responding to the increasing
            socioeconomic demands placed on the physician. In addition to a wide variety of
            practice-related publications and materials, the Academy offers seminars on
            practice management, coding assistance, as well as a career search and employee
            location program. The Academy recognizes the crucial role ophthalmic managers
            and administrators play in the success of any practice. The American Academy of
            Ophthalmic Executives (AAOE) offers a variety of educational and other
            programs and services tailored to their needs.
   v. Quality of Care
        •   Academy members are committed to providing the highest possible quality eye
            care. To assist them, the Academy produces a number of materials to support
            them in the clinical decision-making process. The cornerstone of this program,
            the Academy's Preferred Practice Pattern series, provides a series of guidelines to
            identify the characteristics and components of quality eye care. A number of
            other publications, designed to supplement the Preferred Practice Pattern series,
            provide additional information on new technologies and complementary
            therapies, to help Eye M.D.s sift through an ever-expanding body of clinical
            knowledge. In addition, the Academy provides members with timely information
            to help them avoid potential medical errors and enhance patient safety.
c.) Membership options available at the Academy.
   i.   Types of Membership: The Academy currently offers several different types of
        membership, depending on an individual's training, practice situation and needs.
        These include:
        •   Fellow: A physician who holds a degree of Doctor of Medicine, Doctor of
            Osteopathy, or equivalent medical degree as determined by the board of trustees
            of the Academy, who holds a valid and unrestricted license to practice medicine
            in the United States, Canada, or the country in which the practice of medicine is
            regularly conducted, and who has been certified by the American Board of
            Ophthalmology, the Royal College of Physicians and Surgeons of Canada or a
            medical specialty board acceptable to the board of trustees shall be eligible to
            apply for membership as an Active Fellow. The board of trustees may waive the


                                           26
       requirements that a candidate for Active Fellowship be licensed to practice
       medicine or be certified by a medical specialty board, if the physician has
       contributed significantly to the progress of medicine in its relation to diseases of
       the eye or related structures.
   •   Member: A physician who holds a degree of Doctor of Medicine, Doctor of
       Osteopathy, or equivalent medical degree as determined by the board of trustees,
       who holds a valid and unrestricted license to practice medicine in the United
       States, Canada, or the country in which the practice of medicine is regularly
       conducted, and who has satisfactorily completed an entire program of formal
       residency training in ophthalmology of at least three years duration, shall be
       eligible to apply for membership as an Active Member.
   •   Member in Training A physician who holds a degree of Doctor of Medicine,
       Doctor of Osteopathy, or equivalent medical degree as determined by the board
       of trustees, and who is engaged on a full-time basis in an ophthalmology
       residency training program conducted either in the United States or in Canada
       that is acceptable to the board of trustees, or who has satisfactorily completed
       such a training program and is engaged on a full-time basis either in an
       ophthalmology fellowship training program conducted in the United States or in
       Canada or in a postgraduate educational course of training leading to an advanced
       degree at an accredited college or university in the United States or in Canada, or
       a foreign medical graduate who is otherwise eligible for International
       Membership and is engaged on a full-time basis in a postgraduate ophthalmology
       training program in the United States or in Canada, shall be eligible to apply for
       membership as a Member in Training.
ii. Member Benefits: Apart from the prestige of belonging to an internationally
    renowned medical organization, all Academy members receive access to information
    not available elsewhere, and valuable benefits at no added cost, such as:
   •   Free Annual Meeting registration: The Academy's Annual Meeting, the premier
       ophthalmological meeting in the world, offers a wide array of scientific sessions,
       papers, posters, exhibits, video programs and instruction courses.
   •   Subscription to Ophthalmology: Ophthalmology is the only journal that prints
       exclusively full-length, peer-reviewed reports of original research and is
       recognized as the premiere scientific publication in ophthalmology. Each month,
       members receive valuable information about surgical techniques, treatment
       methods, drug studies, pathophysiology, genetics and clinical trials.
   •   Subscription to EyeNet: The Academy's monthly newsmagazine covers the latest
       in clinical, business and member news. EyeNet is edited by leading
       ophthalmologists and a highly esteemed international editorial board. From
       Specialty Clinical Updates to ethical debates, EyeNet offers members a forum for
       improving the practice of ophthalmology; our Washington office contributes
       information on timely issues such as practice and risk management, clinical
       education and public service.
   •   Subscription to Academy Express. The Academy's bi-weekly e-mail newsletter
       focuses on the latest clinical news, coding updates, and information on legislature



                                       27
              and regulatory issues. It is e-mailed free to all members every other Thursday
              evening
          •   Access to the "Members Only" section of the Web site: This section of the
              Academy Web site features clinical information and forums.
          •   Listing in the Academy's member directory: This publication is the most
              comprehensive "Who's Who" of ophthalmology worldwide in print and online,
              and is an essential reference and networking tool.
          •   Continuing Medical Education (CME) credit reporting service: The Academy
              keeps records and provides free transcripts of member's CME credits.
          •   Discounts on products, programs, materials and services: From clinical education
              to practice management to patient information materials, the Academy is
              renowned for the excellence of its products and services. All are developed by
              dedicated ophthalmologists who volunteer their expertise. Academy members
              save an average of 35 percent off nonmember prices.
          •   SimplifEye Ophthalmic Purchasing Program: A program from Henry Schein,
              Inc. features a special formulary, developed with the help of ophthalmologists,
              designed to give Academy and AAOE members the best possible prices on the
              medical, surgical and front office supplies
          •   Disclosure: The Academy is able to offer a variety of programs and services that
              benefit its members by collaborating with commercial businesses. Some of these
              business arrangements provide the Academy with a royalty or fee that helps the
              Academy offset expenses associated with other membership programs. Among
              these businesses are: Ophthalmic Mutual Insurance Company, MBNA America
              Bank, Elsevier Inc., and Marsh & McLennan Companies.
3. ARVO

  a.) Mission. The purposes of the Association for Research in Vision and Ophthalmology,
      Inc. (ARVO) shall be to encourage and assist research, training, publication, and
      dissemination of knowledge in vision and ophthalmology
  b.) Brief History. ARVO was founded in 1928 in Washington, DC by 73 ophthalmologists.
      ARVO was originally named the Association for Research in Ophthalmology (ARO), but
      the word "vision" was added in 1970 to better reflect the scientific profile of its members.
  c.) The Association's membership, comprised of more than 10,500 individuals, continues to
      grow. Some 44% of members reside in over 68 countries outside of the US. The
      membership is multidisciplinary and consists of both clinical and basic researchers
      (approximately 44% MD/Ophthalmologists, 26% PhD's, and 30% Other, including
      optometrists, osteopaths, and veterinarians).
  d.) In 1986, ARVO established its first permanent office located on the campus of the
      Federation of American Societies for Experimental Biology (FASEB), in Bethesda,
      Maryland. In 2001 the ARVO Office relocated to Rockville, Maryland.
  e.) Organizational Structure. ARVO is governed by a Board of Trustees, who are elected
      from candidates put forth by the 13 Scientific Sections: Anatomy & Pathology;


                                              28
          Biochemistry & Molecular Biology; Clinical & Epidemiologic Research; Cornea; Eye
          Movements, Strabismus, Ambylopia & Neuro-ophthalmology; Glaucoma; Immunology
          & Microbiology; Lens; Physiology & Pharmacology; Retina; Retinal Cell Biology; Visual
          Neurophysiology; and Visual Psychophysics & Physiological Optics.
     f.) Benefits of Membership:
         i.      Eligible to submit abstract and present research at ARVO Annual Meeting,
        ii.      Access to online Membership Directory,
       iii.      Subscription to Investigative Ophthalmology & Visual Science (IOVS),
      iv.        Student and Emeritus members may subscribe at reduced rate,
        v.       Access to full-text IOVS Online,
      vi.        Journal of Vision (online),
      vii.       ARVO Newsletter,
     viii.       The ARVO Blink,
       ix.       Program Summary Book and CD-ROM,
        x.       Advocacy and representation on funding and regulatory legislation, and
       xi.       Discounts on vision- and ophthalmology-related journals.
     g.) Resident Membership (Category F) Dues:              $85.00
          Student Individual enrolled at an institution of higher learning in a scientific field related
          to vision or ophthalmology. Limited to a total of 5 years. (Print subscriptions to IOVS are
          available for an additional $100/year.)
     h.) All Annual Meeting Scientific Program are held in Fort Lauderdale, Florida and take
         place in late April or early May or each year. Abstract submission deadlines are in
         December. Residents are encouraged to submit abstracts and attend this meeting.
     i.) Future Annual Meetings.
          i.     2005   May 1 - May 6           v. 2009      May 3 – 8
          ii.    2006   April 30 - May 5        v. 2010      May 2 – 7
          iii.   2007   May 6 - May 11          vii. 2011    May 1 – 6
          iv.    2008   May 4 – 9               viii. 2012   April 22 – 27

4. Resident Attendance at Meetings

     Residents are allowed to attend AAO, ARVO, and other academic meetings only if they are
     presenting and have submitted a vacation request for cancellation of clinic form. This absence
     does not count against the vacation allotment if three days are used. If the resident is not
     presenting or takes more than three days to attend a meeting the resident will be allowed to
     attend; however, these days will be counted toward the vacation allotment.

     The exceptions to his policy are that attendance at NEOS is not counted towards the vacation
     allotment and the third year resident may attend the AAO meeting regardless if they are
     presenting or not for three days that will not count against the vacation allotment.


B.        Departmental Curriculum


                                                   29
1. Grand Rounds

   a.) Grand Rounds take place on the first Saturday of each month September through June.
       No Grand Rounds takes place during the summer months of July and August. These
       conferences start at 7:30 AM with coffee and pastries, informal interactions with faculty
       and examination of patients. The conference follows from 8:00 to 9:30 AM.

   b.) It is the responsibility of the 3rd year operating RIH resident (RIH C) to submit the
       presenters for each Grand Rounds conference. At least 2 residents need to present at
       each conference. Presentations should last 15-20 minutes with a review of pertinent
       literature and time for questions and interaction with faculty. It is highly advisable to have
       patients to attend the conference where possible as it makes it more enjoyable for all
       attendees.

   c.) A Morbidity and Mortality (M & M) conference should be held at least annually
       depending on the availability of patients. VA patients are not permitted to be presented at
       this conference.

   d.) Please share interesting cases.

2. Lectures

   These are a required part of residency education and must be attended by all residents. They
   are required by the ACGME and will help with preparing for both the AAO OKAP and the
   ABO WQE. Students are expected to prepare for topics presented and to have completed
   reading assignments when applicable. Lectures are devised to supplement the AAO BCSC
   and are by no means intended to serve as a substitute. A sign in book kept in Sally Martone’s
   office verifies mandatory attendance.
   A monthly lecture schedule is provided 1-2 weeks before the first of the month. This
   schedule is part of the written curriculum for program.
   The faculty put much time and energy into these lectures. It is their courtesy to us and we
   should respond to them in kind. Please be prompt and ensure that the equipment is set up as
   necessary for the faculty. For those residents obliged to the VA they are excused at 7:40 AM.

3. BSCS

   The BSCS is a highly recommended curriculum of basic knowledge and new developments in
   ophthalmology but is not meant to be an exhaustive survey of the entire field. Therefore,
   preparation for the OKAP should also include other authoritative sources, like texts and
   scientific journals that cover the entire range of topics.




                                                30
C.       Examinations
1. OKAP

     The Ophthalmology Knowledge Assessment Program (OKAP) is a standardized test taken
     annually by our residents and is mandatory. The OKAP takes place on a Saturday morning
     during the first or second week of April. The location varies but will be assigned when
     possible. Vacations are not permitted for this date.
     The OKAP assesses the cognitive knowledge by a written examination. It is designed to aid in
     the resident's education by pointing out their academic strengths and weaknesses, areas for
     further study, and assessing the standings with other residents throughout the country. It
     should be pointed out that these results are confidential as the AAO releases OKAP results
     only to the resident and their program director, but scores also may be disseminated to other
     program faculty in support of their intended educational purpose. (Upon request the resident
     will be given the names of faculty member who have knowledge of their performance on the
     exam.).
     The OKAP examination is one of the AAO’s clinical-education programs. It is a 250-item
     multiple-choice test that is administered to ophthalmology residents in each year of training. It
     is designed to measure the ophthalmologic knowledge of residents, relative to their peers, in
     order to facilitate the ongoing assessment of resident progress and program effectiveness.
     Each annual OKAP examination is carefully constructed to be a valid and reliable measure of
     ophthalmic knowledge. An OKAP score carries information about how well a resident had
     done relative to the other residents who have taken the examination.
     The primary purpose of the OKAP is to support the clinical and basic-science education of
     residents by providing them a way to assess their ophthalmic knowledge relative to their peers
     and to identify individual objectives. The OKAP is also designed to provide program
     directors with information that is useful in the formative evaluation of residents’ progress and
     program effectiveness. OKAP test results are never to be used in a punitive manner or as the
     sole gauge of a residents’ overall ophthalmic proficiency. Consideration for other relevant
     factors such as clinic acumen, surgical skill, patient rapport, and case-management ability
     always must enter in to the process of resident evaluation. There is no passing or failing
     associated with the OKAP.
     The OKAP is developed from a Content Outline that is divided by subspecialty into the same
     12-section format as the AAO BSCS. The BSCS is a highly recommended curriculum of basic
     knowledge and new developments in ophthalmology but is not meant to be an exhaustive
     survey of the entire field. Therefore, preparation for the OKAP should also include other
     authoritative sources, in addition the BSCS, like texts and scientific journals that cover the
     entire range of topics in the Content Outline. The Content Outline has been distributed to
     residency programs and to department of ophthalmology, for use by faculty and residents.
     From 1980-1992 the Academy and the Board administered the same exam as both the
     OKAP and the written qualifying examination (WQE) administered by the American Board
     of Ophthalmology (ABO), but because the Academy and the Board are two separate
     organizations and their respective exams actually perform two different functions, the OKAP


                                                 31
    and WQE became two separate exams in 1993. The OKAP and WQE and comprised of
    entirely different test questions with different psychometric proprieties, and emphasize
    different aspects of ophthalmic knowledge. (For example, the OKAP gives greater emphasis
    to basic science questions.) Although the two exams are now separate, they both assess the
    knowledge, experience, and skills necessary to deliver high standards of quality patient care in
    ophthalmology. Accordingly, all items for both exams are still written and reviewed by the
    Academy and the Board. This joint process of item development ensures continuity of
    assessment, from the first year of training to Board certification, and also ensures that the
    OKAP will continue to be an excellent way to prepare for the WQE. Both exams are
    administered by the American College Testing (ACT) Inc. ACT also provides assistance in the
    development of test items and with the psychometric analysis of items performance.
    Residents are expected to perform above the mean when compared to the residents at one’s
    own level of training. OKAP scores will be reviews to assess the need for remedial studies.
    Residents that obtain a score less than 30 on the percentile rank below for the whole test will
    be placed on academic probation. This is a formal disciplinary action explained in the later
    section on Due Process. This level of performance if maintained will lead to failing the written
    portion of the board certification process. A remedial study program will be initiated between
    the resident and the program director.
    Residents that obtain a score less than 30 on the percentile rank for three or more sections
    will be placed on academic warning and will be expected to perform remedial work in those
    subjects. Academic warning is not a formal disciplinary action. Rather it is an informal process
    where remedial work is planned to further the education of the resident.

2. Board Certification

    The American Board of Ophthalmology (ABO) is a separate organization whose mission it is
    to serve the public by improving the quality of ophthalmic practice through a certification
    process that fosters excellence and encouraged continuous learning. Like the OKAP, the
    Board’s Written Qualifying Examination (WQE) is also a 250-item multiple choice test in the
    field of ophthalmology, but the WQE is given to physicians who have completed a residency
    training program in ophthalmology and who are candidates for Board certification. The intent
    of the certification process is to provide assurance to the public and to the medical profession
    that certifies a physician has successfully completed an accredited course of education in
    ophthalmology. The WQE is part 1 of the Board’s certification process. Upon successful
    completion of the WQE, a candidate takes part 2, which is the Board’s oral examination.
    a.) Written Qualifying Examination (WQE)
         The WQE is a multiple choice examination given simultaneously in designated cities in
         the United States in the spring of each year. It is necessary to pass this examination before
         being admitted to the Oral Examination. The topics covered in the Written Examination
         include the following:
        i.   Optics, Visual Physiology and Correction of Refractive Errors;
       ii.   Retina, Vitreous, and Uvea;
      iii.   Neuro-ophthalmology;
      iv.    Pediatric Ophthalmology;



                                                 32
       v.     External Disease and Cornea;
      vi.     Glaucoma, Cataract and Anterior Segment;
      vii.    Plastic Surgery and Orbital Diseases; and
     viii.    Ophthalmic Pathology
     a.) Oral Examination
         It is customary for the Board to hold two Oral Examinations per year. Candidates who
         pass the Spring WQE are assigned to the Oral Examinations in either the fall of that same
         year or the spring of the following year. The Oral Examination is administered in a half-
         day session. These examinations include developmental, dystrophic, degenerative,
         inflammatory, infectious, toxic, traumatic, neoplastic, and vascular diseases affecting the
         eye and its surrounding structures. In each of the oral examinations emphasis will be
         placed upon the following:
         i. Data Acquisition
         ii. Diagnosis
         iii. Management


D.       Resident Daily Responsibilities
1. Schedule

     Follow the Resident 2003/2004 Academic Year Schedule. See Appendix C.
     Each first year resident will be assigned to either RIH A or RIH B. These schedules are
     exactly the same, but are kept distinct as they may be changed in the future.
     Each second year resident will be assigned to either VA A or VA B. These schedules reflect
     the level of their involvement at the VAMC. The VA A resident is at the VAMC fulltime
     except for one half day a week at RIH to allow for patient continuity. The resident has OR
     time reserved on Monday and Wednesday mornings and has precedence over those times.
     The VA B resident is as the VAMC part time, at RIH part time, and three half-day sessions
     devote to subspecialty assignment. The VA Retina is time for retina procedures with Dr.
     Tsiaras and Greenberg on Wednesday afternoon and Thursday mornings, respectively. The
     subspecialty assignment guarantees the resident time devoted to the assigned subspecialty; i.e.,
     they have no other responsibilities or commitments to RIH or the VAMC unless they are on-
     call.
     Each third year resident will be assigned to either RIH C or RIH D. These schedules reflect
     the level of their involvement at the RIH. The RIH C resident is the RIH chief resident and is
     the operating resident. He/she has precedence over all surgical cases posted. He will run the
     clinic and assign residents operative assignments when necessary. He is responsible for
     ensuring the clinic runs smoothly. He has OR time on Tuesday afternoons for 2 cases and
     may post cases at other times as warranted. He is a “Floating” resident on Monday mornings
     to allow him to assist in the clinic when necessary, assist and post cases with Dr. Ducharme
     during his operative time on Monday mornings, increase his operative experience with other
     attendings, or he/she may use the time for administrative reasons. He will also be at the
     VAMC one half day a week to allow for patient continuity. The RIH D resident is the senior



                                                 33
    resident at the VAMC. The resident has OR time reserved on Monday and Thursday
    afternoons and has precedence over those times.
    The RIH E is a temporary assignment to allow for Svetlana to complete her requirements up
    to August 6, 2004. Her “Free” days are times to allow her to increase her skills with other
    faculty members. She will be in the RIH clinic all day on Monday, Wednesday, and Friday.

2. Communication

    All residents must be able to articulate their lines of communication (chain-of-command) and
    know the name of the Chief of their Department. Patients are expected to know the names of
    their doctor.
    The residents are expected to provide all of their contact information on the start of their
    training. The residents must notify the Department of any changes in their contact
    information.

3. Staff.

    Please be courteous to the clinical (Jane Cote and Samol Sock) and scheduling staff. They are
    essential to the smooth functioning of the clinic and are a great resource of assistance when
    necessary.

4. Surgical logs

    The ACGME mandates that residents report their operative experience. The resident is
    required to keep track of each and every procedure or surgery that they are involved in. These
    are to be entered into the online Resident Case Log System through the ACGME
    (http://www.acgme.org/. Experiences to report include:
    All classes (Class 1 and Class 3) of procedures.
    All types of procedures (Cataract, Cornea, Strabismus, Glaucoma, Retina, Oculoplastics, and
    Trauma). All surgeries and minor procedures (laser PRP, focal, YAG, and lid lesion excision,
    chalazion) should be entered.
    These logs are vital in allowing the program to monitor the progress of the resident. Gaps in
    logs are unacceptable and may lead to disciplinary action if not completed. These logs are also
    one gauge as to how our program is compared to other programs nationally. These logs will
    also be required as the resident applies to fellowship programs and hospital privileges.

5. Clinic

    Patient care is the primary responsibility of the resident and it takes precedence over all other
    functions of the resident. Residents are expected to give efficient, thorough, and
    comprehensive examinations to patients while displaying appropriate concern and empathy
    towards them and their problems.
    a.) General Clinic Patients


                                                 34
    The resident is expected to see scheduled patients on their template and emergency/walk-in
    patients when necessary. Patients should be seen by the order based on the time of their
    appointment. Every effort should be made to see “priority patients” as soon as possible:
         i.   ACI inmates or patients escorted by a policeman,
        ii.   Patients dependant on agency transportation,
      iii.    Inpatient consultations, and
       iv.    Patient in acute distress.
    During the residency the resident is expected to perform:
          •   >1,500 refractions,
          •   >3,000 outpatient visits where the resident is performs a substantial portion of the
              exam and has responsibility for the care of the patient, and
          •   >1,000 outpatient visits where the resident is directly supervised by the teaching staff
              and the attending also examines the patient and discuses the management before the
              patient leaves the clinic.
    All resident are expected to help the clinic run smoothly. No resident should leave the clinic
    unless all patients have been seen unless otherwise instructed by the chief resident.
    Every patient must have the basic elements of the eye examination. The VA and IOP needs
    to be recorded on every visit unless contraindicated; i.e., EKC. If the last visit by a different
    resident recorded a VA of NLP recheck it yourself. All acute patients require a dilated
    examination unless contraindicated. All routine examinations should have a dilated exam
    annually unless instructed otherwise. Always check as to when the last DFE was performed.
    b.) Subspecialty Clinics
    Patients are assigned to the subspecialty clinic rather than to see a specific doctor. Residents
    are expected to share in the workload and to present the patients to the assigned subspecialty
    attending.

6. Consultations
    Consultations need to be seen promptly and on the day the consult is requested unless the
    requesting service states otherwise and that this is documented in the chart. Consultations are
    to be performed by the first year resident and/or the on-call resident when indicated. All
    questions regarding diagnosis and management should be directed to an appropriate faculty
    member.
    Home call is a privilege. Every call should be treated as if you are in the hospital; i.e., see every
    patient you are requested to see promptly unless other arrangements are made and this is
    agreed to by both you and the requesting service. If you are consulted always ask:
    a.)   Patient identifying information and location,
    b.)   Reason for consultation (e.g., Fungemia, rule out fungal ball),
    c.)   Urgency of consultation (When would you like me to see the patient?),
    d.)   Dilation status (Can we dilate the patient?), and
    e.)   Thank the service for the consultation and state that you will be happy to see the patient.
    A full History and a complete ocular examination including a dilated examination is required
    on every patient. For those where the dilated fundus examination (DFE) is deferred. The



                                                  35
     patient should be examined with the direct ophthalmoscope and then seen daily until the full
     DFE is performed.
     Have an attending see the patient within 24 hours from when the consult is requested where
     possible. Make sure the consult is complete before involving the attending. Priority of
     coverage should go to:
     a.)   The attending assigned to the clinic,
     b.)   The general attending on call for the week,
     c.)   The subspecialty attending on call where indicated,
     d.)   The program director, and
     e.)   The chairman.

7. Documentation

     Medical charts are essential to provide quality patient care. Notes must be thorough, accurate,
     and legible. Date and time must be entered. Charts may not be altered in any way. No
     operative notes may be written in advance of the actual performance of the procedure.

8. Resident Advocacy

     Advice and counseling. Resident should speak with the program director if interpersonal
     conflicts arise. Comments or suggestions on ways to better improve the program should go
     the to the Program Director or a resident representative on the RCC. All problems regarding
     schedules should also be directed to the Program Director.


E.         Other
1. Useful Links

     American Academy of Ophthalmology (AAO)
     655 Beach Street, San Francisco, CA 94109-7424
     www.aao.org
     American Board of Ophthalmology (ABO,)
     111 Presidential Blvd, Suite 241, Bala Cynwyd, PA 19004-1075
     www.abop.org        info@abop.org           (610) 664-1175
     American Society of Cataract and Refractive Surgery (ACRS)
     4000 Legato Road, Suite 850, Fairfax, VA 22033
     www.ascrs.org      ascrs@ascrs.org (703) 591-2220
     American Society of Retina Specialists
     PMB #16A2485 Notre Dame Blvd, Suite 370, Chicago, IL 95928
     www.vitreoussociety.org              (530) 566-9181
     Contact Lens Association of Ophthalmology (CLAO,)
     721 Papworth Avenue, Suite 206, Metairie, LA 70005
     www.clao.org       eyes@clao.org (504) 835-3937


                                                  36
     Red Atlas. Recognizing eye disease: A visual review of ophthalmic disorders.
     http://www.redatlas.org/main.htm

2. Awards and Grants

     Bloomberg Memorial Resident Videotape Competition for cataract/implant surgery
     (sponsored by the American College of Eye Surgeons and Pharmacia-Upjohn). Cash prizes.
     http://www.aces-abes.org


F.        Medical Student Clerkship
1. Medical Students on clinical clerkships participating at RIH must be sponsored, approved,
   and processed by Brown Medical School, through the office of the Clerkship Coordinator.
2. All Clerkships are allocated on a space-available basis.
3. Inquiries for clerkships must be referred to the Clerkship Coordinator at (401) 863-2292. The
   coordinator will then arrange the clerkship with Sally Martone at (401) 444-4669.
4. Brown Medical School will required all students to provide:
     a) Completed application by the student and office of the Dean of his/her medical school,
     b) Proof of health insurance coverage,
     c) Proof of malpractice coverage,
     d) Proof of training in universal precautions,
     e) Up-to-date immunizations records in accordance with Brown Medical Schools/s policy,
        and
     f) Fees, if applicable.
5. The preceptor will complete an evaluation form for academic credit at the end of the clinical
   assignment and forward to the office of the clerkship coordinator at Brown Medical School
   or the student’s medical school.
6. Additional policies, exceptions, restrictions and/or requirements applicable to foreign medical
   schools an osteopathic medical schools, may be in effect at Brown Medical School.


G.        To Come?
1. Faculty Mentor

     Each resident will be assigned a faculty mentor to serve as an advocate for him or her in the
     program and for career advice.

2. Resident Bags

     Equipment will be provided to each resident at the start of his/her residency. The equipment
     will be returned at the completion of the program. The resident will be expected to replace
     any lost or damaged items. The contents of the equipment bag are as follows:


                                                37
a.) Stereo Fly Test (with picture, glasses, and instructions)
b.) Color Plates
c.) Maddox Rod
d.) Pinhole
e.) Rosenbaum Card
f.) Transilluminator Head/Base
g.) Allen Cards
h.) Mask Occluder
i.) 4 Dot worth flashlight with glasses
j.) E Card
k.) Trial Frames (Pediatrics and Adult)
l.) Hertel
m.) Goldman macular contact lens




                                             38
                                                                                  4
                                                                                  Chapter




IV. VA Medical Center
Policies

A.       Orientation
     This will take place in early July of the first year of training. To allow the resident to obtain
     computer training for using the electronic medical records at the VAMC. Also a time will be
     arranged to meet with Christopher Newton (title) for an introduction to the department of
     surgery.


B.       Policies
1. All surgical cases will require three weeks notice to book.
2. All surgical consults generated by optometry as well as the residents will be forwarded directly
   to Fran for booking to eliminate any competition and "hoarding" of surgical cases.
   Optometry has generated a list of surgical pts for 2nd and 3rd yr residents based on VA
   (<20/100 = 3rd yr) & complexity that will be forwarded directly to Fran on a weekly basis for
   booking.
3. Fran will be make the patient an initial consult appointment with the resident at which time all
   IOL measurements, refractions will be done & the surgery will be formally booked; the
   patient will, in turn, have to come back once more to meet, if necessary, his resident surgeon
   in a presurgical clinic slot to ensure the patient will meet his doctor preoperatively and to
   obtain the complete consent and labs within the 30 day window prior to the scheduled
   surgery.
4. This means an extra appointment or two for the patient, but a much smoother and organized
   process for all. Fran & Jackie and all were very pleased with the plan. I think it will do a great
   deal toward fostering teamwork. It will also be nice for the OR who will now receive booked
   cases many weeks in advance so special IOLs, instruments, etc., can be ordered prior to
   scheduled cases.




                                                 39
C.       Surgeries
1. Preoperative Evaluation

     A checklist needs to be reviewed when scheduling a patient for cataract surgery and to
     provide for the most optimal outcome. Should important items be missing, the patient may
     need to be rescheduled. A meticulous assessment of the patient from a historical and clinical
     standpoint is the best way to prevent and manage any complications that may arise. It will also
     ensure that the patient has been fully informed of the risks and benefits of proceeding with
     cataract surgery. This all translates into better care for the patient and a more rewarding
     surgical experience for the resident.
     Preoperative Check List for Cataract Surgery
     a.) Current refraction OU with BCVA <20/40 in operated eye.
     b.) Documented history of decreased vision, preferably with impact on ADLs, or inability to
         examine fundus for diabetic retinopathy or AMD.
     c.) Notation regarding unusual anatomic clinical details that could impact surgery; e.g., small
         orbit, shallow AC, small or large axial length, pseudoexfoliation, white cataract, posterior
         synechiae, poor pupillary dilation, and/or a history of intraocular surgery. Also document
         that the patient was made aware that these details that could present an increased risk of
         complications.
     d.) Notation regarding concomitant disease, which could impact final outcome; e.g.,
         glaucoma, history of ocular trauma, diabetic retinopathy or age-related macular
         degeneration. Also document that the patient was made aware that these conditions could
         impact his final visual outcome. For example, diabetic retinopathy could progress more
         rapidly following surgery requiring additional treatment or that the BCVA may be limited
         by dry AMD.
     e.) Notation regarding any concomitant medical disease that needs to be addressed pre-
         operatively with medical clearance; e.g., MI, CVA, and COPD. Think about whether a
         particular patient may be better suited for general anesthesia if they are unable to lie on
         their back or are particularly nervous. Ensure you know if the patient is taking any
         anticoagulants and that these are stopped at the appropriate time when indicated.
     f.) A-Scan OU with particular attention to any axial length discrepancies between the two
         eyes or prior IOL surprises. Where applicable, discuss refraction options (with
         documentation) with the patient; e.g., hyperopia in both eyes but an early cataract in the
         fellow eye.
     g.) Measure and record “white-to-white + 1” distance for correct AC IOL sizing.
     h.) Order all IOLs: PCIOL, CSIOL, and (3) ACIOLs (with 1st choice from g.).
     i.) Order any unusual operative supplies: e.g., ICG.
     j.) Notify attending of any case that is anticipated to be at higher risk as outlined above.




                                                  40
                                                                              5
                                                                              Chapter




V. GME Policies

A.       GME Organization
1. GME Office

     Contact us:       Graduate Medical Education Office
                       593 Eddy Street
                       Aldrich Building, Room 120
                       Providence, RI 02903
                       (401) 444-8450

     Graduate Medical Education Administration
     John Murphy, M.D., Director               (401) 444-8450
     Lois Booth, Administrative Director       (401) 444-6993
     Roxanne Marsland, Assistant               (401) 444-8450
     Debbra Gomes, Assistant                   (401) 444-8450

2. GME Committee Members

     Chair:     John Murphy, MD, director, GME
     Members: Anthony Caldamone, MD, urology program director
                Michele Cyr, MD, general internal medicine program director
                Christopher DiGiovanni, MD, faculty member
                Joseph Ducharme, MD, faculty member
                John Duncan, MD, neurological surgery program director
                Edwin Forman, MD, faculty member
                James Gilchrist, MD, clinical neurophysiology program director
                Lewis Glasser, MD, faculty member
                David Harrington, MD, surgery associate program director


                                              41
                Boyd King, MD, senior vice president, medical affairs
                Candace Lapidus, MD, dermatology program director
                Henrietta Leonard, MD, child/adolescent psychiatry program director
                Martha Mainiero, MD, radiology-diagnostic program director
                William Metheny, MD, WIH medical education director
                Adam Pallant, MD, pediatrics program director
                Frederick Schiffman, MD, internal medicine assoc. program director
                Robert Sidman, MD, emergency medicine program director
                Dominick Tammaro, MD, medicine/pediatrics program director
                Peter Tilkemeier, MD, cardiovascular diseases program director
                Robert Van Wesep, MD, PhD, pathology program director
                Jeffrey Weinzweig, MD, faculty member
                Janet Wilterdink, MD, neurology program director
                Edward Wing, MD, internal medicine chair
                Paul Yodice, MD, critical care program director
                Lois Booth, administrative director of graduate medical education
    Residents: Brian Livingston, MD, emergency medicine
                Carol Mallette, MD, internal medicine
                Clifford Pellish, MD, dermatology
                Amie Peterson, MD, neurology
                Beth Ryder, MD, surgery

3. Institutional Commitment

    Statement of Institutional Commitment/GMEC Guidelines.

4. ACGME

    What is the Accreditation Council for Graduate Medical Education (ACGME)?
    a.) The ACGME is a private association formed by five member organizations with four
        representatives each:
       i.   The American Board of Medical Specialties (ABMs),
      ii.   The American Hospital Association (AHA),
     iii.   The American Medical Association (AMA),
     iv.    The Association of American Medical Colleges (AAMC), and
      v.    The Council of Medical Specialty Societies (CMSS).
    b.) Each member organization also selects two public members.


                                               42
        i.     The Resident Physician Section of the AMA selects a resident representative and
       ii.     The Secretary of the U.S. Department of Health and Human Services selects a federal
               government representative. The Chair of the Residency Review Committee Council,
               an advisory body of the ACGME, serves as its representative.
     c.) The ACGME is responsible for establishing national standards for graduate medical
         education (GME) by approving and continually assessing educational programs for
         physicians in training. Residency Review Committees (RRC) under its authority makes
         determinations regarding whether GME programs are in compliance with these
         standards. The ACGME accredits nearly 7,800 residency programs in 119 specialty and
         subspecialty areas of medicine.
     d.) For residency programs, ACGME accreditation is a voluntary process. Participating
         programs must undergo regular review and show substantial compliance with the
         Program Requirements developed by the ACGME review committee for programs in its
         specialty. These standards address the essential educational content, instructional
         activities, responsibilities for patient care and supervision, and the necessary facilities of
         accredited programs in a particular specialty. The ACGME has the final authority for
         approving all Program Requirements. Furthermore, the sponsoring institution must
         demonstrate a commitment to GME by:
        i.     Being in substantial compliance with the institutional requirements set forth by the
               ACGME and
       ii.     Assuming responsibility for the educational quality of the sponsored program(s).
      iii.     The web address is: www.acgme.org
     e.) Site visits are conducted every one to five years, with a longer period indicating that the
         ACGME and RRCs are more confident about a program's or institution's ability to
         provide quality education.


B.           General Residency Information
1. Benefits

     RIH offers a competitive benefits package to all house staff. Employee Benefit Plans
     Coverage under the RIH employee benefit program is available to the House Officer. Copies
     of specific policies currently in effect are available from the Human Resources Department.
     These benefits are through “Choice Benefits”. Choice Benefits allows employees to choose
     from a variety of benefit options. At orientation you will receive a Flexible Benefits
     Enrollment Kit that explains each benefit and guides you through the decision making
     process.
     Benefit costs are shared between the hospital and the house staff based upon the house
     officer’s contract and the options selected. The per-pay-period costs for each coverage option
     are shown on your personalized enrollment form and are on a pre-tax basis.
     a.) Health Insurance. The medical plans available through Choice Benefits cover a variety of
         services and protect you from the high costs of medical care. You have the following
         options for medical coverage:


                                                  43
    i.     Lifespan Blue through Blue Cross & Blue Shield of RI,
    ii.    United HealthCare Plus,
    iii.   Tufts Health Plan, or
    iv.    No coverage; and
    v.     Individual,
    vi.    Dual, or
    vii.   Family.
    The services of all Hospital Ambulatory Services are available to House Officer subject to
    Hospital policies and the requirements and/or limitations of the health insurance
    coverage selected by the House Officer.
b.) Dental Insurance. The dental plans available through Choice Benefits cover a variety of
    services, including preventive care and basic services. You have the following options for
    dental coverage:
    i.     DeltaUSA Plan A,
    ii.    DeltaUSA Plan B, or
    iii.   No coverage; and
    iv.    Individual,
    v.     Dual, or
    vi.    Family.
c.) Employee term life and accidental death and dismemberment insurance.
d.) Dependent Life Insurance.
e.) Long Term Disability (LTD) Insurance. In the event of a disabling illness or injury, the
    affected House Officer will be maintained at 100% of stipend for the duration of the
    term of the contract. Should disability continue beyond that point, the disabled House
    Officer will continue to receive disability benefits under the polices and procedures of the
    Hospital’s LTD Insurance Program as in effect for salaried employees.
         The LTD plan replaces a percentage of your income if you become disabled due to
    an illness or injury and you’re unable to work for more than 30 days. You have the
    following options for LTD:
    i. 60% of Pay to $5,000/month,
    ii. 70% of Pay to $5,000/month, or
    iii. No coverage.
f.) HIV Insurance.
g.) Health care and dependent care flexible spending accounts.
h.) Legal services insurance through the ARAG Group. Includes identity theft services,
    immigration services, and financial/tax planning services.
i.) Long-term care insurance.
j.) Lifespan Retirement Program. You may enroll in the Hospital’s 403(b) savings plan or the
    accounts available through TIAA - CREF.
k.) State and federal credentialing costs.




                                             44
2. Cafeteria Hours/Services

    6:30 AM – 7:00 PM              Breakfast        6:30 AM – 10:15 AM
                                   Lunch            10:30 AM – 1:45 PM
                                   Supper           4:30 PM – 7:00 PM
    Au Bon Pain                    Mon – Fri        6:00 AM – 11:00 PM
                                   Sat – Sun        7:00 AM – 11:00 PM
    Vending machines are available next to the gift shop on a 24-hour basis.

3. Certificates

    A diploma certifying satisfactory completion of the Ophthalmology Residency Program at
    RIH and Brown Medical School is presented to the resident upon the completion of the
    residency; i.e., no sooner than June 30th of their 3rd year. This is signed b the following:
    a.)   Dean of Medicine and Biological Sciences,
    b.)   President of Rhode Island Hospital,
    c.)   Department Chief of Ophthalmology, and
    d.)   Program Director of Ophthalmology.

4. House Officer's Contract

    A contract is entered into between the resident and the Director of Graduate Medical
    Education that is renewed annually for each academic year. The contract indicates the name
    of the house officer, specialty, level of training or postgraduate year, duration (academic year),
    and annual stipend.

5. Uniforms/Laundry

   a.)    White lab coats. The Department upon the initiation of training will provide two white
          coats. The coats are expected to be clean and pressed at appropriate intervals dictated by
          their use. Laundering is at the resident’s own expense. The white coats are to be worn as
          the residents needs dictate. Their use in the clinic is optional.
   b.) Scrubs. Scrubs are provided by the operating room to which the resident is assigned.
       Scrubs are permitted elsewhere in the Hospital only if covered by a white lab coat. Scrubs
       brought from home and those that have been outside the Hospital should be replaced
       with a clean pair before reporting to surgery. Scrubs should not be worn in the clinic at
       any time unless the resident is expected to be in surgery or is just returning from surgery.
   c.) Attire. The principle it to represent your program, your institution, and your profession.
       Although no formal requirements are established. The following are suggested:
          i. Be well groomed and appear “professional”,
          ii. Men should wear ties, and
          iii. No jeans, shorts, T-shirts, sneakers are allowed.



                                                   45
6. Loan Deferment/Forbearance

   a.) Deferment. A deferment entitles you to postpone monthly payments on your student
       loan. Deferments are important because they give you flexibility and save you money! For
       example, on Federal Subsidized Stafford Loans, the federal government pays your interest
       during a deferment. And the time your loan is in deferment is not counted in the
       maximum period you have to pay the loan back. So it is worthwhile to protect your
       deferment rights, just as you would be careful with your grace period. (Your Grace Period
       is the time after you leave school, withdraw, graduate or drop below half time until you
       have to start making payments on your loan. A Federal Stafford Loan has a six-month
       grace period.)
       i.   You can apply for a deferment for a number of reasons, such as:
            i.       Education (continuing your education).
       ii. File the deferment at least a month or two before you want the deferment to start.
            For an In-School deferment, file your form when your enrollment status is verified by
            the registrar's office or office of education.
       iii. A deferment may be renewed, but not for longer than the time limit for that specific
            deferment.
   b.) Forbearance. A borrower who is willing but unable to make payments, and who does not
       qualify for a deferment, may request forbearance from the lender. Forbearance allows
       payments to stop temporarily or decrease in amount for a specific length of time. The
       lender may grant forbearance of principal, interest or both. The borrower is always
       responsible for repayment of accrued interest charges. The borrower can make interest-
       only payments, or the interest will be capitalized (added on to the principal).
       Unlike deferment, forbearance is not an entitlement. It is something the lender may
       choose to do for the borrower if the borrower is sincere in meeting his/her loan
       obligation and if the borrower's circumstances indicate forbearance would be helpful.
       Forbearances are processed for a maximum of twelve months. Forbearance will not
       eliminate any prior derogatory credit history.
   c.) A House officer loan program is also available

7. Mail and Notices

   It is advisable that all personal mail and as much professional mail as possible be sent to the
   resident’s home address. For RIH any internal or external mail or departmental
   correspondence will be distributed to the residents boxes located outside their assigned
   examination room. For the VAMC any internal or external mail will be distributed to the
   department office or to the ophthalmology clinic.
   The address and contact information while a resident is as follows:
   Department of Ophthalmology          Department of Surgery (Ophthalmology)
   Rhode Island Hospital                Providence VA Medical Center
   593 Eddy Street, APC 712             830 Chalkstone Avenue
   Providence, RI 02903                 Providence, RI 02908-4799
   Academic: (401) 444-4669             Academic:       (401) 457-3043


                                               46
                  Sally Martone                                 Carol Anthony
    Fax:          (401) 444-6187                Fax:            (401) 457-3053
    Clinic:       (401) 444-8615                Clinic:         (401) 273-7100, Operator
    Upon completion of the residency program, it is the responsibility of the resident to provide a
    forwarding address so that any additional mail received may be forwarded to the resident as
    necessary.

    Residents are advised to regularly review important notices on the bulletin board in the lunch
    area and to regularly check their mailboxes and email for departmental correspondence.

8. Malpractice

    Professional Liability Insurance Coverage. All House Officers are provided with professional
    liability insurance coverage through the Hospitals Self Insurance Program for all activities and
    rotations undertaken as part of the House Officer’s specific training program. Coverage for
    professional activities outside the Programs (e.g., moonlighting) is not provided and must be
    arranged by the House Officer, in accordance with the Policy on Moonlighting of House
    Officers.
    For additional information, go to the Risk Management website available at:
    www.lifespan.org/Risk.
    For verification of coverage, please contact Risk Management at (401) 444-6186.
    a.) Insurer:                        RI Source Enterprise Co. Ltd. (RISE)
    b.) Policy Number:                  LC1-2002/2003
    c.) Type of coverage:               Healthcare Provider Professional Liability
                                        (limited claims)
    d.) Policy Period:                  10/01/2002 – 09/30/2003
    e.) Limits of coverage:             $4,000,000 per medical incident for all Insured

9. Medical Licensure

    Limited medical registration in Rhode Island is provided by RIH for trainees in GME
    programs to practice medicine at the RIH and affiliated Hospitals as dictated by the Residency
    Program and as stipulated under the written lines of supervision. Although not a requirement
    of the Residency Program the resident may elect to obtain full medical licensure in the State
    of Rhode Island at the resident’s own expense. Practice of any kind outside of activities and
    rotations assigned as part of the specific training program (i.e., moonlighting) are not covered
    by the terms of the limited registration.

10. Controlled Substance Registration

    The Hospital will register and pay for controlled substance (narcotic) registration for all
    House Officers with limited medical registration. It is not paid for when a House Officer
    obtains full medical licensure.




                                                          47
    An assigned Drug Enforcement Agency (DEA) Number is provided for the training program
    to be utilized for all patients seen as part of the residency program. The assigned DEA
    number is not applicable for moonlighting activities in non-Rhode Island Hospital facilities.
    This number identifies both the sponsoring hospital and the resident.
    This number is to be kept confidential and is not to be distributed to any patients, staff, or
    physicians not directly affiliated with this residency program.
    The number is as follows: AR3268643-XXX
    XXX is a 3-digit number assigned to the resident upon the initiation of their training.

11. Extracurricular Employment

    Extracurricular employment (“Moonlighting”) is defined as any professional activity (patient
    care, moonlighting, research consulting, etc.) for compensation other than the training
    experience within the program. The terms “moonlighting” and “extracurricular employment”
    do not apply to the performance of assigned professional duties at any medical facility outside
    RIH and it’s affiliated hospitals pursuant to a formal agreement between RIH and other
    medical facilities. Extracurricular employments, therefore, includes employment at any time of
    the day, night or year, or “locum tenens” outside of the RIH training program.
    ACGME Definition: The circumstance of working as a physician outside of one's
    authorized training program is called "moonlighting."
    Department Policy (Modified Institutional Policy), Last revised September 18, 2003.
    a.) The Residency Program considers graduate medical education to be a full-time education
        experience. Residents should not be diverted from their primary educational and patient
        care responsibilities by engaging in extracurricular professional employment.
    b.) Residents must not be required to engage in "moonlighting."
    c.) J1 VISA holders are excluded from participating in moonlighting activities in accordance
        with the Federal Regulations Governing Exchange Visitor Physician: "Visa sponsorship
        authorizes a specific training activity and associated financial compensation. Federal
        regulations do not permit activity and/or financial compensation outside of the defined
        parameters of the training program."
    d.) Licensure:
       i.        Moonlighting activities are not covered by the limited medical registration provided
                 by RIH for trainees in GME programs.
      ii.        Moonlighting licensure is either a full license or a Medical Officer license in the State
                 of Rhode Island.
     iii.        Resident is responsible for the Medical Officer license fee.
     iv.         Assigned DEA number provided for the training program is not applicable for
                 moonlighting activities in non-Rhode Island Hospital facilities.
    e.) Malpractice:
            i.   Moonlighting activities at non-Lifespan facilities are not covered by malpractice
                 insurance provided by Lifespan for training activities. Insofar as extracurricular
                 employment is not an extension of postdoctoral training at RIH or an approved


                                                     48
            activity under any residency or clinical training and education program of RIH,
            medical liability insurance coverage will not be provided to any trainee for such
            activities.
        ii. Residents are responsible for obtaining independent malpractice insurance coverage
            for non-Lifespan moonlighting activities.
    f.) Approval/Monitoring: Program Director:
        i.   Written approval prior to participation in moonlighting. Residents planning to
             undertake extracurricular employment are required to report this activity to their
             Program Director.
        ii. Trainees will be notified at the time of their appointment that extracurricular
             employment which is not disclosed and approved in writing and in advance by the
             Department Program Director is prohibited and that any unreported extracurricular
             employment which is carried on in disregard of the objections of the Department
             Program Director will result in disciplinary action including the possibility of
             termination of appointment.
        iii. Monitor and document in resident's file performance to assure that factors such as
             resident fatigue are not contributing to diminished learning or performance, or
             detracting from patient safety. If moonlighting activities are deemed to have a
             negative effect on performance, permission to moonlight may be withdrawn.
        iv. Document the number of hours and the nature of the workload of residents engaging
             in moonlighting activities. Time spent moonlighting for in-house sponsored activities
             is included in the 80-hour workweek cap.

12. Notary Public

    a.) Sally Martone is a registered Notary Public. Please see her for all issues pertaining to
        hospital and residency education matters.
    b.) A registered Notary Public is also located in the GME office, Aldrich 120. This service is
        free for all House Staff.

13. Paging

    Upon the initiation of training a pager will be assigned to the resident for the duration of
    training. It is the responsibility of the resident that the pager is available, charged, and working
    properly at all times for the duration of the residency. The pager is to be returned upon the
    completion of the residency program.

14. On-Call Sleep Rooms

    Provided by the Hospital as necessary.




                                                  49
15. On-Call Meals Policy

          Benefit                             Criteria                       Recipient

              $6.50           On-Call, In-House 24 Consecutive Hours       Residents Only
                                 Excludes "shift" and "home" call; e.g.,
                                            ophthalmology

     $20-$25/Month            Meal Allocation, All programs: Including     Residents Only
                                            ophthalmology

    A committee of resident representatives developed the above criteria.

16. Parking

    Parking is provided to the resident at no expense. The resident is assigned to a designated lot
    at both RIH and VAMC. Please check with the parking office at each institution to verify
    assignment, access, and vehicle stickers. Courtesy van service is provided at RIH to the
    parking lots as well as to the Coro building. RIH and the VAMC require a parking permit for
    vehicle(s) parked on the facility. These must be displayed on the right rear window of the
    vehicle. Current license plate information must be provided for all vehicles used.
    a.) RIH:      Parking Office: (401) 444-4038
                  Security:       (401) 444-4111
    b.) VA:       Security:          (401) 273-7100, Operator

17. Payroll

    Checks are distributed biweekly on Friday mornings reflecting the annual stipend of the
    resident. They are received and distributed by the Sally Martone, the Department
    Administrator. Direct deposit may be arranged with the resident’s primary financial
    institution.
    Payroll deductions may also be arranged for U.S. savings bonds.

18. Stipends

    RIH offers a competitive salary to all of their house staff. Stipends are reviewed annually and
    the GME committee makes recommendations. Following are the stipends for specific post-
    graduate years (PGY) as of October 2003.
     PGY1         $41,242                     PGY3        $44,936
     PGY2         $42,392                     PGY4        $47,152




                                                    50
    Payment of stipend is in regular installments and is subject to stipulations in Hospital policy
    regarding payroll deduction. All residents in respective years of training will receive the same
    compensation. Prior training in other specialties/sub-specialties will not be considered and all
    residents will be compensated at the PGY level appropriate to the training year in the
    respective specialty.

19. Vacation Policy

    a.) Institutional Policy: Vacation allocation of vacation to residents in GME training
        programs at RIH is as follows (Last revised: April 15, 1999):

          Post Graduate Training Level                      Vacation Allocation

                         1                                        3 weeks

                         2                                        3 weeks

                         3                                        3 weeks

                         4                                        4 weeks


    b.) Department policy. Vacation requests must be submitted in writing to Sally Martone at
        least 6 weeks in advance. The procedure is as follows:
        i. Submit request to Sally Martone 6 weeks in advance. Appendix B.
        ii. The program director or chairman approves the request.
        iii. The request is sent to the scheduling coordinator of the clinic at RIH and the VAMC
               if applicable so that the clinic may be blocked out for that period.
        iv. If requests are submitted less than 6 weeks in advance:
               • The RIH chief resident (RIH C) needs to also approve the request attesting that
                    he or she is responsible for seeing or arranging to see patients that have already
                    been scheduled at RIH to see the resident requesting vacation.
        v. Special arrangements need to take place in order for the full-time second year resident
               to take vacation (VA A).
                    • The resident is only permitted to take vacation if more than 6 weeks
                        notification is given as other residents will need to be assigned to cover the
                        VA clinic in the absence of the full time VA Resident (VA A).
           vi.      As special circumstances arise (e.g., emergencies, interviews, etc.) we will work to
                    ensure patients are seen and/or cancelled as necessary. It is the responsibility of
                    the resident to ensure that on-call coverage, clinic follow-ups, and OR coverage
                    has been arranged.
          vii.      Vacation time cannot be carried over the subsequent academic years.
         viii.      Vacation should taken over a 7 day time period (one week) when possible starting
                    on Monday and ending on Sunday.


                                                  51
           ix.     Vacations are not permitted the first two weeks of July to facilitate the transition
                   of the new residents.
            x.     The resident on subspecialty assignment (VA B) should notify their subspecialty
                   preceptor of there absence in advance.

20. Absenteeism

    It is the responsibility of each resident to inform the clinic manager at RIH and/or the
    VAMC as soon as possible of an unexpected absence from clinical responsibility so that the
    clinic may be rearranged accordingly. The program also needs to be notified.
    RIH:                      Jane Cote     (401) 444-8615, (401) 444-7893
    VAMC:                     Jacky Horner (401) 273-7100 x2475; (401) 933-8512 (pager)
    Program:                  Sally Martone (401) 444-4669

21. On site day care center

    Available as necessary; Bright Horizon          (401) 454-0312

22. Banking facility & ATM

    Available as necessary on the Hospital premises with 24 hour ATM.
    Sovereign Bank       (401) 444-4300
    Lobby Hours:         M - W: 9:00 AM - 3:00 PM
                         Thurs: 9:00 AM - 4:00 PM
                         Fri:    8:30 AM - 5:00 PM

23. Employee Health Services

    Employee Health Services (EHS): Available as necessary for:
    a.) Medical Surveillance for Tuberculosis (no appointment needed);
          The Occupational Safety and Health Administration (OSHA) proposed rule for
          occupational exposures to Tuberculosis (29 CFR Part 1910) requires that all employees
          working in a hospital who are exposed to M. Tuberculosis undergo “medical surveillance”
          (e.g., medical history, TB skin testing, etc.). Because of the number of infectious cases in
          Providence County, all healthcare workers (physicians, nurses clinical associated) at RIH
          require an annual screening. Occupational exposure means reasonably anticipated contact,
          which results from the performance of an employee’s duties with an individual with
          suspected on confirmed infectious TB or air that may contain aerosolized M. Tuberculosis.
    b.)   Color vision testing for employees performing colormetric testing;
    c.)   Latex allergies;
    d.)   Immunizations/antibody titers;
    e.)   Flu shots (Influenza Vaccination);
          Infected persons can transmit influenza virus to person at high risk for complications
          from influenza. Efforts to protect members of high-risk groups might be improved by


                                                   52
          reducing the likelihood of influenza from their caregivers. Therefore, the following
          groups should be vaccinated:
          Physicians, nurses, and other personnel in hospital and outpatient care settings.
    f.) Work-related injuries;
    g.) Needle-stick injuries; and/or
    h.) HIV testing.
    Location:             593 Eddy Street, Grad's Dorm, 1st Floor, RIH
    Contact:              Phone:         (401) 444-4038
                          Fax:           (401) 444-6310
    Hours:                Mon – Fri      7:30 AM - 4:30 PM
    Needle-stick injury protocol:
    a.) Wash area well with soap and water,
    b.) Tell supervisor as soon as possible,
    c.) During clinic hours go to EHS directly, and
    d.) Out of hours: Call page operator and ask for nursing supervisor covering your shift, page
        that person, and discuss your injury, you will be sent to ED or to EHS the next day.
        i. Write down name of source and where incident occurred.
        ii. Complete an incident report.
    e.) More info: (800) 35-NIOSH; www.osha.gov, www.cdc.gov/niosh.

24. Employee assistance program

    Our Employee Assistance Program, a free service available as a benefit to all employees and
    their family members, is confidential, professional resource for persons needing information,
    or assessment and referral to counseling, or other resources within their community.

    Confidential professional assessment, referral and counseling will be available to assist in the
    resolution of personal problems, which may be adversely affecting their personal lives and/or
    job performance. Employees may make a self-referral by directly calling the Employee
    Assistance Program or may request the assistance of Human Resources to arrange an
    appointment.
    To ensure complete confidentiality, we have contracted Resource International Employee
    Assistance Services (RIEAS) to provide management and professional staff services for our
    Employee Assistance Program. Counseling, medical, psychological services, and other
    support services are available.
    Contact RIEAS:        1-800-445-1195; 1-800-833-0453, www.rieashelp.com
    RIEAS consultants have experiences assisting with various concerns, such as:
    a.)   Grief,                       f.)   Depression,
    b.)   Anger,                       g.)   Legal issues,
    c.)   Stress,                      h.)   Family matters,
    d.)   Anxiety,                     i.)   Financial worries, and/or
    e.)   Addictions,                  j.)   Relationship conflicts.
    RIEAS will:


                                                   53
    a.)      Provide information,
    b.)      Provide immediate assistance or schedule a later interview,
    c.)      Assess any crisis needs and concerns,
    d.)      Locate helping resources within the community,
    e.)      Act as a liaison between you and your HMO or insurance company,
    f.)      Provide ongoing support and assistances, and/or
    g.)      Seek free or sliding scale services without insurance coverage.

25. Employee activities

    A monthly newsletter is available through Human Resources that describe all the employment
    activities and discount programs that may be available. Coupons/tickets may be purchased in
    Human Resources in the Potter Building, 1st Floor, Payment is by check or money order only
    as no cash will be accepted Employee discount programs are available at:
    a.)      Showcase cinema     $6.00 per ticket
    b.)      Jiffy Lube          15% off (need coupon)
    c.)      New England Tire    Discounts on tires and auto services (need coupon)
    d.)      'Sew'-phisticated   15% off alterations and repairs (show ID badge)
    e.)      CTX Mortgage Discount on closing costs and misc. items (need coupon)
    f.)      R.A. Yarns          10% off (show ID badge)
    g.)      Sprint Cell Service 25% off regular prices (Call Paul at 774-291-9055)
    h.)      Universal Studios   10-30% off selected items, hotels, tickets

26. Fitness & Wellness Center

    Available as necessary.


C. Graduate Medical Education Policies
1. Compensation

    See Stipends above (Chapter IV. B. 18)

2. Inspection of House Staff Files:

    a.) Policy: RIH will allow residents to inspect their own files (Last revised April 15, 1999).
    b.) Procedure
          i.    Availability of files
                • Residents may inspect their own files during the regular business hours of the
                   department of medical education.
       ii.      Entitled to access
                • Only residents currently in service or on authorized leave of absence may have
                   access to their file.



                                                 54
              •   Applicants to the house staff, designated agents or any other persons are not
                  permitted to see files.
      iii.    Available for inspection: A resident may inspect the following material from the file:
              • Application for residency,
              • Stipend information,
              • Notices of commendation, warning or discipline, and/or
              • Performance evaluations.
      iv.     Excluded from inspection: The following materials are excluded from resident
              inspection:
              • Records relating to the investigation of possible criminal offenses,
              • Letters of reference,
              • Material being developed for use in criminal, civil or grievance procedures,
                  and/or
              • Information available under the Fair Credit Reporting Act.
       v.     Stipulations:
              • Files may not be removed from the office of medical education.
              • The contents of a file cannot be copied.
              • The director of medical education must be present when a resident inspects a file.
              • Only under special circumstances may residents inspect their file more than once
                  a year.
      vi.     Counterstatement: A counterstatement may be placed in the file if a resident
              disagrees with the material in the file.

3. Leave of absence

    Residents are afforded a leave of absence in accordance with the hospital policy on leave of
    absence.
    Purpose as stated in the hospital policy (see Hospital Policy; C. 5.). To define the provisions
    for absences from work for more than two weeks, the effect of such absences on pay and
    employee benefits and the hospital’s implementation of the state Parental and Family Medical
    Leave Act of 1990 and the Federal Family & Medical Leave Act of 1993.
    Residents should discuss all requests for leave of absence with the program director at the
    earliest possible opportunity. Such requests should be documented in the resident’s file along
    with final arrangements.
    The program director will advise the house officer of any impact of the leave time on
    satisfying the completion of the requirements for training and/or board eligibility.

4. Selection for House Officers

    The residency program is a three-year program with two positions annually. The positions are
    filled through the San Francisco Ophthalmology Residency Matching Program (OMP). The
    OMP was established in 1977 by the Association of University of Professors of
    Ophthalmology (AUPO) to coordinate the PGY-2 appointments for Ophthalmology
    programs. The program supplements the PGY-1 matching services of the National Residency
    Matching Program (NRMP). Applications are considered only if processed through the



                                                 55
Central Application Service (CAS) of the OMP. The OMP provides support services to the
residency program to facilitate and standardize the application the selection process. The
applicant must complete PGY-1 training before beginning a PGY-2 position in
ophthalmology. After completing an internship in medicine and/or surgery at an approved
preliminary or transitional year program, the resident then joins the department as a PGY-2
ophthalmology resident. Internship positions are available in surgery or internal medicine at a
number of Brown affiliated hospitals.
Generally, the applicant applies during their fourth year of medical school to both the NRMP
and the OMP for their PGY-1 and PGY-2 assignments. The applicants’ files are completed
by early September and are then distributed to the residency program by the CAS. The CAS
also provides Dean’s letters when they are available later in November. After all applications
are received the program director and a panel of clinical faculty in the department review
them. Residents are also invited to participate in this process. Approximately 40 applicants are
invited to attend one interview session held on a Monday in early December. The applicants
are invited to attend either a morning or an afternoon session and will interview with the
Chairman, the Program Director, and 5-6 additional clinical faculty members in the
department. The applicants will also have the opportunity to be interviewed formally by 1-2
of the residents and to interact with the residents more informally during lunch and tours of
the hospital. The applicants and the program each submit their rank lists independently and
directly to the OMP in mid-January and the results are made public at the “early match” later
in January for spots in July the following year. The applicant then undergoes a separate
process for a PGY-1 “regular match” through the NRMP in March.
a.) Selection Criteria (Last revised October 16, 2003).
   i.   RIH has as its policy to consider all candidates for graduate medical education
        regardless of race, sex, creed, nationality, age, or sexual orientation. Performance
        in medical school, personal letters of recommendation, official letters of
        recommendations, achievements, humanistic qualities, and qualities thought
        important to the desired specialty will be used in the selection process.
  ii.   Application is completed and distributed by the CAS of the OMP. This
        application includes the following:
        • Registration for the match for Ophthalmology Residency,
        • Application,
        • College and medical school transcripts,
        • US-MLE scores with Performance Profiles,
        • ECFMG (applicable to International Medical Graduates),
        • Letters of reference (usually between 3-4 are requested),
        • Dean’s letter, and
        • Personal Statement.
 iii.   First stage of selection process:
        • Residency committee reviews application and the credentials submitted
            indicated above in a fair and equitable manner and
        • Committee decides whom to invite for interviews and invitations are
            distributed.
 iv.    Applicant accepts the invitation and attends the interview session.
  v.    Second stage of selection process:
        • Interviews are performed,


                                            56
             •   The residency committee decides who to rank and is committed to accept
                 any of the applicants ranked, and
             • The residency committee prepares the rank-order list preferences and
                 submits the rank to the OMP by the deadline in mid-January
     vi.     Applicant ranks our program by the deadline in mid-January.
     vii.    Participation in the early match through the OMP resulting in a “Match” in late
             January.
    viii.    Participation in the NRMP for a PGY-1 position in March.
    b.) Entrance Criteria:
       i.    Participation in the OMP with a resultant “Match” to our program,
      ii.    Completion of an approved preliminary or transitional year program in good
             standing,
      iii.   Credentials for limited registration as a House Officer in the state of Rhode
             Island are provided to Lifespan and it’s affiliated hospitals, and
     iv.     Approval of the credentials for limited registration as a House Officer in the state
             of Rhode Island.

5. Promotion/Advancement of House Officers

    Six ophthalmology residents staff the clinic: two in each year at the PGY-2, PGY-3, and
    PGY-4 levels.
    Promotion or advancement of house officers to the next level of the program depends upon
    the house officer’s performance and qualifications. The criteria and goals, which are expected
    to be met by a house officer before he or she is advanced to the next level of training in the
    program, are indicated below. These criteria and goals are reviewed annually by the program
    and the program director and are made known to the house officers and faculty (Last revised
    October 16, 2003).
    a.) Satisfy general goals and objectives of the program with acceptable progress in all
        areas.
    b.) Satisfy specific goals and objectives based on year:
        i.   Objectives for First Year (PGY-2),
       ii.   Objectives for Second Year (PGY-3), and
      iii.   Objectives for Third Year (PGY-4). At the completion of the program the
             resident should be competent to act independently in all areas.
    c.) Satisfy specific objectives based on subspecialty:
       i.    Cataract,                    vi.      Neuro-ophthalmology,
      ii.    Retina,                      vii.     Oculoplastics,
     iii.    Glaucoma,                    vii.     Pediatric ophthalmology,
     iv.     Cornea/external disease,     viii.    Uveitis, and
      v.     Pathology,                   viii.    Optics, refraction, CL, low vision.
    d.) Satisfy lines of supervision and responsibility. The resident should be able to
        supervise and teach others with increasingly independence.
    e.) Participate in resident, faculty, and program evaluation.


                                                  57
    f.) Participate in the annual Ophthalmology Knowledge Assessment Program (OKAP)
        prepared by the AAO and administered by the ACT.
    g.) Follow guidelines for resident duty hours and personal responsibility.
    h.) Documentation of procedures and surgeries.
    i.) Follow the moonlighting policy.
    j.) Upon completion of the residency, graduates should possess the knowledge and
        experience necessary for membership in the ABO.
    k.) Decisions about advancement or reappointment are concluded by the program
        director with advice of the clinical faculty and are to be communicated to the house
        officer no later than four months prior to the end of the house officer’s current
        contract.

    l.) Before the certificate of completion is awarded the resident is expected to complete
        the GME Final Steps Paperwork form and return it to Sally Martone who will return
        the form to Graduate Medical Education, Aldrich Building, Room 120.
        •    All outstanding obligations must be satisfied and equipment or keys returned.
        •    On-Call Room Keys, Gerry House, Department of Environment Services, APC
             Basement, Rom 25, Jimmy Medeiros
        •    Employee ID Badges, Security Office, Jane Brown Ground Floor, Scott LaRue
        •    Pagers (RIH); Telephone Office, Keystone Building, Arlene Moniz
        •    Library Books and Services (RIH), Peter Health Sciences Library, Aldrich Building
        •    Health Information Services (RIH), Medical Records, APC Basement, Jane Warner
        •    Debitek Cards (RIH), Graduate Medical Education, Aldrich Building, Room 120
        •    Department Keys, Sally Martone
        •    Department Books, Videos, Sally Martone
        •    Clean Rooms, Jane Cote and Samol Sock

6. Evaluation of House Officers

    There is a clearly stated process for the evaluation of house officers at RIH (Last revised
    October 16, 2003). The program director meets biannually with the residents to evaluate and
    monitor their progress in the program and to obtain their feedback and recommendations.
    The program director is also available to meet with residents when indicated as issues arise.
    a.) The evaluation used is the long form established by the ACGME for evaluation of the
        ophthalmology resident (See Appendix C).
    b.) Each house officer is evaluated by the program director and/or designee with the
        assistance of the teaching staff, for evidence of satisfactory progressive scholarship and
        professional growth, including demonstrated ability to assume graded and increasing
        responsibility for patient care. The evaluations must be accurately documented, dated and
        signed by both the evaluator and the house officer.
    c.) The evaluations will be based in part on written reviews provided by faculty members at
        the end of each rotation. Other appropriate sources include patients, peers, self, and other



                                                58
    professional staff. Methods of evaluation shall come consist of direct and indirect
    observation, videotapes, faculty evaluations, and the OKAP.
d.) The evaluations are performed at least semi-annually. These are held in December and
    June for each resident with the Program Director and/or the Chairman.
e.) Separate surgical evaluations are completed at the end of each surgical procedure to allow
    for prompt feedback of the procedure. It is the responsibility of the resident to take the
    form to the attending and to return it to Sally Martone for the resident’s file and for the
    program to monitor the resident’s surgical progress (See Appendix E).
f.) The house officers are evaluated against the same criteria when assigned to facilities
    outside the Hospital as part of the residency training.
g.) The evaluation of performance is discussed with the house officer. When weaknesses or
    deficiencies are identified, steps are taken promptly to improve performance and counsel
    the house officer where appropriate.
h.) The evaluations are based on the following elements (Six General Competencies).
    Identification of general competencies is the first step in a long-term effort designed to
    emphasize educational outcome assessment in residency programs and in the
    accreditation process.
    I.       PATIENT CARE
         •   Residents must be able to provide patient care that is compassionate, appropriate,
             and effective for the treatment of health problems and the promotion of health.
             Residents are expected to:
             o Communicate effectively and demonstrate caring and respectful behaviors
               when interacting with patients and their families;
             o Gather essential and accurate information about their patients;
             o Make informed decisions about diagnostic and therapeutic interventions
               based on patient information and preferences, up-to-date scientific evidence,
               and clinical judgment;
             o Develop and carry out patient management plans;
             o Counsel and educate patients and their families;
             o Use information technology to support patient care decisions and patient
               education;
             o Perform competently all medical and invasive procedures considered
               essential for the area of practice;
             o Provide health care services aimed at preventing health problems or
               maintaining health; and
             o Work with health care professionals, including those from other disciplines,
               to provide patient-focused care.




                                            59
II.        MEDICAL KNOWLEDGE
       •   Residents must demonstrate knowledge about established and evolving
           biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral)
           sciences and the application of this knowledge to patient care. Residents are
           expected to:
           o Demonstrate an investigatory and analytic thinking approach to clinical
             situations and
           o Know and apply the basic and clinically supportive sciences, which are
             appropriate to their discipline.
III.       PROFESSIONALISM
       •   Residents must demonstrate a commitment to carrying out professional
           responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
           population. Residents are expected to:
           o Demonstrate respect, compassion, and integrity; a responsiveness to the
             needs of patients and society that supercedes self-interest; accountability to
             patients, society, and the profession; and a commitment to excellence and on-
             going professional development;
           o Demonstrate a commitment to ethical principles pertaining to provision or
             withholding of clinical care, confidentiality of patient information, informed
             consent, and business practices; and
           o Demonstrate sensitivity and responsiveness to patients’ culture, age, gender,
             and disabilities.
IV.        PRACTICE-BASED LEARNING AND IMPROVEMENT
       •   Residents must be able to investigate and evaluate their patient care practices,
           appraise and assimilate scientific evidence, and improve their patient care
           practices. Residents are expected to:
           o Analyze practice experience and perform practice-based improvement
             activities using a systematic methodology;
           o Locate, appraise, and assimilate evidence from scientific studies related to
             their patients’ health problems;
           o Obtain and use information about their own population of patients and the
             larger population from which their patients are drawn;
           o Apply knowledge of study designs and statistical methods to the appraisal of
             clinical studies and other information on diagnostic and therapeutic
             effectiveness;
           o Use information technology to manage information, access on-line medical
             information; and support their own education;
           o Facilitate the learning of students and other health care professionals.
V. INTERPERSONAL AND COMMUNICATION SKILLS
       •   Residents must be able to demonstrate interpersonal and communication skills
           that result in effective information exchange and teaming with patients, their
           patients families, and professional associates. Residents are expected to:



                                            60
                   o Create and sustain a therapeutic and ethically sound relationship with
                     patients;
                   o Use effective listening skills and elicit and provide information using effective
                     nonverbal, explanatory, questioning, and writing skills; and
                   o Work effectively with others as a member or leader of a health care team or
                     other professional group.
         VI.       SYSTEMS-BASED PRACTICE
               •   Residents must demonstrate an awareness of and responsiveness to the larger
                   context and system of health care and the ability to effectively call on system
                   resources to provide care that is of optimal value. Residents are expected to:
                   o Understand how their patient care and other professional practices affect
                     other health care professionals, the health care organization, and the larger
                     society and how these elements of the system affect their own practice;
                   o Know how types of medical practice and delivery systems differ from one
                     another, including methods of controlling health care costs and allocating
                     resources;
                   o Practice cost-effective health care and resource allocation that does not
                     compromise quality of care;
                   o Advocate for quality patient care and assist patients in dealing with system
                     complexities; and
                   o Know how to partner with health care managers and health care providers to
                     assess, coordinate, and improve health care and know how these activities
                     can affect system performance.

7. Supervision of House Officers

    These lines of responsibility and supervision are to provide the optimal care of all patients at
    all clinical sites (Last revised October 16, 2003).
    There must be sufficient oversight to assure that residents are appropriately supervised.
    Residents must be supervised by teaching staff in such a way that the residents assume
    progressively increasing responsibility to their level of education, ability, and experience. On-
    call schedules for teaching staff are structured to ensure that supervision is readily available to
    residents on duty. The teaching staff will determine the level of responsibility accorded to
    each resident. Patients will be evaluated by the resident staff; although a faculty member is
    always available for consultation or assistance when requested.
    Faculty is ultimately responsible for the clinical care given to patients. Supervision of residents
    may be provided by a combination of upper level residents and faculty. No fellows are
    present as part of the residency program. The Department of Ophthalmology within the
    Hospital identifies supervisory faculty for given periods and subspecialties.
    All attending physicians selected for supervision of residents are board-certified
    ophthalmologists and members of the clinical faculty who are in good standing with the
    institution sponsoring their appointment.
    The traditional hierarchy model is enforced in the residency program; i.e., as knowledge and
    experience are gained, the resident is obliged to supervise and teach his junior residents. The


                                                  61
    first year residents are directly supervised by their senior second and third year resident. The
    third year residents likewise directly supervise the second year residents. If the first or second
    year resident has questions the assistance of a third year resident should be sought before the
    patient leaves the clinic. The first and second year residents share first call coverage of the
    emergency room and inpatient consultation service at RIH and affiliated hospitals. The third-
    year residents share back-up call coverage of the first and second-year residents. When further
    complexity of decision making is required and/or surgical management is considered the
    third-year resident communicates directly with the general attending on call for that particular
    week or the subspecialty attending on call for their respective discipline.
    The general attending on call coverage requires staffing the resident clinic at RIH, supervising
    the inpatient consultation service, and to be available after hours to assist the third year
    resident in the medical and surgical management of patients presenting with emergent issues.
    Similarly the subspecialty attending on call for their discipline is available to the residents to
    assist in the medical and surgical management of patients presenting with emergent/urgent
    issues in their respective subspecialty. Supervision by board-certified faculty members is
    always present during surgery, in the outpatient general and subspecialty clinics, and for
    consultations on the inpatient service.

8. Due Process of House Officers

    a.) Application of Policy (Last revised October 16, 2003).
       i.    The procedures described below are applicable to all post-doctoral trainees enrolled
             in the Hospital’s GME program. The term "post-doctoral trainees" shall include
             physicians, or other graduates of a doctoral program who are enrolled in a Hospital-
             sponsored training program as residents or clinical fellows (hereinafter, "trainees").
             Although trainees may also be appointed to the Medical Staff and/or may be
             employed by the Hospital, the procedures described below, and not the review and
             appeal procedures described in the Medical Staff bylaws for other Medical Staff
             members or the grievance or similar procedures afforded to Hospital employees
             through the Hospital’s Human Resource Department, constitute the exclusive
             process by which any adverse action affecting a trainee’s program appointment,
             employment, medical staff appointment or clinical privileges will be reviewed.
    b.) Grievances
       i.    Residents who feel they have been treated unfairly under the interpretation or
             application of a policy, rule or procedure may file a grievance. Residents who believe
             that they may have a complaint involving sexual harassment are advised to follow the
             procedure set forth in the hospital's policy on "Sexual Harassment". Reasonable
             efforts should be made within each department and residency program to resolve
             grievances on an informal basis. Residents may also seek out the Director of
             GME/DIO for assistance with informal resolution of a grievance. The grievance
             process shall be conducted without the presence of legal counsel. This grievance
             procedure is not applicable to any decision regarding probation, suspension, non-
             renewal or termination. Resident appeals of these actions must be filed under the
             appeals process set forth in the "Right to Review" sections of this policy.




                                                 62
  ii.   A request for formal resolution of a grievance shall be submitted in writing by the
        resident to the Program Director within thirty days following the date when the
        resident first had knowledge of the incident that gave rise to the grievance. The
        Program Director shall notify the Director of GME/DIO. The Program Director
        may elect to respond and resolve the grievance, or may in his/her judgment, request
        that the Director of GME/DIO review and adjudicate the grievance. The Director of
        GME/DIO may elect to respond to the grievance or may elect to convene a
        committee of three members of the GMEC; the resident may select one member.
        The Program Director, Director of GME/DIO or the committee may review any
        records, or interview any persons whom they consider helpful for resolution of the
        grievance. The committee will provide a decision of the grievance to the Director of
        GME/DIO. The Program Director or Director of GME/DIO shall issue a decision
        of the grievance within thirty days.
 iii.   Residents who believe that they may have a complaint involving their training
        program, Program Director or faculty may submit the grievance in writing to the
        Director of GME/DIO. The Director of GME/DIO may elect to respond to the
        grievance or may elect to convene a committee of three members of the GMEC; the
        resident may select one member. The Director of GME/DIO or the committee may
        review any records or interview any persons whom they consider helpful for
        resolution of the grievance. The committee will provide a decision of the grievance to
        the Director of GME/DIO. The Director of GME/DIO shall advise the resident in
        writing of the proposed resolution of the grievance within thirty business days after
        receiving the notification of the grievance.
c.) Procedures Prior to Initiating Formal Disciplinary Action
   i.   Program directors are encouraged to address and resolve minor instances of
        unsatisfactory performance or misconduct prior to invoking the formal disciplinary
        actions set forth below. Any trainee whose performance is assessed to be less than
        satisfactory by the program director may be placed on a remedial training status for a
        specified period of time, not to exceed six months. In such cases, the program
        director shall inform the trainee in writing of the deficiencies noted in academic,
        clinical and/or professional performance, and shall outline a program of remediation,
        as well as criteria for successful completion of the program. The trainee shall be
        requested to acknowledge being advised of his/her remediation status by signing the
        notification; refusal to do so shall be noted by the program director, setting forth the
        reasons for refusal if stated by the trainee. The director of GME/DIO shall also be
        notified of the trainee's remedial status, the reasons for the decision, and the plan for
        remediation.
  ii.   If the trainee is successful in completing the remedial program, the trainee will be
        removed from remedial training. Remedial status is not a formal disciplinary action
        and not subject to disclosure to any external inquiries. Documentation of the remedial
        training process will be incorporated into the trainee's evaluation and will be disclosed
        only upon written authorization of the trainee or legal process. In the case where
        deficiencies in the trainee's clinical performance are identified, the trainee may receive
        reduced or limited credit for the relevant portion of the training program pursuant to
        the applicable section below. The program director shall inform the trainee of such
        reduction in credit as part of the remedial training process.


                                             63
 iii.      If the remedial training efforts are unsuccessful or where performance or misconduct
           is of a serious nature, the chief or program director may initiate formal disciplinary
           action as described below.
d.) Formal Disciplinary Action
        Disciplinary action may be taken for due cause, including but not limited to any of the
        following:
   i.      Failure to satisfy the academic or clinical requirements of the training program;
  ii.      Professional incompetence, misconduct or conduct that might be inconsistent with
           or harmful to patient care or safety;
 iii.      Consistently substandard performance;
 iv.       Conduct which calls into question the professional qualifications, ethics, or judgment
           of the trainee;
  v.       Failure to function in a cooperative and reasonable manner with other trainees,
           employees, medical staff, patients, volunteers and/or visitors of the Hospital;
 vi.       Violation of the bylaws, rules, regulations, policies, or procedures of the medical staff,
           Hospital, or applicable department, division or training program, including, without
           limitation, any violation of the Hospital’s sexual harassment policy;
 vii.      Scientific misconduct.
e.) Specific Procedures
        Formal disciplinary action may include, but is not limited to probation, suspension, or
        termination of the trainee from the training program during an academic year. Except
        under circumstances requiring an immediate emergency disciplinary action to preserve
        acceptable standards of care, safety, integrity or ethics at the Hospital, the following
        procedures will be followed.
   i.      Training Program Probation
           •   General
                  Training program academic probation (or "probation") means a temporary
                   modification of the trainee's training program participation or responsibilities,
                   designed to facilitate the trainee's accomplishment of program requirements.
                   Generally, a trainee will continue to fulfill training program requirements
                   while on probation, subject to the specific terms of the probation.
                  The program director, after consultation with the Chief, shall have authority
                   to place the trainee on probation (with pay) and to determine the terms of the
                   probation.
                  Probation may include, but is not limited to, special requirements or
                   alterations in scheduling a trainee's responsibilities, increased supervision,
                   and/or a reduction or limitation in clinical responsibilities.
                  The program director shall notify the trainee and the director of GME/DIO
                   in writing of the probation, the reasons for the decision, the required method
                   and timetable for correction, and the date upon which the decision will be re-
                   evaluated. The trainee shall be requested to acknowledge being advised of
                   his/her probation status by signing the notification; refusal to do so shall be



                                                64
              noted by the program director, setting forth the reasons for refusal if stated
              by the trainee.
             Within 30 days of receiving this notice, the director of GME/DIO will meet
              with the trainee for counseling and appropriate guidance after consultation
              with the program director.
             The program director shall evaluate (in writing) the trainee at not less than
              30-day intervals from the date of sending notification to the trainee. These
              evaluations must be signed by the program director and reviewed and
              discussed with the trainee. The trainee shall also sign the evaluation; refusal to
              do so shall be noted by the program director, setting forth the reasons for
              refusal if stated by the trainee.
             Each such evaluation will be sent to the director of GME/DIO, who shall
              meet with the program director and/or trainee as deemed appropriate.
             No trainee shall remain on probation for more than six months in total over
              the course of his/her training. If the trainee’s performance remains
              unsatisfactory or other reasons for the probation have not been resolved,
              he/she may not continue as a trainee in a training program. The trainee will
              be informed in writing of his/her termination from the program pursuant to
              this provision.
      •   Right to Review
             The trainee shall have the right to a review of the probation decision and shall
              be informed of this right when placed on probation. To initiate such a review,
              a trainee must submit a written request for a review of the probation to the
              director of GME/DIO within five business days of the trainee's receipt of
              the notification of the probation decision. Failure to make a timely request
              for a review will constitute a waiver of the trainee's right to a review.
             If the trainee requests review of the probation status, the director of
              GME/DIO shall meet with the trainee within ten business days and afford
              the trainee an opportunity to provide any information in his or her defense.
              After this meeting, the director of GME/DIO or his/her designee (s)
              following consultations with the Program Director, Department Chief and
              other appropriate individuals, if any, will render a final decision.
             The trainee shall receive written notification of the decision of the director of
              GME/DIO and the reasons for and consequences of the decision.
             Probation is a part of the trainee's permanent record.
             There is no further appeal from a decision to place a trainee on probation.
ii.   Suspension
      •   General
             The program director, after consultation with the Chief, may temporarily
              suspend the trainee from training program duties by placing him or her on an
              unpaid leave of absence for seriously deficient performance or seriously
              inappropriate conduct. Except when the interests of patient care may be


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               adversely affected, the program director shall also consult with the Senior
               Vice President of Medical Affairs at the Hospital and the director of
               GME/DIO, before imposing suspension. A voluntary leave of absence that
               is approved by the program director in advance shall not be considered a
               suspension or other form of disciplinary action.
              The Program Director shall provide the trainee with written notification of
               the reasons for the suspension, the required method and timetable for
               correction, and a date upon which the decision will be re-evaluated. The
               trainee shall be requested to acknowledge being advised of his/her
               suspension by signing the notification; refusal to do so shall be noted by the
               Program Director, setting forth the reasons for refusal if stated by the trainee.
               The written notification shall include a statement that suspension, if final,
               may be reported to the Rhode Island Board of Medical Licensure and
               Discipline. The written notification should also advise the trainee of his or
               her right to request a review of the suspension in accordance with the
               procedures outlined below. This notice shall precede the effective date of the
               suspension, unless a serious risk to patient care or the health or safety of an
               employee warrants immediate suspension, in which case the notice shall be
               provided at the time of the suspension.
       •   Right to Review
              The trainee shall have the right to a review of the suspension decision. To
               initiate such a review, the trainee must submit a written request for a review
               of the suspension to the director of GME/DIO within five business days of
               the trainee's receipt of the notification. Failure to make a timely request for a
               review will constitute a waiver of the trainee's right to a review.
              If the trainee requests review of the suspension, the director of GME/DIO
               or his/her designee(s) shall meet with the trainee within ten business days and
               afford the trainee an opportunity to provide any information in his or her
               defense. After this meeting, the director of GME/DIO or his/her designee
               (s) following consultations with the Program Director, Department Chief and
               other appropriate individuals, if any, will render a final decision.
              The trainee shall receive written notification of the decision of the director of
               GME/DIO and the reasons for and consequences of the decision.
              There is no further appeal from a decision to suspend a trainee.
              No trainee shall remain on suspension for more than three months in total
               over the course of his/her training. If the reasons for the suspension have
               not been resolved at the end of the three-month period, he/she may not
               continue as a trainee in a training program. The trainee will be informed in
               writing of his/her termination from the program pursuant to this provision.
              Suspension is reportable to the Rhode Island Board of Medical Licensure and
               Discipline and part of the trainee's permanent record.
iii.   Involuntary Termination From the Program During an Academic Year
       •   General


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       The program director, after consultation with the Chief, shall have authority
        to terminate a trainee from a training program, for reasonable cause,
        including but not limited to a failure satisfactorily to fulfill the requirements of
        the training program. Prior to the recommendation for termination of any
        trainee, the Chief and/or program director shall consult with the Senior Vice
        President of Medical Affairs for the Hospital and the director of GME/DIO.
        Dismissal of a trainee during an academic year shall constitute a termination.
        Failure to continue a trainee in a program beyond the academic year or failure
        to certify successful completion of a training program does not constitute a
        disciplinary action, as discussed more fully in applicable sections below.
       Written notice of a recommendation of termination from a program,
        including the reasons for the decision and the effective date shall be provided
        by the program director to the trainee. The trainee shall be requested to
        acknowledge being advised of his/her involuntary termination by signing the
        notification; refusal to do so shall be noted by the program director, setting
        forth the reasons for refusal if stated by the trainee. The notice shall include a
        statement that termination, if final, may be reported to the Rhode Island
        Board of Medical Licensure and Discipline, and that an explanatory
        statement may also be submitted to the ACGME of the American Medical
        Association. The notice shall also state that the trainee may request a formal
        review of the termination in accordance with the procedures described
        below.
•   Right to Review
       The trainee shall have the right to a review of the termination decision. To
        initiate such a review, the trainee must submit a written request for a review
        of the termination to the director of GME/DIO within five (5) business days
        of receiving notification. The written request must specify the reasons the
        trainee believes his/her case warrants review and special consideration.
        Failure to make a timely request for a review will constitute a waiver of the
        trainee’s right to a review.
       If the request for a review is timely, the director of GME/DIO will arrange a
        hearing before a committee composed of the director of GME/DIO (who
        shall serve as chairperson), three faculty members on the Hospital staff
        association members and two Hospital house officers. The director of
        GME/DIO shall select the hearing committee members. The director of
        GME/DIO shall not serve on the committee if he or she made the
        recommendation to terminate or if he or she desires to be, or is to be, called
        as a witness at the hearing. In such event, or in the director of GME/DIO’s
        absence or inability to serve, the director of GME/DIO shall appoint one
        other staff association member to the committee, which shall select a
        chairperson. The committee will conduct the hearing as soon as practicable,
        but in no instance more than 30 days from the date of receipt of the trainee’s
        request for a review. By mutual agreement of the parties, this time may be
        further extended.




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             The committee’s sole function shall be to ascertain whether or not: (a) there
              was any reasonable basis to recommend termination, and (b) the provisions
              of this Policy were substantially adhered to. It shall not be the function of the
              committee to recommend alternative disciplinary action.
             Counsel at the hearing with whom he/she may confer, and counsel for other
              interested parties, as determined by the Committee, shall be entitled to attend
              may accompany the House Officer at his/her own expense. Such counsel
              shall be entitled to participate as may be determined in advance by the
              Committee. Furthermore, a record shall be kept of the hearing.
             Prior to the hearing, the trainee and the Hospital will exchange pertinent
              information concerning their respective presentations, including a list of
              witnesses. Prior to the hearing, the trainee and the Hospital will be given
              copies of, or be permitted to review, documents that will be submitted at the
              hearing. Both the trainee and the Hospital are responsible for contacting their
              respective witnesses, scheduling the order of their presentations at the
              hearing and coordinating the witnesses’ appearance with the committee
              chairperson. The committee may prepare specific procedure guidelines for
              use at the hearing.
             The program director (or designee) will present the Hospital’s response, and
              both the program director and the trainee may present witnesses and submit
              documentary material to the committee. Both parties will be permitted to
              question the other party and either party on evidence presented by the other
              party may make its witnesses and rebuttal statements.
             The committee will render a written decision, which shall be forwarded, to
              the trainee and the program director within days after completion of the
              hearing. Based on the committee’s decision, the program director may
              reconsider the proposed disciplinary action. If the program director’s
              recommendation is for termination, this recommendation and the
              committee’s decision shall be forwarded to the GME Committee for review.
              If the GME Committee agrees with the recommendation to terminate, the
              recommendation shall be forwarded to the Hospital’s Board of Trustees for
              final action. If the GME Committee disagrees with the recommendation to
              terminate, then it shall, after discussion with the hearing committee and the
              program director, decide upon an alternative action, which action shall be
              communicated to the trainee and the program director for implementation.
             The trainee’s stipend and benefits will continue during the period of the
              hearing process until action by the Board of Trustees, except that the stipend
              and benefits will cease at the end of the current appointment period should
              the hearing process continue beyond that period.
iv.   Independent Evaluation
      •   If an evaluation of the trainee’s performance by the program director and/or
          designee suggests a situation (such as, but not limited to: medical/mental health,
          behavioral and/or substance abuse problems) which places the trainee or his/her
          patients at risk, the director of GME/DIO may require an independent



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          evaluation by the Physician’s Health Committee of the Rhode Island Medical
          Society. The purpose of this independent evaluation is to determine the trainee’s
          ability to perform his/her clinical duties and responsibilities. This independent
          evaluation may be required on its own or in addition to other formal disciplinary
          action described above.
v.    Other Disciplinary Actions
      •   A trainee who is aggrieved by a formal disciplinary action other than probation,
          suspension or termination, may request a review of the action under the
          procedures described above.
vi.   Nonrenewal of Contract
      •   Failure in performance to progress academically or professionally may be cause
          for a Program Director, after consultation with the Chief, to choose not to renew
          a trainee’s contract. The resident must be provided with a written notice from the
          Program Director of intent not to renew the resident’s contract no later than four
          months prior to the end of the resident’s current contract. The trainee shall be
          requested to acknowledge being advised of the program’s intent to not renew the
          trainee’s contract by signing the notification; refusal to do so shall be noted by the
          Program Director, setting forth the reasons for refusal if stated by the trainee.
          The notice shall also state that the trainee may request a formal review of the
          intent not to renew in accordance with the procedures described below. If the
          primary reason(s) for the non-renewal occur(s) within the four months prior to
          the end of the contract, the program director must provide the resident with as
          much written notice of the intent not to renew as the circumstances will
          reasonably allow, prior to the end of the contract.
      •   Evaluation by the teaching faculty must be considered when a Program Director
          decides to non-renew the contract for academic reasons. If the trainee is not
          already on probation or suspended when the decision to not renew is made, then
          the trainee should be informed and/or be placed in a remedial program prior to
          the decision to not renew his/her contract. When the decision to non-renew the
          contract is made, if the trainee is in remedial status, the remedial status may be
          extended to cover the remainder of the employment period. The director of
          GME/DIO should be notified of any decision by a Program Director of any
          non-renewal of contract prior to the notification of the trainee.
      •   A failure to continue a trainee in a program beyond the current academic year
          does not constitute a disciplinary action.
      •   Right to Review
             The trainee shall have the right to a review of the intent not to renew decision
              and shall be informed of this right. To initiate such a review, a trainee must
              submit a written request for a review of the intent not to renew to the
              director of GME/DIO within five business days of the trainee's receipt of
              the notification of the intent not to renew decision. Failure to make a timely
              request for a review will constitute a waiver of the trainee’s right to a review.
             If the trainee requests review of the intent not to renew, the director of
              GME/DIO shall meet with the trainee within ten business days and afford


                                          69
                   the trainee an opportunity to provide any information on his or her behalf.
                   After this meeting, the director of GME/DIO, following consultation with
                   the program director, Department Chief and other appropriate individuals, if
                   any, will render a final decision.
                  The trainee shall receive written notification of the decision of the director of
                   GME/DIO and the reasons for and consequences of the decision.
                  There is no further appeal from a decision to not renew a trainee’s contract.
    vii.   Failure to Promote to Next Level of Training
           •   The decision to re-appoint and promote a trainee to the next level of post-
               graduate training shall be based on the amount of academic credit received for
               the year as determined by the program director upon review of the trainee’s
               performance. The program director shall consider all evaluations of the trainee’s
               performance and any other criteria that are deemed appropriate by the program
               director. Any trainee who is, in the opinion of the program director, subject to
               not being promoted due to academic performance should be placed in a remedial
               training program and should be notified at the earliest opportunity of any
               decision to reduce or restrict the credit given for one or more rotations during a
               given academic year. If the trainee continues in the program but his/her
               performance continues to be unsatisfactory, he/she may be placed on the next
               level of discipline. In the event a trainee is in a remedial training program at the
               time of the contract renewal, the program director may choose to:
                  Extend the existing contract for the length of time necessary to complete the
                   remediation process, not the exceed six months;
                  Promote the trainee to the next level; or
                  Non-renew the contract pursuant to applicable sections above.
           •   A failure to provide full credit for a rotation or academic year or a failure to
               certify successful completion of a training program does not constitute a
               disciplinary action, and the trainee shall have no right to appeal such actions.

9. Visas

   Institutional Policy for Granting H-1 B1 Visas (Last revised April 22, 2003).
   This policy sets forth the RIH’s policy regarding immigration/visa issues pertaining to
   International Medical Graduates ("IMG") applying for acceptance into a residency-training
   program at RIH.
   Except as noted below, all IMGs are require to obtain a "J-1 Exchange Visitor Visa" before
   commencing a training program at RIH. The J-1 is the visa most commonly held by IMGs
   engaged in residency training in the United States. The department of medical education at
   RIH is responsible for processing IMG J-1 visa applications.
   Certain IMGs may be eligible for another type of visa, known as an "H-1B1 Temporary
   Worker Visa," in addition to a J-1 visa. However, as compared to the J-1 visa, the process to
   obtain an H-1B1 visa does not compel an IMG to practice medicine in his or her home


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   country following completion of training. For these reasons, RIH will only consider
   sponsoring an IMG for an H-1B1 visa, instead of a J-1 visa, in the following situations:
   a.) The IMG presently holds an H-1B1 visa through another institution;
   b.) The IMG is a graduate of a U.S. medical school; and/or
   c.) Extraordinary circumstances unique to the particular IMG, as determined in the sole
       discretion of the GME Committee (GMEC), warrant H-1B1 visa sponsorship.
   Any chief or program director asked to sponsor an IMG for an H-1B1 visa must forward the
   request directly to the GMEC. The GMEC is the only body at RIH authorized to approve
   sponsorship of an IMG for an H-1B1 visa.
   An IMG may only be sponsored for an H-1B1 visa in increments of one year. In most cases,
   the IMG must have passed the Federation Licensing Examination, National Board of Medical
   Examiners Examination or the U.S. Medical Licensing Examination, must have passed the
   ECIMG English language examination, and must hold a Rhode Island medical license.
   Finally, the US Department of Labor must certify a "Labor Condition Application" pertaining
   to the IMG.
   Sponsorship of an IMG for an H-1B1 visa can take several weeks to several months to
   complete. Consequently, all requests for IMG H-1B1 visa sponsorship must be forwarded to
   the GMEC as soon as possible.
   The hospital does not financially support any visa processing fees for procurement of an
   appropriate visa for a house officer to be in a training program.

10. Resident Work Hours

   With regards to resident work hours, the ACGME states that it "is continuing its ongoing
   effort to refine its standards for resident work or duty hours, and to clarify the role of these
   standards in contributing to educational quality and patient and resident safety." Currently, the
   Institutional Requirements state, "the sponsoring institution must ensure that each residency
   program establishes formal policies governing resident duty hours that foster resident
   education and facilitate the care of patients. The educational goals of the program must not be
   compromised by excessive reliance on residents to fulfill institutional service obligations." The
   requirements for duty hours of each ACGME-accredited specialty can be found at
   ftp://www.acgme.org/new/dutyhrequirem.pdf. The ACGME has also appointed a work
   group to review and refine the Council’s accreditation, education, and related activities related
   to the issue of resident duty hours.
   a.) The working hours policy is set by the following principles:
       i.   A limit of 80 hours per week (maximum 80 hours per week),
            • Averaged over a 4-week period, inclusive of call;
       ii. A limit of 24 consecutive working hours worked in one shift;
            • With up to six added hours for continuity of patient care/education;
       iii. A limit of on-call shifts to every 3rd night (no more than Q3);
            • Averaged over a 4-week period;
       iv. A minimum of 10 hours off-duty time between shifts;
            • To provide for adequate time for rest and personal activities;
            • Provided between all daily duty periods and after in-house call;


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     v. At least one 24 hours (one full day) period of off-duty per 7 day week;
         • One day is defined as one continuous period;
         • Free from all educational and clinical responsibilities; and
     vi. At least one full weekend off-duty per month.
b.) This policy is based on the Patient and Physician Safety and Protection Act of 2001 (H.R.
    3236; The Conyers Bill), which amended the Social Security Act to reduce resident work
    hours. The policy reflects the concept of responsibility for patients and provides for
    adequate patient care and ensures that residents are not required to regularly perform
    excessively difficult or prolonged duties.
     i.     The focus is on the needs of the patient and continuity of care balanced with the
            educational needs of the residents.
     ii. This Act can be viewed in its entirety at http://www.thomas.loc.gov.
c.) To determine compliance with such requirements annual anonymous surveys of residents
    will be performed.
d.) Whistleblower protections are in place.
e.) Penalty. Violating hospitals are subject to maximum $100,000 penalty for each resident
    training program.
f.) Compensation. Appropriations are made to hospitals for their additional costs incurred in
    order to comply with proposed requirements.
g.) The bill states the following reasons for federal regulation:
     i. The government spends $8 billion annually to train residents.
     ii. The government has regulated work hours of other industries where the safety of
         employees and the public are at risk.
h.) Issues not considered in current "Resident Working Conditions" reform:
     i.     Resident’s quarters,
     ii.    Vacation/sick leave,
     iii.   Facility safety,
     iv.    Health insurance benefits,
     v.     Child-care,
     vi.    Weekend responsibilities, or
     vii.   Moonlighting restrictions.
i.) Definition. Duty hours are defined as all clinical academic activities related to:
    i.      The residency program (both inpatient and outpatient),
   ii.      Administrative duties related to patient care,
  iii.      Provision for transfer of patient care,
 iv.        All clinical sites at which the resident rotates and/or takes an elective,
   v.       Time spent in-house during all activities such as conferences,
 vi.        Inclusive of all in-house call activities, and
 vii.       In-house moonlighting.
j.) Duty hours do not include reading and preparation time spent away from the duty site.




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k.) Exceptions to the duty hour’s policy may be granted with a formal proposal by the
    program with the appropriate documentation. However, the policy of the ophthalmology
    residency program is that following the established 80-hour work week policy should not
    detract from the education of the residents or the objectives of the residency program.




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                                                                                  6
                                                                                  Chapter




VI. Hospital Policies

A.       Hospital Policies
1. Affirmative Action

     a.) Purpose. RIH will seek qualified and quantifiable minority, women, and handicapped
         applicants for all job categories and will make particular efforts to increase representation
         of these groups in occupations at the higher levels of skill and responsibility.
     b.) Policy (09/01/1991). RIH will review job categories and Hospital training programs
         where few minority person and handicapped persons are presently employed or enrolled
         and seek to determine the cause of such situations.
     c.) Training. RIH-sponsored education and training programs and on-the-job training
         programs, Hospital school, and other training and educational programs to which the
         Hospital give support and sponsorship will be regularly reviewed to ensure that
         minorities, women, and handicapped persons as well as all other employees are given
         equal opportunity to participate.
     d.) Layoffs, terminations, demotions, discipline. RIH will ensure that any lay-offs,
         terminations, demotions, or discipline will be administered in a non-discriminary manner.
     e.) Benefit and compensation. RIH will ensure that there is no disparity concerning any
         benefits or compensation based on race, color, sex, religion, national origin, age, or
         handicap.
     f.) Accommodations for handicapped persons. RIH will make reasonable accommodations
         with regard to physical or mental limitations for its handicapped employees or applicants.
         Reasonable accommodations include adjustments such as making the facility readily
         accessible, restructuring jobs, providing part-time and modified work schedules and other
         similar actions within the limitations of business necessity.

2. Bereavement/Funeral Leave

     a.) Purpose. To define the procedures for granting leaves due to a death in the immediate
         family.


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    b.) Eligibility. All house staff are eligible effective immediately upon initiation of
        employment.
    c.) Policy.
         i.   Bereavement leave shall be granted with pay for three consecutive scheduled
              workdays for the death of a member of the employee’s immediate family. The
              immediate family shall include parent or parent-in-law, legal guardian, spouse, child,
              sibling, grandparent, domestic partner or any person residing with the employee.
         ii. Bereavement shall be granted with pay for one scheduled workday for the death of a
              grandchild, son or daughter-in-law, brother or sister-in-law, aunt, uncle or
              grandparent–in-law.
         iii. For any other funeral, which the employee may wish to attend, accrued earned
              vacation or time off without pay may be granted by the program director.

3. Identification Badge Policy

    a.) Purpose. To provide a means of identification of current RIH employees.
    b.) Policy.
         i.   While on duty, all employees are required to wear the Employee Identification Badge.
              All employees shall have identification badges bearing the employee’s name,
              department, and photo. Identification badges for patient contact employees will
              include job title.
         ii. Identification badges are required to be worn in an easily observed location on the
              upper part of the blouse, coat, dress, shirt, or uniform with the photo side out and no
              attachment.
         iii. In order to receive appropriate discounts and/or admission to restricted areas,
              employees are required to wear an employee identification badge.
    c.) Procedure
         i.   New employees. The Employment department will issue identification badges. The
              initial identification badge will be provided by the Hospital free of charge. The
              information to be shown on the new employee’s identification will be obtained from
              the Employment Department.
         ii. Replacing Lost Identification Badge. If an identification badge is lost or misplaced,
              the employee must contact the Employment Department in order to make
              arrangements for replacement. The replacement fee is $5.00. The employee in the
              Employment Department can then pick up the new identification badge. Payment
              for the cost of the new identification badge is the responsibility of the employee and
              must be made to the Cashier before issuance of the identification badge.
         iii. Reissuing Identification badge. The procedure for reissuing identification badge for
              employees changing their names, transferring to another department, having broken
              or mutilated identification badges, or being promoted will be the same as described in
              the previous paragraphs, except that the cost of the identification badge will be
              absorbed by RIH.
    d.) Assignment of Responsibility
         i.   All employees of RIH are responsible for:


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             •   Wearing their identification badge while at work,
             •   Maintaining the identification badge in proper condition and taking the normal
                 precautions against loss or damage,
             •   Insuring that the identification badge is not misused; e.g., worn by other persons
                 to gain entrance to the Hospital, and
             •   Presenting the identification badge and/or other identification to security
                 personal upon request.
        ii. Supervisory personnel are responsible for:
             •   Insuring that all employees under their jurisdiction received and wear their
                 identification badge,
             •   Assisting employees in obtaining replacement identification badges when
                 necessary, and
             •   Obtaining the identification badges of all terminated employees and retuning the
                 badges to the Employment Department.

4. Jury Duty and Related Absence

    a.) Purpose. The purpose of this policy is to provide guidelines for consistency in authorizing
        absences for court appearances related to jury duty and other legal activities.
    b.) Eligibility. All house staff are eligible effective immediately upon initiation of
        employment.
    c.) Policy. An employee serving on jury duty will be paid straight time earnings.
    d.) Court Appearances
        i.   When, on behalf of Lifespan, an employee is required to appear in court, attends the
             taking of depositions or appears at external fact-finding or investigatory hearings, the
             time will be considered hours worked and will be paid as such, less any service fees
             paid to the employee by the court. Expenses related to mileage, parking and/or meals
             would also be reimbursed.
        ii. Time off from work for appearances in court for other reasons (voluntary or
            involuntary) and/or any other external proceedings will be considered unpaid
            personal time. With supervisory approval, the employee may use accrued vacation
            time or personal time if they so desire.
    e.) Employee Responsibility
        i.   Before Serving
             •   When employees are subpoenaed for jury duty, they must notify their
                 Department Director upon receipt of the subpoena.
             •   If jury duty is for a prolonged period of time, Department Director must be kept
                 apprised on an ongoing basis in writing.
        ii. After Serving
             •   It is the employee’s responsibility to document all time spent on jury duty and
                 verify the amounts received from the courts before pay will be awarded under
                 this policy.


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5. Leave of Absence

    a.) Purpose. To cover the family and medical leaves of absence available to eligible
        employees at RIH. It allows employees to balance their work and personal lives by taking
        leave for certain reasons (in compliance with state and federal laws and regulations) and to
        define the effects of such absences on employees job status, pay and benefits.

    b.) Eligibility. All house staffs that have completed the introductory period (12
        consecutive months).

    c.) Duration. 13 consecutive weeks during a 12-month period. The 12-month rolling
        period is determined by measuring backward from the date an employee's leave
        begins.

    d.) Type. Unpaid leave for birth, placement of child for adoption or foster care provided
        the leave is taken on a continuous basis beginning on the date of the birth or
        placement of the child. To provide care for employee's own parent (including
        individuals who exercise parental responsibility under state law), parents-in-law,
        child, spouse, or domestic partner with serious health condition, or employee's own
        serious health condition.

    e.) Serious health condition. Illness, injury, impairment, or physical or mental condition
        involving incapacity or treatment connected with inpatient care in hospital, hospice,
        or residential medical-care facility; or, continuing treatment by a health care provider
        involving a period of incapacity:

        i.   Requiring absence of more than 3 consecutive calendar days from work, school,
             or other activities;
        ii. Due to a chronic or long-term condition for which treatment may be ineffective;
        iii. Absences to receive multiple treatments (including recovery periods) for a
             condition that if left untreated likely would result in incapacity of more than 3
             days; or
        iv. Due to any incapacity related to pregnancy or for prenatal care.

    f.) Intermittent Leave. Permitted for serious health condition when medically necessary.
        In some cases leave may be taken on an intermittent, non-continuous basis following
        the birth or placement of a child, but only upon specific approval by the affiliate.

    g.) Substitution of paid leave. Employees may elect or Employers may require accrued
        paid leave to be substituted in some cases. No limits on substituting paid vacation or
        personal leave. An Employee may not substitute paid sick, medical, of family leave
        for any situation not covered by any employers' leave plan.

    h.) Reinstatement. Must be restored to same position or an equivalent to it in all benefits
        and other terms and conditions of employment.

    i.) Maintenance of benefits during leave. Health, dental, life, and disability insurance
        must be continued under same conditions as prior to leave.


                                                77
   j.) Leave requests. Employee shall give at least 30 days notice unless prevented by
       medical emergency. Employees must complete an application for leave of absence
       (LOA) form available through Human Resources.

   k.) Medical certification is required. To be made by employee at least 30 days prior to
       date leave is to begin where need is known in advance or, where not foreseeable, as
       soon as practicable but before 15 calendar days from the date of the requesting leave.
       The employee may required to obtain an second opinion by a licensed provider and
       the employee may be asked to provide recertification every 30 calendar days.

   l.) School Involvement Leave. May be taken under the Rhode Island Parental and
       Family Medical Leave Act, as amended in 1999, for a total of up to ten hours of
       unpaid leave during any year in which the employee has worked twelve consecutive
       months. The leave can be used to attend school conferences or other school-related
       activities for the employees’ child, foster child or for any child for whom the
       employee has been appointed guardian. Employees may substitute accrued paid leave
       (vacation or earned time) for any or all of the time off. Employees are required to
       give at least twenty-four hours notice of the need for the leave and should make
       reasonable efforts to schedule the leave so it does not disrupt the affiliate’s
       operation.

   m.) Sick Leave Benefits. Benefits schedules during the term of the annual contract will be
       as per the RIH employee policy.

6. Mandatory Training/Education

   a.) Purpose. To enforce the timely completion of all mandatory training.
   b.) Eligibility. All employees, students, salaried physicians, volunteers, and staff.
   c.) Policy. Mandatory training refers to training and education required by external agencies,
       regulatory bodies, and state law. It also refers to internal training and education required
       by the hospital.
   d.) The Hospital is required to:
       i. Identify and provided listings of all mandated training,
       ii. Provide all necessary training/educational programming and activities, and
       iii. Provide periodic notifications/updates on who has not completed the requirements.
   e.) Those eligible are required to:
       i. To be aware of all training/education required of their position and
       ii. To cooperate and attend all required training/educational sessions and activities in a
           timely manner.
   f.) New Employees.
       i.  All new employees are required to attend New Employee Orientation prior to the
           first day of work.
       ii. Thereafter, new employees will be informed of all mandatory training required by
           their position. Failure to attend said training within the required time frame will result


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            in suspension without pay of the employee and appropriate disciplinary action
            directed towards the immediate supervisor.

7. Smoke-Free Policy

    a.) Purpose. Lifespan’s success depends upon the good physical health of our employees.
        This policy ensures a work environment free from passive smoke, which the
        Environmental Protection Agency has identified as a potential health danger.
    b.) Eligibility. All employees and House Staff.
    c.) Smoking refers to smoking or the carrying of lighted tobacco products.
    d.) Policy. Smoking is prohibited in all Lifespan buildings both inside and outside buildings,
        including leased facilities. In addition, individual locations may choose to restrict smoking
        to designated areas and/or ban smoking entirely. This Policy also applies to all leased
        facilities. Employees who do not adhere to this restriction are subject to correction action,
        up to and including termination of employment with Lifespan.
    e.) Specific areas have been reserved as designated smoking areas and are accessible to all
        employees, patients, and visitors. The locations of these sites are available from the
        security office.
    f.) Noncompliance with the policy is handled as a violation of Hospital policy leading to
        counseling and progressive discipline.
    g.) All employees are asked to assist by politely reminding anyone observed to be smoking of
        the Hospital’s position and the reasons why (fire safety and health hazards) and to direct
        the individual to a designated smoking area. If visitors or patients are refusing to
        cooperate, security should be contacted to follow-up.

8. Sexual Harassment

    a. Purpose. RIH and Brown University, through its policies and procedures, seeks to
       provide an environment that is free from sexual harassment and sexual assault. Such
       conduct seriously undermines the atmosphere of trust and respect that is essential to a
       healthy work and academic environment.
       i.   RIH expressly prohibits any form of unlawful sexual harassment. Sexual harassment
            is considered unacceptable conduct and will not be tolerated or condoned.
    b. Definition. Such harassment includes, but is not limited to, offensive and/or unwelcome
       advances, request for sexual favors and other verbal or physical conduct of a sexual
       nature (offensive sexual comments, jokes, innuendoes, and other sexually oriented
       statements), when such conduct has the purpose of effect of creating an intimidating,
       hostile, or offensive working environment. Mistreatment refers to public belittlement,
       offensive sexist remarks or names, or harassment based on gender, race, ethnicity, or
       sexual orientation.
    c. Outcome. Failure to comply with this requirement may result in disciplinary action,
       including termination.



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    d. Policy. A complete description of the Sexual Harassment Policies & Procedures is available
             through the website of the Office of Women in Medicine at Brown Medical School available at:
             http://bms.brown.edu/wim/policy.html.
    e. Complaint resolution.
       i.        Step 1. Report incident to supervisor, program director, and/or department head.
      ii.        Step 2. Supervisor and/or department head will report it to the Director of
                 Department of Employee Relations in writing. The claim will be promptly reviewed,
                 investigated, and the complaining party will be advised of the recommended
                 dispositions of the claim within seven calendar days.
      iii.       Step 3. If the complaining party is not satisfied an immediate appeal may be filed
                 within seven calendar days to the Vice–President responsible for the employees
                 department. The vice-president will respond to the complaint and appeal, in writing,
                 within seven calendar days.
    f. Guidelines
        i.       If the hospital determines an employee is guilty of harassing another employee;
                 appropriate disciplinary action will be taken against the offending employee up to and
                 including termination of employment.
      ii.        RIH prohibits any form of retaliation against any employee for filing of a bona fide
                 complaint under this policy. However, if after the investigation of any complaint, the
                 hospital determines that the complaint is not bona fide or that an employee has
                 provided false information regarding the complaint, disciplinary action may be taken
                 against the individual who filed the complaint or who gave false information.

9. Solicitations on RIH Premises

    a.) Definition. Solicitation is defined as any act of urging or persuading individuals by any
        means to accept a product or service being offered for sale, a doctrine to follow, or an
        organization to join or support.
    b.) Solicitation is permitted providing no such solicitation is made by employees during their
        working time and the solicitation does not interrupt the work of another employee,
        disrupt normal Hospital operations, or affect patient care.
    c.) Non-working employees in non-patients and non-work areas are permitted to distribute
        literature during their non-working time. Employees are not allowed to distribute material
        in such manner as to likely cause a littering problem.
    d.) Individuals other than employees will not be permitted to distribute literature and solicit
        employees in hospital premises or interfere with normal Hospital operation and patient
        care. The only exceptions to this policy are the Annual Appeal, the United Way and
        periodic Blood Drives.
    e.) Any employee violating this policy is subject to disciplinary action, including discharge.
        Any non-employee violating this policy will be charged with trespassing.

10. Drug-Free Workplace



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a.) Guidelines. RIH agrees to fulfill its responsibility under the Federal Drug-Free Workplace
    Act (effective March 19, 1989), and as an employer, to provide a safe and healthy
    environment for all employees and patients. All employees will perform their duties at an
    acceptable performance level and not be impaired by drug or alcohol use.
b.) RIH will provide assistance to employees who develop substance abuse problems by
    referring them to the Rhode Island Employee Association Program (RIEAP). This
    assistance will include helping employees to identify, understand and use appropriate
    treatment resources to address their problem before it results in harm to themselves or
    others, impairs their job performance, or renders them unemployable.
c.) However, if an employee fails to respond to an offer of assistances for their own drug or
    alcohol problem, or their actions were that of willful misconduct or intent to sell illegal
    substances for personal profit, the hospital will invoke disciplinary action up to an
    including discharge as well as referral of the case to the appropriate law enforcement
    authorities.
d.) At its discretion, the hospital may require employee who violate this policy to successfully
    complete a dug abuse assistance or rehabilitation program as a condition of continued
    employment. The hospital reserves the right to conduct surreptitious videotape
    monitoring.
e.) Illegal substance use, possession and or sale. Narcotics opiates, hallucinogenics, or any
    other controlled substance while on hospital property.
f.) Legal Prescription Drug Use. Act does not apply if the possession and use of controlled
    substances are legally prescribed by a licensed physician for the sole use of the individual.
g.) Employees are required by law to inform the hospital within five days after they are
    convicted of any Federal or State criminal drug statute where such violation occurred on
    hospital property or in the condition of hospital business.
h.) Alcohol. The possession, use or distribution of alcoholic beverages of any kind (beer,
    wine, or distilled spirits) by any employee on hospital property or while on hospital
    business is subject to disciplinary action up to and including discharge.
i.) Violators of this policy will receive an immediate management referral to the EAP. Those
    employees refusing to use the EAP services will have their employment terminated

j.) RIEAP. Confidential consultation or personal concerns are available by calling RIEAP at
    (401) 732-9444 or (800) 445-1195.

k.) The Hospital provides an educational program for House Officers in physician
    impairment. Consult the resource on substance abuse and physician impairment for the
    House Officer.
    Resident Support: Goals
   i.   To establish that physicians are vulnerable to health problems, including mental
        health and substance abuse disorders. As a background physicians have a 5-8%
        impairment rate for alcoholism, 1-2% impairment rate for other substance abuse, and
        1% for psychiatric illness.




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      ii.      The AMA defines physician impairment as any physical, mental, or behavioral
               disorder that interferes with ability to engage safely in professional activities. Three
               major problems are substance abuse, psychological problems, and physical illness.
     iii.      To reinforce that this risk is real and will affect those with whom we work or
               ourselves.
     iv.       To discuss our responsibilities to each other and to our patients with respect to
               physician health as we are each other’s first line of defense.
      v.       To help house staff recognize important signs and symptoms of physician
               impairment:
               •   “Just not the same person we used to know”,
               •   “We can’t trust his work anymore”, and
               •   “She seems different somehow”,
     vi.       To familiarize the physician with what resources exist and how to access these
               resources for yourself or a colleague who may be impaired.
     vii.      Early intervention is critical.
               •   Approach you colleague. Inquire directly is there is a problem.
               •   If he/she denies it, call a reliable source for advice (this can be anonymous).
               •   Based on above, decide if you still think there is a problem.
               •   If convinced of a problem, you must take action by contacting any of the
                   following:
                       Supervising physician program director chief resident, division chief, or
                        department chairman.
                       RIH mental health crisis group. Available 24 hours a day at 444-4779.
                       RI Physician’s health committee administered through the RI Medical
                        Society. Available at 331-3207.
                       State Department of Health’s Board of Medical Licensure and Discipline
                        Diversion Programs through the RI State Medical Board. Available at 222-
                        3855.
               •   Once you have taken one of these steps your personal responsibility and
                   involvement are probably concluded.
    viii.      Other resources to contact:
               •   Alcoholics anonymous. (800) 439-8860
               •   Al-Anon and Al-A-Teen Information Services. (401) 781-0044
               •   Narcotics anonymous. (401) 461-1100
               •   24-hour helpline: (800) 234-0420
               •   Cocaine anonymous. (800) 234-0246
               •   24-hour helpline: (800) 888-9383; (800) 274-2042
     ix.       To stress the importance of early recognition and preventative measures in
               successfully dealing with physician impairment.

11. Holidays



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    a.) Purpose. The purpose of this policy is to recognize specific days as holidays
    b.) Eligibility. All house staff are eligible effective immediately upon initiation of
        employment.
    c.) Policy. Lifespan Corporate Services observes the following holidays each year:
        •   Independence Day             July 4
        •   Labor Day                    First Monday in September
        •   Columbus Day                 2nd Monday in October
        •   Thanksgiving Day             4th Thursday in November
              The Eye clinic is also closed the Friday after Thanksgiving
        •   Christmas Day                December 25
        •   New Year's Day               January 1
        •   Presidents' Day              3rd Monday in February
        •   Memorial Day                 Last Monday in May
    d.) Policy. Providence VAMC observes the following holidays each year:
        •   Independence Day             July 4
        •   Labor Day                    First Monday in September
        •   Columbus Day                 2nd Monday in October
        •   Veterans Day                 November 11
        •   Thanksgiving Day             4th Thursday in November
        •   Christmas Day                December 25
        •   New Year's Day               January 1
        •   Martin Luther King Day       3rd Monday in January
        •   Washington’s Birthday        3rd Monday in February
        •   Memorial Day                 Last Monday in May
    e.) For those Holidays that differ between the RIH and the VAMC only the resident that is
        assigned to the site observing a Holiday is allowed to observe the Holiday; i.e.,
        i. A resident at the RIH cannot observe Veterans Days or Martin Luther King Day and
        ii. A resident at the VAMC cannot observe the day after Thanksgiving if the VA clinic is
            open on that day.
    f.) Holidays during vacation. When a holiday falls during a scheduled vacation, the time is
        recorded as a holiday and not as a vacation day.
    g.) Holidays during leaves of absence. If a holiday occurs while an employee is on a leave of
        absence, no holiday time is credited or paid.
    h.) Holidays during bereavement leave. If a holiday occurs while the employee is on
        bereavement leave, the day is to be recorded as holiday time and the employee will be
        granted an extra day of bereavement leave.
    i.) Holiday during call coverage. No compensation is provided to house staff. Holiday call
        coverage is to be shared among all residents. Senior residents have priority over choice of
        Holidays to cover.

12 Internet Email Usage



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a.) Purpose. To define the policies required for the development, operation, and integration
    of Internet/Email capabilities.
b.) Eligibility. All house staff accessing the Internet and Email through Lifespan connectivity.
    All house staff may request Internet/Email access.
c.) Policy. Lifespan provides physician access to the Internet/Email to promote the efficient
    conduct of its business and to facilitate patient care. Connectivity to the Internet/Email
    through Lifespan for any other purpose should be restricted to personal time or use from
    home-based personally owned equipment. Physicians are always expected to maintain
    professional standards and be knowledgeable of standard Internet/Email conventions.
d.) Personal use of the Internet/Email from Lifespan-based PC’s during an employee’s work
    hours is prohibited. Misuse or abuse of the Internet/Email may result in the revocation of
    Internet/Email access privileges and/or disciplinary action, up to and including
    termination.
e.) By management request, employee Internet/Email and Email usage may be monitored.
    Users are reminded that the use of the Internet and Email systems are for business
    purposes only and that employees do not have an exception of privacy in their use of
    these systems.
f.) Creating and distributing Email content containing profanity, defamatory remarks,
    obscenities, offensive materials, patient information, trade secrets, or Lifespan
    confidential material is prohibited.
g.) Lifespan also provides employees’ access to the Internet/Email from home as a
    convenience; web sites deemed inappropriate for business use will also be blocked from
    home access when the connectivity is made through Lifespan.
h.) Misuse or abuse of the Internet/Email can expose Lifespan and its employees to civil and
    criminal liability. Disciplinary action ranges from revocation of Internet/Email access and
    verbal warnings to termination.
i.) Prohibited behavior
    i.    Using another employees login ID/password to gain access to Internet/Email
          resources.
    ii. Using the Internet/Email to send Lifespan confidential information,
    iii. Using the Internet/Email to present opinions or make statements that may be
          attributed to Lifespan unless appropriately authorized to do so.
    iv. Attempting to break into local or remote systems.
    v. Unsolicited, inappropriate or unauthorized advertising of Lifespan services.
    vi. Advertising of personal property, except on the Lifespan Intranet Bulletin Board
          which is provided for this purpose.
    vii. Connecting to the Internet/Email via Lifespan workstations for personal gain or
          entertainment during work hours.
    viii. Sending threatening or harassing E-mail messages.
    ix. Refusing to cooperate with reasonable Internet/Email access security investigations
          or audits.
    x. Participating in Internet/Email based pyramid schemes or betting pools.




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    j.) Help Desk. Please contact Lifespan Network Services Help Desk for assistance with all
        access and operations at x4-6381 or x6-6485

13. Emergency Preparedness

    a.) All physician need to know that the levels to the RIH disaster plan.
    b.) Codes:
        i.   Code Red:             ER Mass Casualty
       ii.   Code Pink:            Infant/Child Abduction
      iii.   Code Yellow:          Radiation Incident
      iv.    Code word for fire:   Drill
    c.) Drill Procedure
        i.   Remove persons in danger
       ii.   Pull alarm
      iii.   Call 444-5111
      iv.    Close doors
       v.    Extinguish fire if able to do so
    d.) Incidents:
        i.   To staff: report to Employee Health 4-4038
       ii.   To patients/visitors/equipment: report to risk management 4-8265
    e.) Emergency Numbers:                      f.)        Resources
        i.   Fire: 444-5111                            i. Biomedical Equipment: 444-8779
       ii.   Medical: 444-5111                         ii. Electrical: 444-8030
      iii.   Radiation: 444-5961                       iii. Infection Control: 444-4773
     iv.     Security: 444-4111                        iv. Fire Safety: 444-8008
       v.    Utilities: 444-8030                       v. Hazardous Spills: 444-8357
     vi.     Utilities (off hours): 444-8357           vi. Radiation Safety: 444-5961
     vii.    Spills (incidents): 444-8357              vii. Safety Issues: 444-8357
    viii.    Spills (mercury): 444-5432                viii. Security: 444-5221
      ix.    Spills (uncontrolled) 444-5111            ix. Waste Disposal: 444-8357




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B. Patient Care Policies
1. Deaths/Autopsy

         The RIH autopsy policy is not applicable to our department. Consult the House
    Officer’s Handbook for a description of the full policy.

2. Clinical Documentation

    a.) Reminder summary
        i.   A complete History and Physical must be completed before patients undergo surgical
             procedures.
       ii.   Medical records of patients who visit ambulatory sites should contain a list of all
             significant diagnoses, allergies, and medications.
      iii.   All verbal orders must be signed with the physician name, date, and provider ID
             number within the next calendar day.
     iv.     Hospital Pain assessment and management policy must be implanted in all patient
             care areas.
    b.) On Admission
        i.   Include in the history
             •   Reason for admission
             •   Now versus outpatient observation or home care
             •   How outpatient therapy failed
             •   History and Physical must be completed within 24 hours of admission
       ii.   Include in the physical
             •   Vital signs
             •   Assessment of distress, acuteness, and severity of illness
             •   Description of patient’s frailty, dependency, or dementia
             •   Plan
    c.) In Progress Notes:
        i.   Account for any unexpected laboratory and x-ray finding and untoward events or
             contradictory allied health observations
       ii.   Explain thinking behind major changes in diagnostic efforts and therapy
    d.) At Discharge
        i.   Final diagnosis
       ii.   Discuss abnormal lab, x-ray, and nursing observations
      iii.   Note tests not reported at time of summary
     iv.     Describe
       v.    Support and caregiver arrangements
     vi.     Level of functioning
     vii.    Special problems


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     viii.       Details of diet, medication, activity, and education efforts
      ix.        Follow-up visit plan

3. Isolation Precautions

    a.) Isolation precautions are instituted to prevent the spread of communicable disease or
        highly resistant organisms within the hospital. They are designed to protect patients,
        personnel and visitors. The decision regarding what category of precautions to utilize is
        based on:
        i.       The source of the infection,
       ii.       The mode of transmission, and
      iii.       The susceptibility of the host.
    b.) This is a two-tiered system.
        i.       First: Standard Precautions replaces Universal Precautions and are designed to protect
                 health care personnel.
       ii.       Second: Transmission based and is designed for the care of specific patients.
    c.) Droplet Precautions. Droplets require close contact with source (>3 feet).
             Private room, surgical masks are required for all persons entering room, hand hygiene
             before and after patient contact, mask patient during transport, gowns and gloves are not
             required.
    d.) AFB precautions.
             Negative pressure room, high filtration respirators (N95) that have been fit tested, mask
             patients during transport, surgical masks are required for all persons entering room, hand
             hygiene before and after patient contact.
    e.) Airborne precautions.
             Negative pressure room, surgical masks are required for all persons entering room, hand
             hygiene before and after patient contact, gowns and gloves are not required.
    f.) Contact precautions/multiple antibiotic resistant organisms (e.g., MRSA, VRE,
        etc.). Transmission requires direct contact.
             Private room, surgical masks are required for all persons entering room (if MRSA in the
             sputum), hand hygiene before and after patient contact with Chlorhexidine or alcohol,
             mask patient during transport, gowns and gloves are required to for all persons entering
             room, all patient care equipment should be cleaned with a hospital approved disinfectant
             after patient contact.
             MRSA Control protocol.
        i.       Patients can be removed from isolation once cultures performed on the nares or
                 previously colonized or infected sites are repeated twice at 5-7 day intervals and found
                 to be negative.
       ii.       High-risk patients will routinely have a nasal culture for MRSA. These include:
                 •   Patients from nursing homes,



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                 •   Patients from rehabilitation centers,
                 •   Anyone who has been admitted to a hospital in the last 30 days,
                 •   Admission to the ICU, and/or
                 •   Discharged from the ICU.
      iii.       MRSA patients should be washed with a 2% Chlorhexidine agent rather than regular
                 soap and shampoo for 5 days (discontinue of skin irritation occurs). Intranasal
                 application of mupirocin (nasal Bactroban) ointment bid for 5 days may be added for
                 nasal carriers. Repeat MRSA surveillance cultures after therapy is completed.
                 Clearance of MRSA should be attempted prior to surgical intervention whenever
                 possible; however in the event this cannot be done, perioperative prophylaxis with
                 vancomycin should be used if per-operative systemic antibiotic prophylaxis is
                 indicated for that procedure.
     iv.         MRSA surveillance; 1 culture swab applied to the anterior of both nostrils (Use of 2
                 swabs is not necessary).
    g.) Strict airborne/contact isolation (agents of bioterrorism).
             Negative pressure room, high filtration respirators (N95) that have been fit tested, mask
             patients during transport, surgical masks, gowns, shoe covers, eye protection are required
             for all persons entering room, hand hygiene before and after patient contact, incinerate all
             trash and linen.
    h.) Neutropenic Precautions (absolute neutrophilic count below 1,000).
             Private room, surgical masks are required for all persons entering room, hand hygiene
             before and after patient contact with Chlorhexidine or alcohol, mask patient during
             transport, wear gloves, gowns are not required, all patient care equipment should be
             cleaned with a hospital approved disinfectant before patient contact.
    i.) Burns Isolation Precautions. (If burn is > 20% TBSA). To prevent development of a
        nosocomial infection.
             Private room, surgical masks are required for all persons entering room, hand hygiene
             before and after patient contact, mask patient during transport, gowns, hats, and gloves
             are required for all with direct patient contact.
    j.) Ophthalmic isolations.
        i.       Adenovirus infection. Contact and droplet precautions. During epidemics patients
                 believed to have adenovirus infection may be placed in the same room.
      ii.        Conjunctivitis. Bacterial, acute, viral hemorrhagic. Standard and Contact Precautions.
                 For the duration of the illness.
      iii.       Herpes Zoster in an immunocompromised host. Contact precautions.

4. OR Scheduling Guidelines

5. Organ and tissue Donation

6. Pathology


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7. Physician-Patient Communication
    a.) Good communication skills can help you to:
       i.    Give better patient care,
      ii.    Learn more form your patients,
     iii.    Enjoy your patients more,
     iv.     Reduce your risk of malpractice claims, and
      v.     Demonstrate achievement of some of the required resident competencies.
    b.) Initial encounter:
        i.   Compose yourself, refocus,
       ii.   Gather pertinent information before entering room (name, gender, etc.),
      iii.   Knock,
     iv.     Smile,
       v.    Introduce yourself, explain your role and purpose for the interaction,
     vi.     Make and maintain eye contact,
     vii.    Use the patient’s name, offer a handshake where appropriate,
    viii.    Sit down when possible,
      ix.    Check for patient comfort and maintain privacy, and
       x.    Recognize the patient may have his or her own agenda.
    c.) Delivering bad news:
        i.   Recognize common defensive reactions that patients may have to bad news,
       ii.   Set aside adequate uninterrupted time in a location that affords maximum quiet and
             privacy,
      iii.   Provide a simple summary using descriptive, clear, and specific language
     iv.     Allow silences,
       v.    Reassure the patient of your support,
     vi.     Be accurate, realistic, and honest as possible while providing hope and support,
     vii.    End by asking for questions,
    viii.    Reassure of availability for future questions, and
      ix.    Arrange for follow up.
    d.) Informed consent:
        i.   Find out what patient already knows,
       ii.   Solicit as to what patient wants or needs to know,
      iii.   Ask patient if they have any questions,
     iv.     Use silence to allow patient to process the information,
       v.    Make sure the patient reads the consent,
     vi.     Ask patient to restate the risks and benefits of the treatment, and
     vii.    Complete the forms as necessary.
    e.) Adverse event:
       i.    Attend to the patient’s medical needs,
      ii.    Confer with the rest of the patients care team,
     iii.    Identify which clinician will assume responsibility for communicating with the family,
     iv.     Contact the risk manager,
      v.     Talk to the patient and family,


                                                 89
      vi.       Complete the medical record, and
      vii.      Continue to communicate with the patient and family as necessary.

8. Lifespan's Joint Privacy Policy

    To be in compliance with the Health Insurance Portability and Accountability Act (HIPAA)
    privacy rule, all healthcare providers are required to be knowledgeable about Lifespan’s
    HIPAA policies and procedures.
    Key points.
    a.) The HIPAA privacy rule establishes national standards to control the use and disclosure
        of what is known as Protected Health Information (PHI).
    b.) PHI is any health information that is collected from the patient or created or received
        from Lifespan that relates to the past, present or future physical or mental health or
        condition of a patient that could potentially identify that individual.
    Privacy rule gives patients the right to:
    a.)      Receive a privacy notice,
    b.)      Inspect and get a copy of their PHI,
    c.)      Request restrictions on disclosures of PHI,
    d.)      Request alternative means of communication, and
    e.)      Obtain accounting of non-routine disclosures of PHI.
    Obligations of RIH staff:
    a.) Use or disclose PHI only for work related purposes,
    b.) Limit uses and disclosures to the “minimum necessary” to achieve those work purposes,
    c.) Exercise reasonable caution to protect PHI under their control,
    d.) Understand Lifespan’s privacy policies and follow them,
    e.) Try to remedy any privacy problems or to report them to the Privacy Officer,
    f.) Note that “incidental uses and disclosures” are inevitable and do not violate the privacy
        rule as long as reasonable precautions are taken,
    g.) Understand that reasonable limits and efforts, appropriate to the circumstances and the
        nature of the information, are all that HIPAA requires, and
    h.) Recognized that Lifespan will not retaliate or discriminate against any patient or worker
        who exercise their rights or express a privacy concern.
    A Lifespan summary notice of Privacy Policies is as follows:
    Lifespan and its partners are required by federal law to provide a Privacy Notice that describes
    how medical and health information maintained is used or disclosed. Patient health
    information is confidential. The Privacy Notice describes the use and disclosure of
    information that Lifespan is permitted to make, as well as Lifespan’s obligations and the
    patients’ rights under the law.
    Uses and disclosures. Under a variety of circumstances Lifespan may use patient medical
    information without obtaining prior authorization. For example, Lifespan may use
    information to:
    a.) Provide treatment,
    b.) Ensure the quality of care,


                                                   90
     c.) Bill and/or collect payment for the services provided, and/or
     d.) Report communicable disease, domestic violence or criminal activity.
     Lifespan may use medical information in other situations, but patients have the opportunity
     to object. For example, unless an objection, the hospital directory will include limited
     information about patients, or may release information, as permitted under the law, about the
     patients condition to family and friends involved in, or who may help pay for, your care.
     Patients’ rights. While the records Lifespan maintains belong to Lifespan, patients have
     rights with regard to the information contained in those records. For example, patients have
     the right to:
     a.) Correct, but not delete, and update information,
     b.) Choose where and how the information is sent to you, and
     c.) Obtain a list of the non-routine disclosures of your information that have been made.
     All of these rights are subject to some exceptions, which are described in the Full Privacy
     Notice. A copy of the complete Lifespan Privacy Notice that is distributed to patients is
     available at: www.lifespan.org/services/ethics/Privacy/Notice.
     Lifespan’s obligations. To provide patients with the Privacy Notice and to abide by its
     terms. The Privacy Notice maybe amended from time to time. Lifespan reserves the right to
     make the amended or changed Notice effective for medical information it may already have,
     as well as for any medical information received in the future. If after reviewing the Privacy
     Notice, patients have any questions or need additional information, they may call the
     hospitals’ contact person or the Lifespan Privacy Officer.
     For more information:        RIH                               (401) 444-4560
                                  Lifespan Privacy Officer:         (401) 444-4728

9.       Patient Payment Policy

     a.) Goal. To financially clear as many patients prior to service as possible and to assist
         patients in determining their eligibility for coverage and creating payment plans.
     b.) For elective or non-urgent cases, the policy will require formal clearance prior to service
         or an exception from the Medical Director based on the clinical circumstances. RIH: Dr.
         O’Brien; GOBrien@lifespan.org
     c.) Emergent or urgent cases will never be cancelled or deferred.
     d.) If a patient is unwilling to meet the financial obligations, services may be postponed or
         cancelled.
     e.) Table of community free service guidelines. The revised guideline will provide at least
         partial coverage to a greater number of patients and encourage payment by those who are
         able to pay.
     f.) Immigration. For illegal aliens, disclosure of identity and financial status will not lead to
         notification of the immigration services. This information is kept strictly confidential.
     g.) Financial documents include IRS returns, bank statements, credit statements, etc.




                                                 91
C. Support Services & Resources
1. Bloodborne Pathogen Exposure

    Bloodborne Pathogen Exposure Control plan. In accordance with the OSHA standard
    1910.1030 (Bloodborne Pathogens), the following plan outlines the policies and procedures
    of RIH. For a complete description see the House Officer’s Handbook.
    a.) Exposure determination.
          i.   Personnel: Residents are in Category 1: staff who are likely to have contact with blood
               or body fluids, based on the nature of their position (e.g., physicians)
          ii. Body fluids: (OPIMs; Other Potential Infectious Material) any body fluids
          iii. Type of exposure: Defined as “reasonably anticipated skin, eye, mucous membrane,
               non-intact skin, or parenteral contact with blood and other potentially infectious
               materials that may result from the performance of an employee’s duties”.
    b.) Methods of compliance
          i.   Standard precautions (SP): Us of appropriate protective devices for contact with
               Body fluids to protect healthcare workers from infections.
          ii. Engineering controls. Sharps disposal units, recapping disposable units, mechanical
               pipetting, splash guards/hoods, IV catheters that resheath automatically, blood gas kit
               needle protection devices, protect point needle systems, blood drawing, needleless IV
               systems, lancets with safety shields, safety syringe needles, and huber needles
          iii. Work practice Controls. Hand washing, sharps disposed of properly, combative
               patients must be handled appropriately, equipment sent out for repairs, and proper
               handling of specimens.
          iv. Personnel protective equipment. Gloves, gowns, lab coats, fluid resistant aprons,
               safety glasses, side shields, caps, shoe covers, and mouthpieces.
    c.)        Hepatitis B Vaccine; free of charge to all employees
    d.)        Post exposure evaluation and follow-up; Report all exposure to the Employee Health
               Services.
    e.)        Infectious waste disposal/hazard communication. All medical waste in RED bags
               marked with biohazard symbol.
    f.)        Housekeeping and laundry considerations. All dirty laundry is considered
               contaminated.
    g.)        Employee education and training. All employees are required to attend New
               Employee Orientation prior to beginning their employment.
    h.)        Record Keeping. Medical records are monitored for each employee
    i.)        Compliance monitoring.
    j.)        Standard Precautions (for complete description see the House Officer’s Handbook).
               RIH definition of SP includes all bodily fluids.

2. Clinical Social Work


                                                  92
         Hospitalization can be a stressful experience. Everyday problems often become more
    difficult to manage when faced with an illness or injury. It's comforting to know that in
    addition to doctors and nurses, masters prepared clinical social workers are available to assist
    patients and family members with clinical and psychosocial issues during this difficult time.
    These social work services are free of charge. To access a clinical social worker at RIH &
    Hasbro, call:
    a.) During regular hours:       (401) 444-5711
        Monday to Friday:           8:30 AM – 5:00 PM
    b.) After hours page the social worker through the operator in the ED
        Monday to Friday:       7:00 PM – 11:00 PM
        Saturday and Sunday: 12:00 PM – 10:0 0 PM
    Reason to refer to Clinical Social Work
                 ADULT                                          PEDIATRIC
           Rhode Island Hospital                          Hasbro Children’s Hospital                3
  Davol Emergency Department (ED)                   Hasbro Emergency Department (ED)                    .
Adjustment to illness                             Adjustment to illness
                                                                                                        I
Elder Abuse                                       Child Abuse (initial referral to CPS)                 n
Family issues & conflict                          Family & parenting issues                             t
Domestic violence                                 Parental conflict                                     e
                                                                                                        r
Community violence (e.g., subject to gang violence or environment with violence)                        p
Cultural issues (e.g., clashing values of patient and caregivers or adjustment to culture)              r
HIV/AIDS                                          Custody issues                                        e
                                                                                                        t
Prescription assistance                           Prescription assistance
                                                                                                        e
Social vulnerability (e.g., is isolated or vulnerable by virtue of retardation, disability, etc.)       r
Grief & Loss                                      Grief & Loss
Discrimination                                    PICU admit                                            S
                                                                                                        e
Advance directives                                Police involvement                                    r
                                                  Elevated lead levels                                  v
                                                                                                        i
    ces

    Depending upon the language, the hospital may have staff interpreters, or you may access an
    interpreter service in the community. In urgent situations, the AT&T language line can access
    virtually any language on earth, for interpretation by speakerphone. Through the Brown
    Interpreter Aid Program Brown University students volunteer to provide interpreter services
    for some hours during the week.
    It is advisable to:


                                                     93
    a.) Avoid using children while interpreting, and
    b.) Access a trained interpreter when performing functions such as:
        i.   Obtaining an initial history and physical,
       ii.   Obtaining informed consent for an invasive procedure,
      iii.   Discussing code status,
      iv.    Reviewing medications, and/or
       v.    Reviewing diet instructions.

         Interpreters are available by calling:    (401) 444-8708

4. Chaplain services

    a.) The catholic chaplaincy team. The primary mission to provide pastoral and spiritual care
        to catholic patients, their families and staff, but are available upon request if a non-
        Catholic chaplain is unavailable. Team can be reached though the operator 24 hours a
        day.
    b.) The protestant chaplaincy team. Consists of local ministers trained in hospital chaplaincy.
        The Episcopal Chaplain is in the hospital three afternoons during the week and is on 24-
        hour call.
    c.) Jewish Chaplain. A Rabbi is available upon request.
    d.) Other Denominations. A chaplain ministering to patients of all denominations is in the
        hospital for a few hours each day and another is on call 24 hours a day.
    e.) For chaplain services call the page operator or (401) 444-5616.

5. Counseling Support Services
    See section on Employees Assistance Program (EAP) above.

6. Ethics Committees

    a.) Established to develop and maintain the highest ethical standards.
    b.) Purpose: To assist in the ethical dimensions of health care decisions and treatment and
        too assist in deliberations on difficult ethical decisions.
    c.) The ethics committee shall assist health care providers, administrators, patients, and
        families in resolving problems with ethical dimensions. The committee’s activities shall
        include education, development of policy and guidelines, and case review and
        consultation.
    d.) Activities include education, policy development and review, case review and
        consultation, and communication through conferences, grand rounds, publications and
        consultations.
    e.) The committee shall include representatives from the Staff Association, Nursing, Clinical
        Social Work, Administration, Risk Management, the clergy, the legal profession,
        ethicists/philosophers, and the Boards of Trustees.


                                                  94
   f.) It shall meet monthly, or more often as needed for case consultation. It shall report to the
       Quality Analysis Committee. A committee member is scheduled to be on call for urgent
       consultations and may be reached as follows:
       i.                    At extension 4-6175 during regular business hours or
      ii.                    Through the operator 24 hours a day.
   g.) When urgent a meeting will be held with the committee within 24 hours.
   h.) A useful site is available at http://www.lifespan.org/services/ethics/.
            This site provides information on Ethics & Patient Rights. Information that may be of
            assistance to patients in planning for care at the end of life. Highlights of this site include
            the following:
       i.       Patient Rights and Responsibilities. Each patient has legal rights while in the
                hospital.
      ii.       Lifespan's Joint Privacy Policy. See above section.
     iii.       Ethics Committee. The hospital's Ethics Committee offers guidance and support to
                patients, families and caregivers in difficult decision-making situations.
     iv.        Advance Directives. An overview of end-of-life care options.
      v.        Comparing Your Legal Options. Living will or durable power of attorney?
     vi.        Living Will. General information about Rhode Island's Rights of the Terminally Ill
                Act, instructions for creating a living will and a sample form.
    vii.        Durable Power of Attorney for Health Care. Information about durable power of
                attorney for health care, its advantages and limitations, how to create one and a
                printable version of Rhode Island's form.
    viii.       Related Links. Online resources and more information.
     ix.        Community Education. Seminars and workshops regarding advance directives and
                end-of-life care decisions are available free of charge to community groups, schools,
                churches and agencies.

7. Risk Management

   The Legal Counsel or Risk Management Department within Lifespan Corporate Services and
   related corporations coordinate all risk management activities throughout the Lifespan
   system.
   The Lifespan Malpractice Plan is administered by Lifespan Risk Services, Inc., which is a
   Rhode Island-based corporation, wholly owned by Lifespan, with an office in Providence.
   The Lifespan Malpractice Plan (LMP) provides insurance coverage to all entities within the
   Lifespan system, as well as to eligible physician groups.

   Lifespan Risk Services, Inc. (LRS) is incorporated in Rhode Island and wholly owned by
   Lifespan. LRS is responsible for all underwriting, loss prevention and claim activities done on
   behalf of the LMP.
   Contact Lifespan Risk Services about information on what to do if:


                                                     95
    a.)   You have a patient/visitor related incident to report,
    b.)   You have a patient/visitor related claim to report,
    c.)   You have a work related injury to report,
    d.)   You are served with a Subpoena,
    e.)   You receive notice of pending litigation,
    f.)   You are served with a Summons and Complaint,
    g.)   You have questions about your insurance coverage, or
    h.)   You would like to apply for malpractice coverage.
    If a case is identified which may result in a legal action, Risk Management and the Program
    Director must be notified immediately. A detailed account should be provided to the Program
    Director to be retained on file.

    Incident reports. Any patient or visitor sustaining an injury on hospital property must be
    examined by a physician. An incident report must be filled out in its entirety and given to the
    clinical manager. It is important that these are documented extensively at the time they occur
    for future legal reference. Do not reference the incident report in the patient’s medical record.

    Contact Information
    Lifespan Risk Services: Insurance and Claims Matters
    The CORO Building                  Telephone:    (401) 444-8273
    167 Point Street, Coro 170         Fax:          (401) 444-8963
    Providence, RI 02903
    Director of Risk Management:                  (401) 444-8265
    RIH Risk Manager:                             (401) 444-3257
    Emergency on-call pager (24 hour):            (401) 350-5274
    Lifespan Legal Counsel:                       (401) 444-3103

8. Lifespan Intranet

    Lifespan Medical Computing (MC). MC is a Department within the Information Services
    Department at Lifespan. As such, it is responsible for managing all website operations at
    Lifespan, as well as the nine web servers and the HTTP network that connects all to them. It
    is also responsible for website security and backup operations.
    The Lifespan Intranet is maintained by MC and is available at: http://intra.lifespan.org/.
    To date there are more than 200 web sites at Lifespan, most of them managed by
    departmental webmasters or web authors. The authors create and manage content by using a
    web-authoring program such as Microsoft FrontPage or Macromedia Dreamweaver. MC
    staff helps users learn to use such programs.
    Lifespan website operations is broken down into the internal web network (or intranets) and
    external (or Intranet) web sites. By far, the most active are the internal web sites, which now
    register more than 20 million hits a month. The general public cannot access the internal web
    sites, which makes them ideal for conducting clinical operations.
    a.) Health Information Services Information
    b.) Lifespan Internet Access Policy


                                                 96
        See section on Internet Email usage policy above.
    c.) Lifespan employee Internet access
        Questions or help:      (401) 444-6381

9. Lifespan Library

    Our Mission is to help medical professionals, students and patients become independent
    problem solvers who have state-of-the-art information tools and know how to use them to
    address health care challenges.
    The Lifespan Libraries form an integrated information management center. The libraries hold
    more than 40,000 serial volumes, subscribe to approximately 700 journals, and house more
    than 8,000 books, specializing in the clinical medical sciences and nursing. Among the
    libraries' strengths are electronic literature searching, online cataloging, collection
    management, library instruction and research consultation.
    Our services include inter-library loan, book circulation and online database searches:
    a.) Sydney PLUS. The Lifespan Libraries online card catalog system.
    b.) PubMed. Medline Database—provides access to references and abstracts from 4,600
        biomedical journals.
    c.) Brown Medical Connection
    d.) MD Consult
    e.) Search OVID. 73 on-line full text medical, nursing, and drug books are available.
    f.) NLM Gateway
    g.) MedlinePlus® Health Information. Health topics, drug information, medical
        encyclopedia, dictionary, directories, news and other resources.
    h.) ClinicalTrials.gov. Clinical research studies for new drugs and treatments
        (A service of the NIH developed by the National Library of Medicine).
    Lifespan Library Locations
    a.) Rhode Island Hospital Peters Health Science Library
        Phone Numbers            Circulation desk:       (401) 444-4671
                                 Administration:         (401) 444-8070
                                 Fax:                    (401) 444-8260
        Hours                    Monday - Thursday:      8 AM - 7 PM
                                 Friday                  8 AM - 5 PM
                                 Holidays                Closed
        Location                 Aldrich Building, RIH, (Main campus)
    b.) Hasbro Children's Hospital Family Resource Center
        Phone Numbers            Circulation:          (401) 444-6090
                                 Fax:                  (401) 444-8260
        Hours                    Weekdays              9 AM - 5 PM
        Location                 Room 118, (1st Floor)

    Department of Ophthalmology Library




                                                97
    A smaller collection of ophthalmic textbooks and journals is available. Numerous videotapes
    and CD-ROMS are also available. On-line access to Brown University is available allowing
    access to an extensive list of on-line journals. The resident has readily access to literature
    regarding specific topics and patient care. The medical aphorism “you see what you know” is
    particularly appropriate to ophthalmology. As an enhanced knowledge base will expedite the
    learning process.

10. Pharmacy Services at Lifespan

    Lifespan hospitals provide a full range of pharmacy services to their patients. For more
    information about pharmacy services at Lifespan hospitals, please contact the department at:
    (401) 444-8172.
    Lifespan Academic Medical Center (AMC) Pharmacy website. The purpose for this site is to
    present various pharmacy department initiates and to provide up-to-date drug news as well as
    information on the AMC formulary, new products, and drug guidelines. The site contains:
    a.)   Formulary,                               j.) ADR reporting,
    b.)   Formulary changes,                       k.) P&T committee,
    c.)   Drug News,                               l.) Pharmacy services,
    d.)   Drug costs,                              m.) Policies and procedures,
    e.)   Drug storage guidelines,                 n.) Therapeutic policy management,
    f.)   Food and drug interactions,              o.) Digimedics Manual,
    g.)   Intravenous medication guidelines,       p.) Micromedex, and
    h.)   Medication incident reporting program,   q.) Staff information.
    i.)   Medication use guidelines,

11. OnCall Data. Prescription Services

    OnCallData provides a convenient way to write prescriptions using mobile phones, desktop
    computers, or any other web-enabled device. In addition, you can review your patients'
    laboratory results as soon as they are available on these same devices.
    This is set up to be on-line on 08/02/2004

12. Bioterrorism
    RIH may be the site of recognition and response to bioterrosism events. If a bioterrorism
    event is suspected, local emergency response system should be activated. Notification should
    immediately include local infection control personnel and the healthcare facility
    administration.
    At RIH different bioterrosism infection control guideline and clinical plans are in effect.
    These are adapted from the Bioterrorism Readiness Plan: A template for Healthcare Facilities
    from APIC and CDC, the USPS, and the California Hospital Bioterrorism Planning Guide.
    For concern about possible biological or chemical terrorist attacks and outbreaks.
    a.) Isolate and stabilize patient
    b.) Protective gown, gloves, mask



                                                 98
    c.) Contact Hospital pediatric or adult infectious disease attending physician on the consult
        service at the affected institution through the hospital operator.
    d.) Contact Program Director to coordinate RIH efforts.
    Summary of biological and chemical warfare agents:
    Distilled mustard                       Brucella                 Yersinia pestis
    Bacillus anthracis                      Chemical                 Variola major
    Francisella tularensis                  Vesicants                Lewisite
    Viral hemorrhagic fever                 Biological               Others

13. Security

    Security services are available on a 24-hour basis. Escort services should be requested if you
    must use the Hospital lots at night. Any theft or suspicious activities should be reported.
    When the safety/security of patients, visitors, or staff is threatened, call Security.
    Security is located in the Jane Brown Basement. (401) 444-4111; (401) 444-5221
    ID Badges (Photos):            Mon - Thurs:     8:00 AM - 11:30 AM
                                                    2:00 PM - 3:00 PM
                                                    4:00 PM - 4:30 PM

14. Dictations

    a.) Dictated discharge summaries and operative notes are required for both documentation
        and reimbursement purposes.
    b.) All discharges need to have a Discharge Summary dictated within 24 hours.
    c.) All operations and procedures should be dictated immediately after the procedure. If
        unable to dictate after the surgery the procedure may be dictated later that day but the
        dictation must be complete before leaving the hospital. Failure to dictate promptly could
        lead to suspension of the resident’s surgical privileges.
    d.) Dictation Instructions (RIH)
        i.     Log On: Dial 444-7799 (4-7799)
       ii.     Enter your physician dictation number:
      iii.     Select work type (confidential): #
               • 101, Inpatient OP note (901)
               • 102, Discharge Summary (902)
               • 103, Ambulatory Clinic (903)
               • 104, Outpatient OP note (904)
               • 105, H&P (905)
               • 106, Consultation (906)
               • 107, Letter (907)
      iv.      Enter Medical Record Number: #
       v.      Press 2 (a beep will occur) and begin dictating; if you hear "not recording: press 2 and
               listen for the beep and then begin dictating
      vi.      Dictate:


                                                   99
          • MR number
          • Patients name
          • Date of service or admission or discharge
  vii.    Press 2 to pause
 viii.    Press 2 to re-dictate
   ix.    Press 5 to disconnect
    x.    Press 8 for multiple dictations
   xi.    To Edit:
          • Press 3 to rewind multiple times if necessary
          • Once for short review
          • Multiple times for longer review
  xii.    Press 7 for total rewind
 xiii.    Press 4 to fast forward to the end
 xiv.     Press 2 to stop playback
  xv.     Press 2 to re-dictate
 xvi.     Press # to leave open an incomplete account
xvii.     To finish an open account sign on with the same MR and work type
xviii.    At end of dictation press# for job number
e.) RIH Operative Note:
     i.   MR number:
    ii.   Patients name:
   iii.   Date of procedure:
  iv.     Primary Attending Surgeon:
    v.    Other Attending Surgeon:
  vi.     Fellow/Resident:
  vii.    Pre-operative Diagnosis: (ICD code)
 viii.    Operation: Type of Procedure (include CPT code)
   ix.    Indications for surgery:
    x.    Post-operative Diagnosis: (ICD code)
   xi.    Anesthesia (type): MAC, local, GA
  xii.    Specimens sent (to micro/path):
 xiii.    Implant/Prostheses: Type or none
 xiv.     Complications
  xv.     Dictate procedure:
 xvi.     (Skin prep, incision, closure)
xvii.     Description of findings
xviii.    Post-operative condition: Stable
 xix.     CC List
f.) RIH History & Physical
     i.   MR number
    ii.   Patients name
   iii.   Date of service
  iv.     Date
    v.    HPI
  vi.     PMH
  vii.    Meds


                                          100
viii.   PE
 ix.    Impression
g.) RIH Discharge Summary
   i.   Patient Name: full name
  ii.   Admission Number:
 iii.   Admission Date
 iv.    Discharge Date
  v.    Chief Complaint
 vi.    Past history: brief history of illness, diagnostic procedures performed prior to
        admission
 vii.   Physician Examination: brief admission physical to include pertinent or significant
        findings
viii.   Laboratory Data: Abnormal admission studies, abnormal in-hospital tests, or studies
        with significant results as related to the present hospitalization
 ix.    Hospital Course: A concise statement of the treatment of the patient, significant
        events, and progress during hospitalization
  x.    Diagnosis: List in order of importance, Use standard medical terminology, no
        abbreviations
  xi.   Condition on discharge:
 xii.   Operations/Procedures: Type and date performed
xiii.   Complications:
xiv.    Discharge Instructions
        • Medications
        • F/U
        • Diet
        • Activities
 xv.    CC:
h.) RIH Consultation Note:
   i.   MR number
  ii.   Patients name
 iii.   Date of consultation:
 iv.    Consultation to:
  v.    Requesting physician or service
i.) RIH Clinic Note:
   i.   MR number:
  ii.   Patients name:
 iii.   Date of Clinic Visit:
 iv.    Name of Clinic: Ophthalmology
  v.    Attending Physician: Kent L. Anderson, M.D., Ph.D.
 vi.    Subjective
        • CC: Reason for visit
        • HPI: Mr./Mrs. is a __ y/o M/F with a PMH significant for __.
        • POH:
        • PMH/PSH: Reviewed with pt and no changes from prior visit
        • FH: ocular disease


                                          101
        • SH: smoking
        • Medications:
        • Ocular Medications:
        • Allergies:
        • ROS: Reviewed with pt and no changes from prior visit
vii.    Objective
        • Major Findings: Exam
        • VA (cc/sc): ___ PH ___ Near: ___
        • Compared to last visit's VA
        • Wearing:
        • MR:
        • PAM:
        • Color Vision:
        • Pupils:
        • EOMs:
        • VF:
        • IOP: Measured by tonopen/applanation
        • External (lids ocular adnexa):
        • Conjunctiva:
        • Cornea:
        • A/C:
        • Iris:
        • Lens: NO, CO, PSC, PP
        • Gonio:
        • Extended ophthalmoscopy of - eyes after dilation
        • Vitreous:
        • C/D
        • ON, macula, vessels, periphery wnl
        • Except as noted below
        • Labs
        • Imaging
viii.   Assessment
        • Problems/Diagnoses
 ix.    Plan
        • Plans (procedures/change of meds)
        • Studies: FA/HVF:
        • Laser, PDT, surgery
  x.    CC List




                                       102
Appendix A. Minimum Numbers
Ophthalmology Training Program Experience

Operative Experience Minimum Numbers

Procedure                 Class I Minimum          Class I + III Minimum

Cataract                  45                       75

Strabismus                10                       15

Corneal Surgery           0                        5

Glaucoma Laser            5                        10

Glaucoma Filtering        5                        10

Retina/Vitreous           3                        10

Other Retinal             10                       10

Oculoplastics & Orbit     15                       25

Globe Trauma              4                        6

Class 1: Primarily by the resident with direct supervision; faculty present
Class 3: Primarily by faculty with resident as first assistant




                                                 103
Appendix B. Vacation Request
Form

Rhode Island Hospital
Department of Ophthalmology



                             Request for Cancellation of Clinic(s)
          (Vacation request must be submitted 6 weeks prior to Request Date(s)

If submitted less than 6 weeks in advance, this form must be signed by the Chief Resident




Resident’s Name:                                                      Today’s Date:
Date(s) of Absence:

Reason:

I HAVE ARRANGED APPROPRIATE CALL COVERAGE:
                                                                        Initial

Request Approved:                                                                         Date
                               Chair man/ Pro gra m Dir ector

Request Not Approved:                                                                     Date
                               Chairm an/ Pro gra m Direct or

                                                                                          Date
                               Chief Re si dent ( Op hthalm ol ogy)


Comments:




Date Request Received for Cancellation:


Cancellation completed by:                                                        Date:


CC:       Tammie Dickerman
          Jacqueline Horner
          Christopher Newton




                                                                 104
Appendix C. Resident Evaluations
The forms used are the Ophthalmology Residency Evaluation Long Forms prepared by the
ACGME.

A copy of this 7-page form is included in the following pages.




                                               105
106
107
108
109
110
111
112
Appendix D. Resident Schedule




               113
114
Appendix E. Surgical Evaluation
                           Rhode Island Hospital
                                 Department of Ophthalmology

                               Resident Surgical Evaluation Form


Resident Name:                                         Date of Surgery:

Attending:

Procedure:                                             Machine Used:

Local:                RIH
                      VA
                      Miriam

Anesthesia:       Local        GA            MAC                Topical

Complications:



Resident Strengths:



Resident Weaknesses:



Suggestions for Improvement:




Attending Signature:




                                             115

				
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